Should antihypertensive medication be started for a patient with stage 2 hypertension and a mean blood pressure of 110 mmHg?

Management of Stage 2 Hypertension with Mean BP of 110 mmHg

Yes, antihypertensive medication should be started immediately for this patient with stage 2 hypertension (155/92 mmHg), regardless of the mean BP of 110 mmHg. 1

Rationale for Treatment

• The patient's BP reading of 155/92 mmHg clearly falls into stage 2 hypertension (≥140/90 mmHg) according to the 2017 ACC/AHA guidelines 1
• The mean arterial pressure (MAP) of 110 mmHg does not override the classification based on systolic and diastolic readings
• The ACC/AHA guidelines explicitly recommend prompt treatment for patients with stage 2 hypertension, especially those with BP ≥160/100 mmHg 1

Treatment Approach

Initial Therapy

• Initiate treatment with two antihypertensive agents from different classes 1
• Recommended first-line combinations:
  • Thiazide or thiazide-like diuretic (preferably chlorthalidone) + ACE inhibitor or ARB
  • Calcium channel blocker + ACE inhibitor or ARB 2

Medication Selection Considerations

• Chlorthalidone is preferred over hydrochlorothiazide due to its longer half-life and proven cardiovascular disease reduction 1
• For black patients, a thiazide diuretic or calcium channel blocker may be more effective as initial therapy 3
• For patients with comorbidities such as diabetes or chronic kidney disease, an ACE inhibitor or ARB is particularly beneficial 2

Monitoring and Follow-up

• Schedule follow-up within 1 month of initiating therapy 1
• Monitor for adherence and response to treatment monthly until BP control is achieved 1
• Assess electrolytes and renal function 2-4 weeks after initiating therapy with diuretics, ACE inhibitors, or ARBs 1
• Consider home blood pressure monitoring to improve BP control 1

Important Considerations

Why Mean BP Is Not the Determining Factor

• Treatment decisions are based on systolic and diastolic readings, not mean arterial pressure 1
• The risk of cardiovascular events increases progressively with higher systolic and diastolic readings 3
• Even when mean BP appears acceptable, elevated systolic pressure significantly increases cardiovascular risk 1

Common Pitfalls to Avoid

1. Delaying treatment: All guidelines recommend immediate pharmacological treatment for stage 2 hypertension 1
2. Using single-agent therapy: For stage 2 hypertension, combination therapy is more effective at achieving control 1
3. Inadequate follow-up: Monthly monitoring is essential until BP control is achieved 1
4. Overlooking adherence: Assess and address medication adherence at each visit 1

Target Blood Pressure Goal

• For most adults: <130/80 mmHg 1
• For elderly patients (≥80 years): <150/90 mmHg may be appropriate 1
• For patients with high cardiovascular risk, diabetes, or chronic kidney disease: <130/80 mmHg 1

The evidence clearly supports initiating prompt antihypertensive therapy for this patient with stage 2 hypertension, regardless of the mean BP value. The focus should be on reducing cardiovascular risk through effective blood pressure control.