How to manage high diastolic blood pressure?

Management of High Diastolic Blood Pressure

For patients with sustained diastolic blood pressure ≥100 mmHg, prompt initiation and timely titration of pharmacologic therapy is strongly recommended along with lifestyle modifications to achieve blood pressure goals. 1

Understanding Diastolic Hypertension

Diastolic hypertension is defined by the following blood pressure categories:

• Normal: <80 mmHg
• Elevated: <80 mmHg (with systolic 120-129 mmHg)
• Stage 1 Hypertension: 80-89 mmHg
• Stage 2 Hypertension: ≥90 mmHg 2

Treatment Thresholds

Treatment decisions should be based on the following thresholds:

• Diastolic BP ≥100 mmHg: Immediate initiation of pharmacologic therapy plus lifestyle modifications 1
• Diastolic BP 90-99 mmHg:
  • With target organ damage, cardiovascular disease, diabetes, or 10-year cardiovascular risk ≥20%: Start pharmacologic therapy plus lifestyle modifications 1
  • Without complications: Trial of lifestyle modifications for up to 6 months before considering medications 1

Target Blood Pressure Goals

• General population: Target diastolic BP <80 mmHg 1
• Diabetes or chronic kidney disease: Target diastolic BP <80 mmHg (with systolic 130-139 mmHg) 1
• Elderly patients (≥65 years): Target diastolic BP <80 mmHg (with systolic 130-139 mmHg) 1
• Pregnancy: Target diastolic BP 80-85 mmHg (not below 80 mmHg) 1

Pharmacological Management

Initial Drug Selection

1. For diastolic BP 90-99 mmHg (Stage 1):

   • First-line: Thiazide-type diuretics for most patients 1
   • Alternatives: ACE inhibitors, ARBs, beta-blockers, or calcium channel blockers 1

2. For diastolic BP ≥100 mmHg (Stage 2):

   • Two-drug combination therapy is recommended:
     • Thiazide-type diuretic plus ACE inhibitor, ARB, beta-blocker, or calcium channel blocker 1

3. For resistant hypertension (BP uncontrolled on 3 drugs):

   • Add spironolactone or eplerenone
   • If not tolerated, add beta-blocker (if not already prescribed)
   • Consider centrally acting agents, alpha-blockers, or hydralazine 1

Special Populations

• Diabetes: ACE inhibitor or ARB should be included in the regimen 1
• Chronic kidney disease: ACE inhibitor or ARB recommended as part of treatment 1
• Pregnancy: ACE inhibitors and ARBs are contraindicated; methyldopa, labetalol, and nifedipine are preferred 1

Lifestyle Modifications

All patients with elevated diastolic blood pressure should implement the following lifestyle changes:

1. Weight management:

   • Target healthy BMI (18.5-24.9 kg/m²)
   • Each 1 kg weight loss can reduce systolic BP by ~1 mmHg 2

2. Dietary modifications:

   • DASH diet (rich in fruits, vegetables, whole grains, low-fat dairy)
   • Sodium restriction (<2,300 mg/day)
   • Increased potassium intake (3,500-5,000 mg/day) 1, 2

3. Physical activity:

   • 150 minutes/week of moderate aerobic activity
   • 30-60 minutes, 5-7 times weekly 2

4. Alcohol moderation:

   • Men: ≤2 drinks/day (maximum 14/week)
   • Women: ≤1 drink/day (maximum 8/week) 1

5. Smoking cessation 3, 4

Monitoring and Follow-up

• Monitor blood pressure every 2-4 weeks until target is achieved
• Check electrolytes and renal function 2-4 weeks after initiating therapy, especially with diuretics, ACE inhibitors, or ARBs
• Once target is reached, follow-up every 3-6 months 2
• Consider home blood pressure monitoring to guide treatment adjustments 2

Urgent Treatment Scenarios

Immediate hospitalization should be considered for:

• Diastolic BP ≥110 mmHg with signs of impending complications
• Accelerated hypertension (severe hypertension with grade III-IV retinopathy)
• Particularly severe hypertension (>220/120 mmHg) 1

Common Pitfalls to Avoid

1. Excessive diastolic BP lowering: In patients with coronary heart disease, avoid reducing diastolic BP below 60 mmHg as this may increase cardiovascular risk 1

2. Inadequate combination therapy: For Stage 2 hypertension, single-drug therapy is often insufficient; start with combination therapy 1

3. Overlooking secondary causes: Consider screening for secondary hypertension in patients with:

   • Resistant hypertension (≥3 drugs)
   • Young age (<30 years needing treatment)
   • Sudden onset or worsening of hypertension 1

4. Neglecting lifestyle modifications: Even when medications are required, continuing lifestyle changes can reduce the number and doses of medications needed 3

By following this structured approach to managing high diastolic blood pressure, you can effectively reduce cardiovascular morbidity and mortality while improving patient quality of life.