What is the management approach for systolic arterial hypertension?

Management of Systolic Arterial Hypertension

The management of systolic arterial hypertension requires both lifestyle modifications and pharmacological therapy, with a target blood pressure of <130/80 mmHg for most patients, achieved through a stepped approach beginning with a two-drug combination for stage 2 hypertension (≥140/90 mmHg). 1, 2

Diagnosis and Classification

• Classification of hypertension:

  • Normal BP: <120/80 mmHg
  • Elevated BP (Prehypertension): 120-129/<80 mmHg
  • Stage 1 Hypertension: 130-139/80-89 mmHg
  • Stage 2 Hypertension: ≥140/90 mmHg
  • Hypertensive Crisis: >180/120 mmHg 2

• Initial evaluation should include:

  • Urine testing for blood and protein
  • Blood electrolytes and creatinine
  • Blood glucose
  • Serum total:HDL cholesterol ratio
  • 12-lead ECG 2

Treatment Approach

Blood Pressure Targets

• General population: Target BP <130/80 mmHg 1, 2
• Older patients (≥65 years): Target systolic BP 130-139 mmHg 1
• Patients with diabetes, chronic kidney disease, or established cardiovascular disease: Target BP <130/80 mmHg 1, 2
• Very elderly (≥85 years) or frail patients: Consider more lenient targets (<140/90 mmHg) 1

Lifestyle Modifications (First-line for all patients)

1. Weight management:

   • Maintain BMI between 20-25 kg/m² 1
   • Waist circumference <94 cm in men and <80 cm in women 1
   • Expected BP reduction: 1 mmHg per kg lost 2

2. Dietary modifications:

   • DASH diet: Increased vegetables, fruits, low-fat dairy, reduced red meat 1, 2
   • Sodium restriction to <2.4 g/day (BP reduction 3-6 mmHg) 2
   • Increased potassium intake (BP reduction 3-5 mmHg) 2

3. Physical activity:

   • 30-60 minutes of moderate-intensity aerobic activity 5-7 days/week 1, 2
   • Complementary resistance training at least 2 days/week 1
   • Expected BP reduction: 3-8 mmHg 2

4. Alcohol moderation:

   • <14 units/week for men
   • <8 units/week for women 1
   • Expected BP reduction: 3-4 mmHg 2

5. Smoking cessation 2

Pharmacological Therapy

When to Initiate Drug Therapy

• Immediately for:

  • Stage 2 hypertension (≥140/90 mmHg) 2
  • Stage 1 hypertension (130-139/80-89 mmHg) with cardiovascular disease, target organ damage, diabetes, or 10-year cardiovascular risk ≥20% 1, 2

• After 3 months of failed lifestyle modifications for Stage 1 hypertension without high-risk conditions 2

Drug Selection

1. First-line options (all equally effective at reducing BP and cardiovascular events):

   • ACE inhibitors
   • Angiotensin receptor blockers (ARBs)
   • Calcium channel blockers (CCBs)
   • Thiazide or thiazide-like diuretics 1

2. Initial therapy approach:

   • Stage 1 hypertension: Start with a single agent (thiazide diuretic, ACE inhibitor, ARB, or CCB) 2
   • Stage 2 hypertension: Start with a two-drug combination, preferably:
     • ACE inhibitor/ARB + CCB, or
     • ACE inhibitor/ARB + thiazide-like diuretic 1, 2

3. If BP not controlled with a three-drug combination, add:

   • Spironolactone (first choice)
   • Eplerenone (if spironolactone not tolerated)
   • Beta-blocker
   • Centrally acting agent
   • Alpha-blocker
   • Hydralazine 1

Special Populations

• Diabetes or chronic kidney disease: Prefer ACE inhibitors or ARBs 2
• African American patients: Consider starting with CCB + thiazide diuretic 2
• Elderly patients: Start with lower medication doses and titrate more slowly 2
• Pregnant patients: Avoid ACE inhibitors and ARBs; prefer calcium channel blockers, beta-blockers, or labetalol 2
• Women of childbearing potential: Avoid ACE inhibitors and ARBs 2

Monitoring and Follow-up

• Evaluate patients within 1 month of initial diagnosis and treatment initiation
• Monitor BP every 2-4 weeks until goal is achieved, then every 3-6 months 2
• Assess medication adherence and potential barriers (cost, side effects)
• Consider simplifying regimen with once-daily dosing and single-pill combinations 2

Potential Pitfalls to Avoid

• Clinical inertia (failure to intensify treatment when goals not met)
• Inadequate diuretic therapy
• Ignoring medication adherence issues
• Overlooking interfering substances (NSAIDs, stimulants, oral contraceptives)
• Inappropriate combinations (e.g., combining two RAS blockers) 2

By implementing this comprehensive approach to systolic hypertension management, clinicians can significantly reduce the risk of stroke by 35-40%, heart attacks by 20-25%, and heart failure by 50% 2.