What is the optimal blood pressure (BP) management regimen?

From the Guidelines

The optimal blood pressure management regimen involves lifestyle modifications and medications tailored to individual needs, with a treatment goal of blood pressure below 130/80 mmHg, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1.

Lifestyle Modifications

Key lifestyle modifications include:

• Regular physical activity, such as 150 minutes of moderate exercise weekly
• Adoption of the DASH diet, rich in fruits, vegetables, whole grains, and low-fat dairy
• Reduction of sodium intake to less than 2,300mg daily
• Limitation of alcohol consumption
• Maintenance of a healthy weight
• Stress management These modifications are crucial for reducing blood pressure, preventing or delaying the incidence of hypertension, enhancing antihypertensive drug efficacy, and decreasing cardiovascular risk, as supported by the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1.

Medications

First-line medication options typically include:

• Thiazide diuretics, such as hydrochlorothiazide 12.5-25mg daily
• ACE inhibitors, such as lisinopril 10-40mg daily
• ARBs, such as losartan 25-100mg daily
• Calcium channel blockers, such as amlodipine 5-10mg daily Combination therapy is often necessary, with medications taken at consistent times daily, to effectively lower blood pressure and reduce cardiovascular risk.

Treatment Goals

Treatment goals generally aim for blood pressure below 130/80 mmHg, though targets may vary based on age and comorbidities, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1.

Monitoring and Follow-up

Regular monitoring and healthcare provider follow-up are essential for adjusting treatment as needed to ensure optimal blood pressure management and reduce cardiovascular risk.

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake. Many patients will require more than 1 drug to achieve blood pressure goals For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)

The optimal blood pressure management regimen is not explicitly stated in the provided drug labels. However, it is recommended that control of high blood pressure should be part of comprehensive cardiovascular risk management, including:

• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake It is also noted that many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, it is recommended to consult published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 2.

From the Research

Optimal Blood Pressure Management Regimen

The optimal blood pressure (BP) management regimen involves a combination of lifestyle modifications and pharmacologic therapy.

• Lifestyle modifications are recommended as first-line treatment for hypertension, including diet adaptation, sodium reduction, alcohol restriction, physical exercise, and weight reduction 3, 4.
• The dietary approaches to stop hypertension (DASH) diet may be considered the most effective treatment for reducing blood pressure 3.
• For patients with high-normal blood pressure or grade 1 hypertension without high risk factors, lifestyle medicine should be used first for 3-6 months, and if blood pressure is still not controlled, then medication should be started 3.
• First-line drug therapy for hypertension consists of a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker, which should be titrated according to office and home SBP/DBP levels to achieve a target blood pressure of <130/80 mm Hg for adults <65 years and SBP <130 mm Hg in adults ≥65 years 4.
• The European Society of Cardiology (ESC) guidelines recommend initiating lifestyle modifications and antihypertensive medication concurrently for patients with hypertension (≥140/90 mm Hg), with a target systolic blood pressure of 120-129 mm Hg 5.
• Triple fixed-dose combination therapy with an angiotensin II receptor blocker, a calcium channel blocker, and a thiazide diuretic may be required in 15%-20% of treated uncontrolled hypertensive patients 6.
• Maintaining healthy lifestyle factors, such as a healthy diet, regular exercise, and minimal alcohol consumption, could lower systolic blood pressure by 3.5 mm Hg and reduce the risk of cardiovascular disease by about 30% 7.

Lifestyle Modifications

Lifestyle modifications play a crucial role in the management of hypertension.

• Diet adaptation, sodium reduction, and alcohol restriction are effective in reducing blood pressure 3, 4.
• Physical exercise and weight reduction are also recommended 3, 4.
• The DASH diet may be considered the most effective treatment for reducing blood pressure 3.
• Maintaining healthy lifestyle factors could lower systolic blood pressure and reduce the risk of cardiovascular disease 7.

Pharmacologic Therapy

Pharmacologic therapy is recommended for patients who do not respond to lifestyle modifications or have high-risk factors.

• First-line drug therapy for hypertension consists of a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker 4.
• The European Society of Cardiology (ESC) guidelines recommend initiating lifestyle modifications and antihypertensive medication concurrently for patients with hypertension (≥140/90 mm Hg) 5.
• Triple fixed-dose combination therapy with an angiotensin II receptor blocker, a calcium channel blocker, and a thiazide diuretic may be required in 15%-20% of treated uncontrolled hypertensive patients 6.