How to manage a patient with high systolic blood pressure (SBP) and low diastolic blood pressure (DBP)?

Management of High Systolic Blood Pressure with Low Diastolic Blood Pressure

For patients with high systolic blood pressure (SBP) and low diastolic blood pressure (DBP), treatment should focus on gradually lowering SBP to 120-129 mmHg while carefully monitoring for symptoms of hypoperfusion, as this approach reduces cardiovascular disease outcomes while minimizing risks. 1, 2

Initial Assessment

• Confirm blood pressure measurements on separate occasions before initiating treatment 1
• Assess for orthostatic hypotension before starting or intensifying treatment, especially important in patients with wide pulse pressure 2
• Evaluate cardiovascular disease risk to guide treatment decisions 2
• Consider age, frailty status, and comorbidities when determining treatment targets 1

Treatment Targets

• Target SBP to 120-129 mmHg for most adults to reduce cardiovascular disease risk, if well tolerated 1, 2
• Consider more lenient SBP targets (<140 mmHg) for patients with:
  • Pre-treatment symptomatic orthostatic hypotension 1
  • Age ≥85 years 1
  • Moderate to severe frailty 1
  • Limited life expectancy (<3 years) 1
• For DBP, target <80 mmHg for all hypertensive patients 1
• When SBP is at target (120-129 mmHg) but DBP remains ≥80 mmHg, consider further lowering DBP to 70-79 mmHg if tolerated 1

Lifestyle Modifications

• Implement lifestyle changes for all patients with elevated BP (>120/80 mmHg) 1, 2
• Recommend weight loss if overweight/obese, aiming for BMI 20-25 kg/m² 1, 3
• Adopt DASH or Mediterranean dietary pattern with reduced sodium and increased potassium intake 1, 2, 4
• Encourage regular physical activity: 150 min/week moderate-intensity or 75 min/week vigorous aerobic exercise plus resistance training 2-3 times/week 1, 5
• Limit alcohol consumption (preferably avoid completely) 1, 5
• Smoking cessation for those who use tobacco 2, 5

Pharmacological Approach

First-line Treatment

• For confirmed hypertension (≥140/90 mmHg), initiate combination therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine CCB or thiazide/thiazide-like diuretic 2
• Use single-pill combinations when possible to improve adherence 2
• For patients with high SBP but low DBP (wide pulse pressure):
  • Consider starting with lower doses to avoid excessive DBP reduction 1
  • Long-acting dihydropyridine CCBs (like amlodipine) may be preferred as they primarily reduce SBP with less effect on DBP 6

Treatment Escalation

• If BP not controlled with a two-drug combination, escalate to a three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 1, 2
• For resistant hypertension, add spironolactone as fourth-line agent 1
• If spironolactone is not tolerated, consider eplerenone, beta-blocker, or alpha-blocker 1

Special Considerations for Wide Pulse Pressure

• Monitor for symptoms of hypoperfusion (dizziness, falls, confusion) when DBP is already low 1
• Consider administering one or more antihypertensive medications at bedtime to reduce nocturnal BP and cardiovascular events 1
• Titrate medications more gradually than usual, with more frequent follow-up 2
• Home BP monitoring is particularly valuable to detect excessive BP lowering 2

Implementation and Adherence

• Schedule more frequent follow-up visits during treatment initiation and titration 1
• Use appointment reminders and follow up with patients who miss appointments 1
• Simplify medication regimens to once-daily dosing when possible 1
• Collaborate with other healthcare professionals (nurses, pharmacists, dietitians) 1, 2
• Address potential barriers to medication adherence, including cost concerns 1

Common Pitfalls to Avoid

• Aggressive BP lowering in patients with already low DBP (<60 mmHg), which may compromise coronary perfusion 1
• Delaying combination therapy in patients with confirmed hypertension ≥140/90 mmHg 2
• Using monotherapy when combination therapy would be more effective 2
• Combining two RAS blockers (ACE inhibitor and ARB), which is not recommended 2
• Discontinuing treatment prematurely - BP-lowering treatment should be maintained lifelong if tolerated 2