When should I start antihypertensive (blood pressure lowering) medication in a patient with hypertension?

When to Start Antihypertensive Medication in Patients with Hypertension

Antihypertensive medication should be started immediately in patients with blood pressure ≥160/100 mmHg (Grade 2 or 3 hypertension), as well as in patients with blood pressure 140-159/90-99 mmHg (Grade 1 hypertension) who have high cardiovascular risk, target organ damage, established cardiovascular disease, or diabetes. 1

Blood Pressure Thresholds for Starting Medication

Immediate Treatment (Start Drug Therapy Now):

• Blood pressure ≥160/100 mmHg (Grade 2-3 hypertension) 1
• Blood pressure 140-159/90-99 mmHg (Grade 1 hypertension) WITH any of the following:
  • Established cardiovascular disease 1
  • Target organ damage (e.g., left ventricular hypertrophy, retinopathy) 1
  • Chronic kidney disease 1
  • Diabetes 1
  • 10-year cardiovascular risk ≥20% (or high/very high total cardiovascular risk) 1

Delayed Treatment (Try Lifestyle Modifications First):

• Blood pressure 140-159/90-99 mmHg (Grade 1 hypertension) WITHOUT high-risk factors:
  • Try lifestyle modifications for 3-6 months 1
  • Start medication if blood pressure remains elevated after this period 1
• High-normal blood pressure (130-139/85-89 mmHg) WITHOUT diabetes or previous cardiovascular events:
  • Focus on lifestyle modifications and close monitoring 1
  • No clear evidence of benefit for drug treatment in this group 1

Lifestyle Modifications

Before and alongside medication, recommend these evidence-based lifestyle changes:

• 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
• Regular physical activity (aerobic or dynamic resistance 90-150 min/week) 1, 3
• Moderation of alcohol intake (≤2 drinks/day for men, ≤1 drink/day for women) 1, 4
• DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy products 1, 2

Drug Selection for Initial Therapy

For Non-Black Patients:

• Start with low-dose ACE inhibitor or ARB (e.g., lisinopril 10 mg daily) 1, 5
• Can increase to full dose as needed 1
• Add thiazide/thiazide-like diuretic if BP control not achieved 1

For Black Patients:

• Start with low-dose ARB plus calcium channel blocker or calcium channel blocker plus thiazide-like diuretic 1
• ACE inhibitors are less effective as monotherapy in black patients 1

Treatment Targets

• Reduce BP by at least 20/10 mmHg initially 1, 6
• Target BP <140/90 mmHg for most patients 1
• Lower target (<130/80 mmHg) for patients with diabetes, chronic kidney disease, or established cardiovascular disease 1, 6

Monitoring and Follow-up

• For patients starting medication, follow up approximately monthly until BP is controlled 1
• For those with elevated BP (130-139/85-89 mmHg), recheck every 3-6 months 1
• For those with normal BP, recheck annually 1

Common Pitfalls to Avoid

• Delaying treatment in high-risk patients can lead to worse outcomes 1
• Inadequate dosing or not adding a second agent when needed 3
• Not accounting for white coat hypertension (consider home or ambulatory BP monitoring to confirm diagnosis) 1
• Neglecting to assess for secondary causes in resistant hypertension 1, 6
• Underestimating the impact of lifestyle modifications (can reduce or eliminate need for medications in some patients) 4

Remember that early BP-lowering treatment before organ damage develops is prudent, especially in high-risk patients 1. The decision to start medication should balance the benefits of BP reduction against potential side effects, with the primary goal of reducing morbidity and mortality from cardiovascular disease 3.