What is the recommended treatment for prehypertension?

Prehypertension Management

For patients with prehypertension (BP 120-139/80-89 mmHg), lifestyle modifications are the primary treatment, and drug therapy should NOT be initiated based on blood pressure level alone unless the patient has diabetes or chronic kidney disease. 1

Definition and Risk Stratification

Prehypertension is defined as systolic BP 120-139 mmHg or diastolic BP 80-89 mmHg. 1 This is not a disease category but rather a designation to identify individuals at high risk of developing hypertension and cardiovascular disease. 1

• Stage 1 prehypertension: 120-129/80-84 mmHg 2
• Stage 2 prehypertension: 130-139/85-89 mmHg 2, 3
• Stage 2 prehypertension carries approximately 3-fold greater risk of developing hypertension and 2-fold higher risk of cardiovascular events compared to normal BP. 4, 5, 3

Primary Treatment Approach: Lifestyle Modifications

All patients with prehypertension should be firmly and unambiguously advised to practice lifestyle modifications. 1 These interventions can reduce BP, decrease progression to hypertension, or prevent hypertension entirely. 1

Specific Lifestyle Interventions

• Weight reduction to ideal body weight through caloric restriction 6
• Sodium restriction to <2,300 mg/day 6
• DASH diet pattern: 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products 6
• Alcohol limitation: ≤2 drinks/day for men, ≤1 drink/day for women 6
• Elimination of sugar-sweetened beverages and restriction of free sugar to maximum 10% of energy intake 6
• Complete tobacco cessation with referral to smoking cessation programs 6
• Regular physical activity 1

Evidence for Lifestyle Modifications

Even brief physician counseling (3 minutes or less) can be effective, as demonstrated in the PREMIER study where the "Advice Only" group showed nearly as much BP reduction as the intensive counseling group. 1 Intensive lifestyle intervention reduces the relative risk of incident hypertension by approximately 20%. 2

When to Consider Pharmacological Therapy

Absolute Indications for Drug Therapy in Prehypertension

Drug therapy is indicated for prehypertensive patients with specific comorbidities: 1

1. Diabetes mellitus: If lifestyle modification fails to reduce BP to 130/80 mmHg or less after a maximum of 3 months 1, 4, 5
2. Chronic kidney disease: If lifestyle modification fails to reduce BP to 130/80 mmHg or less after a maximum of 3 months 1, 4, 5
3. Coronary artery disease: Consider pharmacotherapy in this high-risk population 4, 5, 7

Drug Therapy NOT Recommended for Uncomplicated Prehypertension

Individuals who are prehypertensive are NOT candidates for drug therapy on the basis of their BP level alone. 1 The benefits of drug treatment in uncomplicated prehypertension are unproven, despite the high (90%) risk of eventually developing hypertension. 1

The 2017 ACC/AHA guidelines use different terminology but align with this approach: they recommend nonpharmacological therapy for "elevated BP" (120-129/<80 mmHg) and for "stage 1 hypertension" (130-139/80-89 mmHg) when 10-year ASCVD risk is <10%. 1

Follow-Up Strategy

• Repeat BP evaluation within 3-6 months for patients with prehypertension managed with lifestyle modifications alone 1
• Annual BP screening is reasonable for those with normal BP, given the >80% lifetime risk of developing hypertension 1
• Consider home BP monitoring to exclude white coat hypertension before any treatment decisions 1

Treatment Goals

The goal for individuals with prehypertension and no compelling indications is to lower BP to normal (<120/80 mmHg) with lifestyle changes and prevent progressive rise in BP. 1

Common Pitfalls to Avoid

• Do not initiate drug therapy based solely on prehypertensive BP readings without diabetes or kidney disease 1
• Do not adopt a nihilistic attitude toward lifestyle counseling; even brief advice can be effective 1
• Do not ignore cardiovascular risk stratification: Prehypertensive patients often have multiple cardiovascular risk factors (59% have ≥3 features of metabolic syndrome, 84% are overweight) that require comprehensive management 1
• Prevention of weight gain has better prospects than actual weight loss for preventing hypertension 1

Special Considerations

For stage 2 prehypertension (130-139/85-89 mmHg) with high absolute cardiovascular risk, some experts suggest it may be reasonable to consider pharmacotherapy when lifestyle changes are ineffective, though this remains controversial and is not supported by guideline recommendations. 3 The number needed to treat to prevent one cardiovascular event is similar for stage 2 prehypertension and stage 1 hypertension when matched for concomitant risk factors. 3