What are the goals of drug therapy for hypertension?

Goals of Drug Therapy for Hypertension

The primary goal of antihypertensive drug therapy is to reduce blood pressure to target levels that minimize cardiovascular morbidity and mortality, with specific targets of <130/80 mmHg for most patients, <130 mmHg systolic for high-risk patients, and <140/90 mmHg as a minimum for all patients. 1

Primary Treatment Targets by Patient Category

Standard-Risk Patients

• Target BP <140/90 mmHg for all patients with hypertension without comorbidities as the minimum acceptable goal 1
• The ACC/AHA guidelines recommend a more intensive target of <130/80 mmHg for most adults under 65 years 1, 2
• For adults 65 years and older, target systolic BP <130 mmHg (no specific diastolic target recommended) 1, 2

High-Risk Patients Requiring Intensive Targets

High-risk patients should achieve BP <130/80 mmHg or systolic <130 mmHg 1, 2. High-risk status is defined by:

• Known cardiovascular disease (strong recommendation for systolic <130 mmHg) 1
• Diabetes mellitus (target <130/80 mmHg) 1, 2
• Chronic kidney disease (target <130/80 mmHg) 1, 2
• High calculated cardiovascular risk (≥10% 10-year ASCVD risk) 1
• Age 65 years or older 1

Special Consideration: Secondary Stroke Prevention

• For drug-naïve patients requiring secondary stroke prevention, initiate therapy at BP ≥140/90 mmHg (higher threshold than other high-risk conditions) 1

Patients with Proteinuria

• Consider maintaining BP below 125/75 mmHg to reduce progression of renal disease 2

Ultimate Clinical Outcomes

The fundamental goal is cardiovascular risk reduction, not simply blood pressure lowering. 3, 4, 5, 6

Expected Benefits of Achieving Target BP

• 20-30% reduction in cardiovascular events with each 10 mmHg systolic BP reduction 5
• Primary benefit is stroke risk reduction (largest and most consistent outcome) 3, 4, 5
• Reductions in myocardial infarction and cardiovascular mortality 3, 4, 5
• Decreased progression to heart failure 5, 7
• In diabetic nephropathy, reduced rate of doubling serum creatinine and progression to end-stage renal disease 3

Treatment Initiation Thresholds

When to Start Drug Therapy

For high-risk patients: Initiate pharmacological treatment at BP ≥130/80 mmHg 1

For standard-risk patients: Initiate pharmacological treatment at BP ≥140/90 mmHg 1

For Stage 1 hypertension (130-139/80-89 mmHg) without high-risk features: Lifestyle modification first, with drug therapy reserved for those who fail non-pharmacological approaches 1

Treatment Intensity Based on Initial BP

Stage 1 Hypertension (130-139/80-89 mmHg)

• Begin with single antihypertensive agent and titrate before adding additional drugs 2

Stage 2 Hypertension (≥140/90 mmHg)

• Initiate with two-drug combination therapy when BP is >20/10 mmHg above goal 1, 2
• Preferably use single-pill combination to improve adherence 1

Important Caveats and Pitfalls

Diastolic BP Lower Limit

• Avoid lowering diastolic BP below 60 mmHg in high-risk patients with treated systolic BP <130 mmHg, as this may increase cardiovascular events 1
• Optimal diastolic BP appears to be 70-80 mmHg in this population 1

Rate of BP Reduction

• Avoid excessively rapid BP lowering, particularly in older adults, to prevent orthostatic hypotension 2
• Initial BP reduction should be gradual 2

Realistic Expectations

• Most patients require two or more medications to achieve BP goals 2, 5
• Standard first-line antihypertensive doses typically reduce BP by approximately 9/5 mmHg 2

Monitoring to Achieve Goals

• Monthly follow-up after initiating or changing medications until target BP is achieved 1, 2
• Every 3-5 months for patients at goal 1
• Assess both adherence and response at each visit 2
• For patients on ACE inhibitors, ARBs, or diuretics, monitor renal function and potassium within first 3 months 2