How do you treat diastolic hypertension?

Treatment of Diastolic Hypertension

Yes, treat elevated diastolic blood pressure using the same approach as systolic hypertension—lifestyle modifications first for borderline elevations, and prompt pharmacological therapy for confirmed hypertension, targeting blood pressure to 120-129/<80 mmHg in most patients. 1

When to Initiate Treatment

For diastolic BP 90-99 mmHg with systolic 140-159 mmHg:

• Start lifestyle modifications immediately 1
• In patients with diabetes: if targets not achieved after 3 months of lifestyle changes, initiate pharmacological therapy 1
• In patients without diabetes but with target organ damage, established CVD, or 10-year CVD risk ≥15-20%: initiate drug therapy 1

For diastolic BP ≥100 mmHg:

• Initiate pharmacological therapy promptly in addition to lifestyle modifications, regardless of systolic pressure 1
• If diastolic BP ≥100 mmHg with systolic ≥160 mmHg: start with two-drug combination or single-pill combination immediately 1

Lifestyle Modifications (All Patients)

Dietary interventions:

• Adopt DASH diet pattern: 8-10 servings fruits/vegetables daily, low-fat dairy products, reduced saturated fat 1, 2, 3
• Restrict sodium to <2,300 mg/day (ideally <1,500 mg/day for resistant hypertension) 1
• Limit free sugar to maximum 10% of energy intake; eliminate sugar-sweetened beverages 1

Weight and physical activity:

• Achieve BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1, 4
• Exercise minimum 150 minutes moderate-intensity aerobic activity weekly, distributed over ≥3 days 1

Alcohol restriction:

• Men: ≤2 drinks/day (≤14 units/week) 1
• Women: ≤1 drink/day (≤8 units/week) 1

Tobacco cessation:

• Complete cessation with referral to smoking cessation programs 1, 4

Pharmacological Treatment Algorithm

First-line therapy (for confirmed hypertension):

• Preferred initial regimen: Combination of ACE inhibitor or ARB plus either dihydropyridine calcium channel blocker OR thiazide/thiazide-like diuretic, preferably as single-pill combination 1, 4
• For patients with diabetes and hypertension: regimen must include ACE inhibitor or ARB; if one class not tolerated, substitute the other 1
• Monitor renal function and potassium within first 3 months, then every 6 months if stable 1

Treatment escalation if BP not controlled:

• Step 2: Three-drug combination of ACE inhibitor/ARB + dihydropyridine CCB + thiazide/thiazide-like diuretic, preferably as single-pill combination 1, 4
• Step 3: Add spironolactone (or eplerenone if not tolerated), then beta-blocker, then centrally acting agent, alpha-blocker, or hydralazine as needed 1

Important contraindication:

• Never combine two RAS blockers (ACE inhibitor + ARB) due to increased risk of hyperkalemia, syncope, and acute kidney injury without added cardiovascular benefit 1

Blood Pressure Targets

Standard target for most adults:

• Systolic: 120-129 mmHg (if well tolerated) 1, 4
• Diastolic: <80 mmHg 1

Special populations:

• Diabetes: <130/80 mmHg 1, 4
• Age ≥65 years: Systolic 130-139 mmHg 1
• Age ≥85 years or moderate-to-severe frailty: More lenient targets (<140/90 mmHg) may be considered, but continue treatment if well tolerated 1

Critical consideration for isolated diastolic elevation:

• If systolic BP is at target (120-129 mmHg) but diastolic remains ≥80 mmHg, intensifying treatment to achieve diastolic 70-79 mmHg may be considered to reduce CVD risk 1

Timeline and Monitoring

• Achieve target BP within 3 months of initiating therapy 4
• Measure BP at every routine visit 1
• Confirm elevated readings on separate day before diagnosis 1
• Maintain treatment lifelong, even beyond age 85 if well tolerated 1, 4

Common Pitfalls to Avoid

Do not delay treatment in high-risk patients: Those with diastolic BP ≥100 mmHg, diabetes, established CVD, or target organ damage require prompt pharmacological intervention, not prolonged lifestyle-only trials 1

Do not undertitrate therapy: Multiple drugs are typically required to achieve targets; most patients need 2-3 antihypertensive agents 1

Do not ignore orthostatic hypotension: Check standing BP in elderly and diabetic patients before intensifying therapy 1