Should a patient with elevated blood pressure (hypertension) readings be started on antihypertensive medication?

Should This Patient Be Started on Antihypertensive Medication?

Yes, this patient should be started on antihypertensive medication. Both blood pressure readings (139/85 and 138/90 mmHg) meet the threshold for pharmacological treatment according to the most authoritative current guidelines.

Treatment Threshold Analysis

The WHO 2022 guidelines provide the clearest directive: initiation of pharmacological antihypertensive treatment is strongly recommended for individuals with confirmed hypertension and systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg 1. Your patient's readings of 139/85 and 138/90 mmHg place them at or very near this threshold, and the diastolic reading of 90 mmHg definitively meets treatment criteria 1.

The 2024 ESC guidelines reinforce this approach: in hypertensive patients with confirmed BP ≥140/90 mmHg, irrespective of cardiovascular disease (CVD) risk, lifestyle measures and pharmacological BP-lowering treatment should be initiated promptly to reduce CVD risk 1. While your patient's systolic readings are just below 140 mmHg, the diastolic component at 90 mmHg triggers the treatment threshold 1.

Risk-Based Considerations

If this patient has additional cardiovascular risk factors, the case for treatment becomes even stronger:

• The WHO conditionally recommends pharmacological treatment for individuals without existing CVD but with high cardiovascular risk, diabetes mellitus, or chronic kidney disease when systolic BP is 130-139 mmHg 1
• The 2017 ACC/AHA guidelines define high-risk stage 1 hypertension (BP 130-139/80-89 mmHg) requiring treatment when any of the following are present: 10-year ASCVD risk ≥10%, diabetes mellitus, estimated glomerular filtration rate <60 mL/min per 1.73 m², or age ≥65 years 1
• Most patients with average SBP ≥140 or DBP ≥90 mmHg are at high risk for CVD, and initiation of antihypertensive drug therapy is indicated 1

Recommended First-Line Medications

Start with combination therapy using a single-pill combination for most patients:

• The WHO strongly recommends using drugs from any of these three classes as initial treatment: thiazide and thiazide-like agents, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or long-acting dihydropyridine calcium channel blockers 1
• The 2024 ESC guidelines recommend combination BP-lowering treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg) as initial therapy, with preferred combinations being a RAS blocker (ACE inhibitor or ARB) with a dihydropyridine calcium channel blocker or diuretic 1
• Fixed-dose single-pill combinations are recommended to improve adherence and persistence 1

If initiating monotherapy is more appropriate (such as in frail elderly patients or those with symptomatic orthostatic hypotension), first-line agents include thiazide diuretics, calcium channel blockers, and ACE inhibitors or ARBs 1, 2.

Treatment Target

Aim for a systolic BP of 120-129 mmHg in most adults:

• The 2024 ESC guidelines recommend that treated systolic BP values in most adults be targeted to 120-129 mmHg, provided the treatment is well tolerated 1
• The WHO recommends a treatment goal of <140/90 mmHg in all patients with hypertension without comorbidities, and SBP <130 mmHg in high-risk patients with hypertension 1
• The 2017 ACC/AHA guidelines recommend an SBP/DBP target of <130/80 mmHg for adults <65 years 1

Important Caveats

Confirm the diagnosis before initiating treatment:

• Blood pressure should be confirmed by repeated measurements on separate occasions 1
• Consider 24-hour ambulatory blood pressure monitoring or home blood pressure measurements to confirm the diagnosis 3

CVD risk assessment is helpful but should not delay treatment:

• While cardiovascular risk assessment can guide decisions about initiating pharmacological treatment for those with lower average SBP (130-139 mmHg), it is not mandatory before initiating antihypertensive drug treatment 1
• Whenever CVD risk assessment may impede the timely initiation of hypertension treatment, it should be postponed and included as a follow-up strategy 1

Lifestyle modifications should be implemented concurrently:

• Weight reduction to achieve BMI 20-25 kg/m² and waist circumference <94 cm in men or <80 cm in women 1
• Dietary sodium restriction to 5 g/day and adoption of a Mediterranean or DASH diet 1
• Regular physical activity and alcohol restriction to <100 g/week of pure alcohol 1
• Smoking cessation 1