What is the treatment for anxiety-related hypertension?

Treatment for Anxiety-Related Hypertension

Treat anxiety-related hypertension with standard antihypertensive medications (RAS inhibitors and diuretics as first-line) while addressing the underlying anxiety disorder, as blood pressure control—not anxiolytic therapy—is what reduces cardiovascular morbidity and mortality. 1

Step 1: Confirm True Hypertension and Exclude White Coat Effect

• Verify blood pressure readings using a validated automated upper arm cuff device with appropriate cuff size 2
• Confirm hypertension with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) to exclude white coat hypertension, which is common in anxious patients 2
• Measure BP in both arms at first visit and use the arm with higher readings for subsequent measurements 2

Step 2: Initiate Standard Antihypertensive Therapy Based on BP Level

For Grade 1 Hypertension (140-159/90-99 mmHg):

• Start drug treatment immediately if the patient has high cardiovascular risk (CVD, CKD, diabetes, organ damage, or age 50-80 years) 2
• Combine with lifestyle modifications 1, 2

For Grade 2 Hypertension (≥160/100 mmHg):

• Start drug treatment immediately in all patients regardless of anxiety status 2, 3
• For severely elevated BP (≥160/100 mmHg), initiate two drugs or a single-pill combination 3

Step 3: Select First-Line Antihypertensive Medications

The 2020 International Society of Hypertension guidelines specifically recommend for patients with psychiatric diseases (including anxiety):

• Preferentially use RAS inhibitors (ACE inhibitors or ARBs) plus diuretics as first-line therapy 1
• These agents have a lower rate of pharmacological interactions with antidepressants and anxiolytics 1
• Use calcium channel blockers (CCBs) and alpha-1 blockers with caution in anxious patients due to risk of orthostatic hypotension, especially if taking SSRIs 1

Specific medication selection:

• For non-Black patients: Start with low-dose ACE inhibitor or ARB, then add dihydropyridine CCB if needed 2
• For Black patients: Start with ARB plus dihydropyridine CCB or CCB plus thiazide/thiazide-like diuretic 2

Step 4: Consider Beta-Blockers Only in Specific Circumstances

• Use beta-blockers (except metoprolol) only if drug-induced tachycardia is present from antidepressant or antipsychotic medications 1
• Beta-blockers are not first-line for anxiety-related hypertension despite their anti-anxiety effects, as they do not reduce cardiovascular events as effectively as RAS inhibitors in this population 1

Step 5: Address Anxiety Disorder Concurrently

Pharmacological considerations:

• Monitor for drug-drug interactions between antihypertensives and psychiatric medications 1
• Check for ECG abnormalities and postural BP changes when combining medications 1
• One small study (n=36) showed oral diazepam 5 mg reduced BP from 213/105 to 170/88 mmHg in patients with excessive hypertension, similar to sublingual captopril 4
• However, anxiolytic therapy alone is not recommended as primary treatment since BP reduction through standard antihypertensives—not anxiolysis—drives cardiovascular risk reduction 1

Non-pharmacological interventions:

• Implement lifestyle modifications including sodium restriction (<2,300 mg/day), increased physical activity, weight loss, and moderation of alcohol intake 1
• Consider relaxation techniques (autogenic training, progressive muscle relaxation, biofeedback) which can lower BP by approximately 10/5 mmHg 5, 6
• These stress management techniques should complement—not replace—standard antihypertensive therapy 5, 6

Step 6: Titrate to Target Blood Pressure

• Target BP <130/80 mmHg for most patients 2
• Aim to achieve target within 3 months of treatment initiation 2, 3
• If BP remains above target on initial therapy, increase RAS inhibitor to full dose, then add dihydropyridine CCB, then add thiazide/thiazide-like diuretic 2

Step 7: Manage Resistant Hypertension if Present

• If BP remains ≥140/90 mmHg despite three medications (including a diuretic), add spironolactone as fourth-line agent 1, 2
• Alternative options include amiloride, doxazosin, eplerenone, or beta-blocker 2
• First exclude pseudoresistance (poor measurement technique, white coat effect, medication nonadherence) 1

Critical Pitfalls to Avoid

• Do not rely on anxiolytic medications alone to control BP—while anxiety may contribute to hypertension, standard antihypertensive therapy is required to reduce cardiovascular morbidity and mortality 1
• Do not use short-acting nifedipine for acute BP management due to risk of precipitous drops 3
• Avoid excessive BP reduction (>25% in first hour) in severely elevated BP, as this may precipitate organ ischemia 3
• Do not combine ACE inhibitors with ARBs or use direct renin inhibitors with RAS blockers 1
• Monitor for orthostatic hypotension when using CCBs or alpha-1 blockers in patients on SSRIs 1

Cardiovascular Risk Management

• Manage additional cardiovascular risk factors according to SCORE/ASCVD calculator 1
• Psychosocial stress and psychiatric disorders increase cardiovascular risk beyond BP elevation alone 1
• Depression has been associated with cardiovascular morbidity and mortality, emphasizing the importance of BP control in this population 1