Management of Isolated Diastolic Hypertension
When your systolic blood pressure is within guidelines but your diastolic blood pressure is higher than recommended, you should be treated according to the same principles as other forms of hypertension, with the goal of bringing your diastolic blood pressure below 85 mmHg (or below 80 mmHg if you have diabetes, chronic kidney disease, or established cardiovascular disease). 1
Understanding Blood Pressure Components
- Both systolic and diastolic blood pressure are important components of cardiovascular risk, though isolated diastolic hypertension is less common than isolated systolic hypertension, especially in older adults 2
- Diastolic blood pressure ≥ 90 mmHg is classified as hypertension, even when systolic pressure is normal 1
- A widened pulse pressure (the difference between systolic and diastolic readings) is a strong predictor of cardiovascular risk 3, 2
Thresholds for Treatment
When to Initiate Treatment:
- Initiate antihypertensive drug therapy if diastolic blood pressure is sustained at ≥ 100 mmHg, regardless of systolic values 1
- For diastolic blood pressure between 90-99 mmHg with normal systolic pressure, treatment should be initiated if: 1
- Target organ damage is present
- Established cardiovascular disease exists
- Diabetes is present
- 10-year cardiovascular disease risk is ≥ 20%
Treatment Targets:
- For most patients: diastolic blood pressure < 85 mmHg 1
- For patients with diabetes, chronic kidney disease, or established cardiovascular disease: diastolic blood pressure < 80 mmHg 1, 4
Treatment Approach
First-Line Interventions:
- Lifestyle modifications should be recommended for all patients with elevated diastolic blood pressure 4, 5:
- Weight reduction to achieve ideal body weight
- Regular physical exercise (predominantly dynamic exercise like brisk walking)
- Limited alcohol consumption (< 21 units/week for men, < 14 units/week for women)
- Reduced salt intake
- Increased consumption of fruits and vegetables
Pharmacological Management:
- If lifestyle modifications alone are insufficient after 4-6 weeks, or if initial diastolic BP is ≥ 100 mmHg, drug therapy should be initiated 1
- First-line medications include: 6, 7, 8
- Thiazide or thiazide-like diuretics
- ACE inhibitors (e.g., lisinopril)
- Angiotensin receptor blockers (ARBs)
- Calcium channel blockers (e.g., amlodipine)
Special Considerations
- Be cautious about excessively lowering diastolic pressure in patients with coronary heart disease, as very low diastolic pressure may compromise coronary perfusion 3
- Most patients will require at least two blood pressure-lowering drugs to achieve recommended goals 1, 8
- Regular monitoring of blood pressure (both office and home readings when possible) is essential 4
Common Pitfalls to Avoid
- Not confirming elevated diastolic readings with multiple measurements before diagnosis 4
- Focusing exclusively on systolic blood pressure while ignoring elevated diastolic values 2
- Inadequate dosing or inappropriate combinations of antihypertensive medications 4
- Not addressing lifestyle modifications alongside pharmacological treatment 5
Remember that controlling your diastolic blood pressure is important for reducing cardiovascular risk, even when your systolic pressure is within normal limits 1, 2.