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 <130/80 mmHg in most adults under 65 years and to systolic <130 mmHg in adults 65 years and older, which reduces cardiovascular morbidity and mortality including stroke, myocardial infarction, heart failure, and death. 1

Blood Pressure Targets by Patient Category

Standard-Risk Adults Under 65 Years

• Target blood pressure: <130/80 mmHg 1
• Initiate pharmacologic treatment when BP ≥140/90 mmHg 1
• This target applies to adults without high cardiovascular risk, diabetes, or chronic kidney disease 2

Adults 65 Years and Older

• Target systolic blood pressure: <130 mmHg (no specific diastolic target) 1
• For some older adults at high cardiovascular risk, consider individualized targets with systolic <140 mmHg as an alternative based on patient discussion 2
• Avoid excessive rapid lowering to prevent orthostatic hypotension 3

High-Risk Patients

• Target blood pressure: <130/80 mmHg 2, 1
• High-risk status includes: known cardiovascular disease, diabetes mellitus, chronic kidney disease, or ≥10% 10-year ASCVD risk 2, 1
• Initiate pharmacologic treatment at BP ≥130/80 mmHg 2, 1

Patients with Diabetes

• Target blood pressure: <130/80 mmHg 2
• Most adults with diabetes and hypertension automatically qualify as high-risk 2
• Initiate treatment at BP ≥130/80 mmHg 2

Patients with Chronic Kidney Disease

• Target blood pressure: <130/80 mmHg 2
• Patients with CKD are automatically assigned to high-risk category 2
• For patients with proteinuria (urinary albumin to creatinine ratio ≥300 mg/g), maintaining BP even below 125/75 mmHg may reduce progression of renal disease 3

Treatment Intensity Based on Initial Blood Pressure

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

• Begin with single antihypertensive agent and titrate before adding additional agents 3
• Expected BP reduction with standard first-line medication doses: approximately 9/5 mmHg 3

Stage 2 Hypertension (≥140/90 mmHg)

• Initiate treatment with two-drug combination therapy when BP is >20/10 mmHg above goal 2, 1
• Preferably use single-pill combination to improve adherence 1
• Patients with BP ≥160/100 mmHg should be treated promptly with careful monitoring and prompt regimen adjustment 2

Critical Diastolic Blood Pressure Caveat

Avoid lowering diastolic blood pressure below 60 mmHg in high-risk patients with treated systolic BP <130 mmHg, as this may paradoxically increase cardiovascular events. 1

• Optimal diastolic BP appears to be 70-80 mmHg in this population 1
• This is a common pitfall when aggressively treating systolic hypertension 1

Monitoring Strategy to Achieve Goals

Initial Treatment Phase

• Monthly follow-up after initiating or changing medications until target BP is achieved 2, 1, 3
• Assess both medication adherence and therapeutic response at each visit 2, 1
• Interventions such as home blood pressure monitoring, team-based care, and telehealth improve BP control 2

Maintenance Phase

• Follow-up every 3-5 months for patients at goal 1
• For patients on ACE inhibitors, ARBs, or diuretics, monitor renal function and potassium within first 3 months 1, 3

Underlying Rationale for These Goals

The fundamental principle is that blood pressure reduction itself, rather than specific drug properties, is largely responsible for cardiovascular benefits. 4, 5, 6

• A 10 mmHg systolic BP reduction decreases cardiovascular events by approximately 20-30% 6
• The largest and most consistent benefit is stroke reduction, with additional reductions in myocardial infarction and cardiovascular mortality 2, 4, 5
• Progressive reduction in cardiovascular risk occurs at lower achieved systolic BP levels 2
• Meta-analysis of major trials (including SPRINT and ACCORD) supports intensive BP lowering to <130 mmHg systolic 2

First-Line Drug Selection to Achieve Goals

• Thiazide diuretics (especially chlorthalidone), calcium-channel blockers, ACE inhibitors, or angiotensin-receptor blockers 2
• Thiazide diuretics and calcium-channel blockers are preferred for most U.S. adults due to efficacy 2
• In Black patients, thiazide diuretics and calcium-channel blockers are recommended as first-line agents 2
• Most patients require two or more medications to achieve BP goals 3, 6