Should a 24-hour mean blood pressure (BP) of 141/80 mmHg and mean awake blood pressure of 148/83 mmHg be treated?

Treatment of 24-Hour Blood Pressure of 141/80 mmHg and Mean Awake BP of 148/83 mmHg

Yes, a 24-hour mean blood pressure of 141/80 mmHg and mean awake blood pressure of 148/83 mmHg should be treated with antihypertensive medication, as these values exceed the recommended thresholds for hypertension diagnosis and treatment. 1, 2

Interpretation of Ambulatory Blood Pressure Monitoring Results

The provided 24-hour ambulatory blood pressure monitoring (ABPM) results show:

• 24-hour mean BP: 141/80 mmHg
• Mean awake BP: 148/83 mmHg
• Success rate: 57/59 readings (97% - excellent technical quality)

These values exceed the diagnostic thresholds for hypertension using ABPM, which are:

• 24-hour mean BP ≥130/80 mmHg
• Daytime (awake) BP ≥135/85 mmHg 2

Treatment Decision Algorithm

1. Confirm diagnosis: The ABPM results clearly confirm hypertension with values well above diagnostic thresholds.

2. Assess cardiovascular risk:

   • If 10-year CVD risk ≥10% OR 5-10% with risk modifiers: Initiate pharmacological therapy
   • If lower risk: Consider 3-month trial of lifestyle modifications first 1

3. Treatment approach:

   • The mean awake BP of 148/83 mmHg is significantly above the treatment threshold of 140/90 mmHg
   • This level of BP elevation warrants pharmacological intervention along with lifestyle modifications 1, 2

Recommended Treatment Plan

First-line Pharmacological Options:

• Thiazide or thiazide-like diuretic (e.g., chlorthalidone)
• ACE inhibitor or ARB
• Calcium channel blocker (dihydropyridine type) 2, 3

Target Blood Pressure:

• For most adults: <130/80 mmHg
• For adults ≥65 years: 130-139 mmHg systolic (or <130 mmHg if tolerated) 2

Expected BP Reduction:

• Single agent at standard dose: approximately 9/5 mmHg reduction in office BP
• If BP remains uncontrolled, combination therapy can lower BP by up to 20/11 mmHg 1

Lifestyle Modifications (Concurrent with Medication)

These should be implemented alongside pharmacological therapy:

• Sodium restriction (<2.3 g/day)
• DASH diet (high in fruits, vegetables, low-fat dairy; low in red meat and fats)
• Regular physical activity (minimum 30 minutes, 3 days/week)
• Weight loss if overweight/obese (target BMI 20-25 kg/m²)
• Alcohol moderation (≤2 drinks/day for men, ≤1 drink/day for women) 2, 4

Monitoring and Follow-up

• Recheck BP in 2-4 weeks after initiating therapy
• Monitor for orthostatic hypotension before further medication adjustments
• If using ACE inhibitors/ARBs: Check serum creatinine/eGFR and potassium 1-4 weeks after starting therapy 2
• Consider home BP monitoring to assess treatment efficacy

Important Considerations

• Therapeutic inertia: Avoid delays in treatment intensification if BP remains above target. The 2024 ESC guidelines emphasize prompt addition of pharmacological therapy within 3 months if lifestyle changes are insufficient 1

• Combination therapy: Consider initiating with two agents if BP is >20/10 mmHg above target 1

• Benefit of treatment: A 5 mmHg reduction in systolic BP can decrease mortality from coronary heart disease by 9%, stroke by 14%, and all-cause mortality by 7% 4