What is the management for elevated diastolic blood pressure?

Management of Elevated Diastolic Blood Pressure (97 mmHg)

A diastolic blood pressure of 97 mmHg requires immediate initiation of antihypertensive therapy to reduce cardiovascular risk, with a target of <80 mmHg. 1, 2

Blood Pressure Classification and Risk

A diastolic blood pressure of 97 mmHg falls into Stage 2 Hypertension category, which is defined as systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg 2. This level of diastolic hypertension significantly increases the risk of:

• Cardiovascular events (stroke, myocardial infarction)
• Heart failure
• Chronic kidney disease
• Microvascular complications

Treatment Goals

The current evidence-based blood pressure targets are:

• Primary target: <130/80 mmHg for most patients 1
• Specifically for diastolic BP: <80 mmHg for all hypertensive patients 1
• Optimal diastolic range: 70-79 mmHg to maximize cardiovascular risk reduction 2

Pharmacological Management

First-line Therapy

1. Initial medication selection:

   • For non-Black patients: ACE inhibitor (e.g., lisinopril) or ARB 2, 3
   • For Black patients: Calcium channel blocker (e.g., amlodipine) or thiazide-like diuretic 2, 4

2. If not at goal within 2-4 weeks:

   • Add a second agent from a complementary class
   • Preferred combinations: ACE inhibitor/ARB + calcium channel blocker OR ACE inhibitor/ARB + thiazide-like diuretic 2

3. If still not at goal:

   • Add a third agent (typically the remaining class from ACE inhibitor/ARB, calcium channel blocker, or thiazide-like diuretic) 1, 2

Resistant Hypertension

If BP remains uncontrolled on a three-drug regimen:

• Add spironolactone (or eplerenone if spironolactone is not tolerated)
• Consider adding a beta-blocker if not already indicated
• Consider centrally acting agents, alpha-blockers, or other vasodilators 1

Non-Pharmacological Interventions

These interventions should be implemented concurrently with medication:

1. Dietary modifications:

   • DASH diet: ~5 mmHg SBP reduction 2
   • Sodium restriction: <1500 mg/day (1-3 mmHg reduction per 1000 mg sodium reduction) 2
   • Increase potassium intake through fruits and vegetables 2

2. Physical activity:

   • 90-150 minutes/week of aerobic or dynamic resistance exercise 2
   • Alternative: isometric resistance exercises 3 sessions/week 2

3. Weight management:

   • Target BMI 20-25 kg/m² 1
   • Weight loss: ~1 mmHg SBP reduction per 1 kg weight loss 2

4. Alcohol limitation:

   • Men: <14 units/week
   • Women: <8 units/week 1

Monitoring and Follow-up

1. Initial follow-up: 2-4 weeks after starting or adjusting medication 2
2. Home BP monitoring: Encourage regular self-monitoring to guide treatment adjustments 2
3. Laboratory monitoring:
   • Baseline and follow-up electrolytes, creatinine, and eGFR, especially when using ACE inhibitors, ARBs, or diuretics 2
   • Monitor for adverse effects of medications

Special Considerations

• Diabetes: ACE inhibitor or ARB should be included in the regimen 2
• Chronic kidney disease: ACE inhibitor or ARB recommended as part of treatment 2
• Elderly patients (≥65 years): Target diastolic BP <80 mmHg with systolic 130-139 mmHg 2
• Pregnancy: ACE inhibitors and ARBs are contraindicated; methyldopa, labetalol, and nifedipine are preferred 2

Clinical Pitfalls to Avoid

1. Therapeutic inertia: Failure to intensify treatment when BP remains above goal
2. Inadequate dosing: Not titrating medications to effective doses before adding new agents
3. Overlooking adherence issues: Always assess medication adherence when BP is not controlled
4. Ignoring white-coat or masked hypertension: Consider ambulatory or home BP monitoring to confirm diagnosis
5. Neglecting secondary causes: Consider screening for secondary hypertension in resistant cases
6. Excessive BP lowering: Avoid reducing diastolic BP below 70 mmHg, especially in elderly patients with coronary artery disease

By following this structured approach to managing diastolic hypertension, cardiovascular risk can be significantly reduced while minimizing adverse effects of treatment.