At what blood pressure reading should medication be initiated in a patient with hypertension?

When to Start Blood Pressure Medication in Hypertension

Blood pressure medication should be initiated immediately when office BP is ≥140/90 mmHg for most patients, and at ≥130/80 mmHg for high-risk patients with cardiovascular disease, diabetes, or chronic kidney disease. 1

Blood Pressure Thresholds for Medication Initiation

General Population:

• BP ≥140/90 mmHg: Start medication immediately 1
• BP 130-139/80-89 mmHg (Stage 1 Hypertension):
  • Start medication immediately in high-risk patients 1
  • For low-risk patients: Try lifestyle modifications for 3-6 months first, then start medication if BP remains elevated 1

High-Risk Patients (Start at Lower Threshold):

• BP ≥130/80 mmHg: Start medication immediately in patients with: 1
  • Established cardiovascular disease
  • Diabetes mellitus
  • Chronic kidney disease
  • 10-year CVD risk ≥10%
  • Age 65-80 years

Confirming Hypertension Before Starting Medication

Before initiating medication, confirm hypertension using:

• Multiple readings at each visit (average of at least 2 readings)
• Measurements on 2-3 separate office visits
• Consider home BP monitoring (hypertension if ≥135/85 mmHg) or 24-hour ambulatory monitoring (hypertension if ≥130/80 mmHg) 1, 2

Special Populations

Elderly Patients:

• Age ≥80 years: Consider more conservative approach; start medication at BP ≥140/90 mmHg 1
• Frail elderly: Consider personalized and more lenient targets (e.g., <140/90 mmHg) 1

Pregnancy:

• BP ≥140/90 mmHg: Start medication in women with pre-existing hypertension 1
• BP ≥140/90 mmHg: Start medication in women with gestational hypertension with organ damage or symptoms 1
• BP ≥150/95 mmHg: Start medication in all other cases of gestational hypertension 1

Diabetes:

• BP ≥130/80 mmHg: Start medication after maximum 3 months of lifestyle intervention 1, 2

Chronic Kidney Disease:

• BP ≥140/90 mmHg: Start medication with lifestyle advice 1
• BP ≥130/80 mmHg: Consider starting medication in those with albuminuria 2, 3

Medication Selection When Starting Treatment

When initiating antihypertensive therapy, consider:

First-line options:

• Non-Black patients: Low-dose ACE inhibitor/ARB, dihydropyridine CCB, or thiazide/thiazide-like diuretic 1, 2
• Black patients: Low-dose ARB + dihydropyridine CCB or dihydropyridine CCB + thiazide/thiazide-like diuretic 1, 2

When to start with combination therapy:

• BP >20/10 mmHg above target 1
• High cardiovascular risk 1

Common Pitfalls to Avoid

1. Therapeutic inertia: Delaying medication initiation when clearly indicated by guidelines
2. White coat hypertension: Failing to confirm office readings with home or ambulatory monitoring
3. Orthostatic hypotension: Not checking for postural drops in elderly or diabetic patients
4. Medication intolerance: Starting with full doses rather than low doses and titrating up
5. Inadequate follow-up: Not reassessing within 2-4 weeks of medication initiation

Monitoring After Initiation

• Follow up every 2-4 weeks until BP goal is achieved
• Monitor electrolytes, creatinine, and eGFR, particularly when using ACE inhibitors or ARBs
• Allow at least 4 weeks to observe full response to medication changes 2

The decision to start blood pressure medication should be based on accurate measurements, cardiovascular risk assessment, and consideration of individual patient factors, but the thresholds outlined above provide clear guidance for most clinical scenarios.