How is elevated diastolic pressure managed?

Management of Elevated Diastolic Blood Pressure

For patients with elevated diastolic blood pressure, treatment should include a combination of lifestyle modifications and pharmacological therapy targeting a diastolic BP <80 mmHg, with initial therapy consisting of a RAS blocker (ACE inhibitor or ARB) combined with either a calcium channel blocker or thiazide-like diuretic. 1, 2

Initial Assessment and Classification

• Elevated diastolic blood pressure is defined as diastolic BP ≥80 mmHg, with hypertension diagnosed when BP ≥140/90 mmHg 1, 2
• Confirm elevated readings through multiple measurements, preferably using home or ambulatory BP monitoring 1
• For BP 160-179/100-109 mmHg, confirm as soon as possible (within 1 month) 1
• For BP ≥180/110 mmHg, evaluate for hypertensive emergency 1

Treatment Goals

• Target diastolic BP <80 mmHg for all hypertensive patients, regardless of comorbidities 1
• Target systolic BP to 120-129 mmHg for most adults if well tolerated 1, 2
• For patients with diabetes or chronic kidney disease, maintain BP <130/80 mmHg 1
• When systolic BP is at target (120-129 mmHg) but diastolic BP remains elevated, consider intensifying treatment to achieve diastolic BP of 70-79 mmHg 1

Lifestyle Modifications (First-Line for All Patients)

• Weight management: Aim for healthy BMI (20-25 kg/m²) and waist circumference (<94 cm in men, <80 cm in women) 1, 2
• Dietary approaches: Adopt Mediterranean or DASH diet patterns with increased consumption of vegetables, fruits, fish, nuts, and unsaturated fatty acids 1, 3
• Sodium restriction: Limit to approximately 2g per day (equivalent to about 5g of salt) 1, 2
• Physical activity: Engage in ≥150 minutes of moderate-intensity aerobic exercise weekly, complemented with resistance training 2-3 times weekly 1, 4
• Alcohol moderation: Limit consumption to <14 units/week for men and <8 units/week for women, preferably avoid completely 1, 2
• Smoking cessation: Stop tobacco use and refer to smoking cessation programs 1, 2

Pharmacological Therapy

First-Line Treatment

• For confirmed hypertension (≥140/90 mmHg), initiate combination therapy with two drugs 2:
  • Preferred combination: RAS blocker (ACE inhibitor like lisinopril or ARB) + either a dihydropyridine CCB (like amlodipine) or thiazide/thiazide-like diuretic 1, 2, 5, 6
  • Single-pill combinations improve adherence and should be used when possible 2

Treatment Escalation

• If BP not controlled with two-drug combination, escalate to three drugs 2:
  • Recommended three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1, 2
• If BP remains uncontrolled on a three-drug regimen, add spironolactone or, if not tolerated, eplerenone 1
• Further options include beta-blockers, alpha-blockers, or centrally acting agents 1, 7

Special Considerations

• Beta-blockers are recommended when there are specific indications such as angina, post-myocardial infarction, heart failure, or for heart rate control 1, 2
• For patients with diabetes, ACE inhibitors or ARBs are preferred first-line agents 1
• For patients with chronic kidney disease, RAS blockers are more effective at reducing albuminuria 2

Monitoring and Adherence

• Schedule regular follow-up visits to assess BP control and medication adherence 2
• Consider home BP monitoring to improve control and patient engagement 2
• Take medications at the most convenient time of day to establish a habitual pattern 1
• Monitor for adverse effects, particularly orthostatic hypotension in older adults 2
• For patients on ACE inhibitors, ARBs, or diuretics, monitor serum creatinine/eGFR and potassium levels 1

Common Pitfalls to Avoid

• Delaying combination therapy in patients with confirmed hypertension ≥140/90 mmHg 2
• Using monotherapy when combination therapy would be more effective 2, 8
• Combining two RAS blockers (ACE inhibitor and ARB), which increases adverse effects without additional benefit 2
• Discontinuing treatment prematurely - BP-lowering treatment should be maintained lifelong if tolerated 2
• Failing to address lifestyle modifications alongside pharmacological treatment 4, 3