What is the recommended treatment for a blood pressure of 130 mmHg, indicating stage 1 Hypertension?

Management of Blood Pressure at 130 mmHg (Stage 1 Hypertension)

For a blood pressure of 130 mmHg, indicating stage 1 hypertension, lifestyle modifications should be initiated for all patients, with pharmacological therapy added for those with high cardiovascular risk, established cardiovascular disease, diabetes, or chronic kidney disease. 1

Classification and Risk Assessment

• A systolic blood pressure of 130 mmHg is classified as stage 1 hypertension according to the ACC/AHA guidelines 1
• This blood pressure level was previously classified as "prehypertension" in older guidelines but is now recognized as a level requiring intervention 1
• Risk assessment is essential for determining the need for pharmacological therapy in addition to lifestyle modifications 1

Initial Management Approach

For All Patients with BP of 130 mmHg:

• Implement comprehensive lifestyle modifications as first-line therapy 1:
  • Sodium restriction to <1500 mg/day or reduction by at least 1000 mg/day 1
  • Increased potassium intake (3500-5000 mg/day) 1
  • Weight loss if overweight/obese (target ideal body weight) 1, 2
  • Physical activity: 150 minutes of moderate-intensity aerobic exercise weekly 1
  • Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women) 1
  • DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy products 1, 2

For High-Risk Patients with BP of 130 mmHg:

• Initiate pharmacological therapy in addition to lifestyle modifications if any of the following are present 1:
  • Established cardiovascular disease 1
  • 10-year ASCVD risk ≥10% 1
  • Diabetes mellitus 1
  • Chronic kidney disease 1
  • Risk modifiers or abnormal risk tool tests with 5-10% ASCVD risk 1

Pharmacological Therapy When Indicated

• First-line antihypertensive medications include 1, 3:

  • Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide)
  • ACE inhibitors or ARBs
  • Calcium channel blockers (dihydropyridine type)

• For specific comorbidities, preferred initial agents include 1:

  • Diabetes with albuminuria: ACE inhibitor or ARB
  • Heart failure with reduced ejection fraction: GDMT beta-blockers
  • Coronary artery disease: GDMT beta-blockers, ACE inhibitor, or ARB
  • Chronic kidney disease: ACE inhibitor or ARB

Blood Pressure Targets

• For most adults <65 years: Target BP <130/80 mmHg 1, 3
• For adults ≥65 years: Target systolic BP 130-139 mmHg 1
• For patients with diabetes or CKD: Target BP <130/80 mmHg 1

Follow-up and Monitoring

• For patients managed with lifestyle modifications alone: Follow-up every 3-6 months 1
• For patients started on pharmacological therapy: Monthly follow-up until BP control is achieved, then every 3-6 months 1
• Home BP monitoring is recommended to assess treatment effectiveness 1

Special Considerations and Caveats

• Avoid aggressive BP lowering in patients with orthostatic hypotension, age ≥85 years, or moderate-to-severe frailty 1
• Single-pill combinations may improve adherence when multiple medications are needed 1
• The magnitude of BP reduction with standard doses of first-line medications is approximately 9/5 mmHg with office BP 1
• White coat hypertension should be ruled out with home or ambulatory BP monitoring before initiating therapy 1

Common Pitfalls to Avoid

• Therapeutic inertia: Failure to intensify therapy when BP targets are not met 1
• Inadequate lifestyle counseling: Lifestyle modifications can reduce BP by 5-10 mmHg and enhance drug efficacy 2, 4
• Overlooking secondary causes of hypertension, especially in younger patients or those with resistant hypertension 1
• Starting with multiple medications in low-risk patients, which may lead to adverse effects and reduced adherence 1