How to normalize elevated systolic blood pressure?

How to Normalize Elevated Systolic Blood Pressure

For most adults with elevated systolic blood pressure, target a treated systolic BP of 120-129 mmHg using combination pharmacological therapy (RAS blocker + CCB or diuretic) alongside comprehensive lifestyle modifications to reduce cardiovascular morbidity and mortality. 1

Blood Pressure Targets

The 2024 ESC Guidelines establish clear, evidence-based targets that prioritize cardiovascular outcomes:

• Primary target: Systolic BP 120-129 mmHg in most adults, provided treatment is well tolerated 1
• Initial goal: First lower BP to <140/90 mmHg in all patients, then titrate to 120-129 mmHg 1
• Older adults (≥65 years): Target systolic BP 130-139 mmHg 1
• Very elderly (≥85 years) or symptomatic orthostatic hypotension: Consider more lenient targets (<140 mmHg) 1
• Moderate-to-severe frailty or limited lifespan (<3 years): May consider <140/90 mmHg 1

Special Population Targets

• Diabetes: Target 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg; older diabetics (≥65 years) target 130-139 mmHg 1
• Chronic kidney disease (eGFR >30): Target 120-129 mmHg if tolerated; otherwise 130-139 mmHg 1
• History of stroke/TIA: Target 120-129 mmHg if BP ≥130/80 mmHg confirmed 1
• Pregnancy: Lower BP below 140/90 mmHg but not below 80 mmHg diastolic 1

Pharmacological Treatment Strategy

Initial Therapy

Combination therapy is recommended as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg) rather than monotherapy, as it achieves better BP control 1

Preferred initial combinations 1:

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB
• RAS blocker + thiazide/thiazide-like diuretic

Use fixed-dose single-pill combinations to improve adherence 1

Exceptions to combination therapy (consider monotherapy) 1:

• Age ≥85 years
• Symptomatic orthostatic hypotension
• Moderate-to-severe frailty
• Elevated BP (120-139/70-89 mmHg) with specific indication for treatment

Evidence-Based Drug Classes

Five major drug classes have demonstrated effective BP reduction and cardiovascular event reduction in RCTs 1:

• ACE inhibitors 1, 2
• ARBs 1
• Beta-blockers 1
• Calcium channel blockers (CCBs) 1, 3
• Thiazide and thiazide-like diuretics (chlorthalidone, indapamide) 1

Treatment Escalation Algorithm

If BP not controlled on 2-drug combination 1:

• Escalate to 3-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic
• Preferably use single-pill combination

If BP not controlled on 3-drug combination (resistant hypertension) 1:

1. Reinforce lifestyle measures, especially sodium restriction
2. Add low-dose spironolactone
3. If spironolactone not tolerated: eplerenone, amiloride, higher-dose thiazide/thiazide-like, or loop diuretic
4. If still uncontrolled: add beta-blocker (if not already prescribed), then centrally acting agent, alpha-blocker, or hydralazine

Never combine two RAS blockers (ACE inhibitor + ARB) 1

Special Considerations for Black Patients

Initial therapy should include diuretic or CCB, either in combination or with a RAS blocker 1

Lifestyle Modifications

Lifestyle interventions are recommended for all patients and can reduce BP independent of medication 1, 4

Dietary Interventions

Sodium restriction 1:

• Limit sodium chloride to 5 g/day (approximately 2000 mg sodium)
• Particularly important in resistant hypertension 1
• Reduces systolic BP by up to 7 mmHg when combined with exercise 5

DASH diet pattern 1, 4:

• Increased vegetables, fresh fruits, fish, nuts, unsaturated fatty acids (olive oil)
• Low consumption of red meat
• Low-fat dairy products
• Reduced dietary cholesterol and saturated fat

Alcohol restriction 1:

• Men: <14 units/week (approximately 100 g pure alcohol/week)
• Women: <8 units/week
• Preferably avoid alcohol entirely for best health outcomes

Weight Management

Target healthy BMI and waist circumference 1:

• Avoid obesity: BMI >30 kg/m² or waist >102 cm (men), >88 cm (women)
• Aim for BMI 20-25 kg/m²
• Target waist <94 cm (men), <80 cm (women)

Physical Activity

Recommended exercise regimen 1, 6:

• 150 minutes of moderate-intensity aerobic exercise per week (e.g., brisk walking) over 5-7 days
• OR 75 minutes of vigorous-intensity aerobic exercise per week over 3 days
• Complement with low- or moderate-intensity resistance training 2-3 times/week
• Moderate-intensity rhythmic exercise (50-60 minutes, 3-4 times/week) more effective than vigorous exercise for BP reduction 6
• Reduces systolic BP by up to 7 mmHg at 3 months 5

Treatment Initiation Timing

Promptness depends on BP level and cardiovascular risk 1:

• Immediate initiation: Grade 3 hypertension (≥180/110 mmHg) or grade 1-2 hypertension with high/very high cardiovascular risk 1
• Elevated BP (120-139/70-89 mmHg) with high CVD risk: After 3 months of lifestyle intervention, initiate pharmacological treatment if BP ≥130/80 mmHg confirmed 1
• Confirmed hypertension (≥140/90 mmHg): Initiate lifestyle measures and pharmacological treatment promptly, irrespective of CVD risk 1
• Grade 1-2 hypertension at moderate risk: May delay drug treatment for several weeks 1
• Grade 1 hypertension without other risk factors: May delay for several months, but add drugs if BP remains uncontrolled 1

Maintenance and Monitoring

Continue BP-lowering treatment lifelong, even beyond age 85 years, if well tolerated 1

If target systolic BP 120-129 mmHg not achievable due to poor tolerance: Target systolic BP "as low as reasonably achievable" (ALARA principle) 1

Common Pitfalls to Avoid

• Do not use device-based therapies (renal denervation) routinely; reserved only for resistant hypertension in specialized centers after multidisciplinary assessment 1
• Do not start with monotherapy in most patients with confirmed hypertension—combination therapy achieves better control 1
• Do not target systolic BP <120 mmHg in diabetic patients 1
• Do not ignore lifestyle modifications even when using pharmacological therapy—they reduce medication requirements 1, 4
• Do not prescribe RAS blockers in pregnancy—use dihydropyridine CCBs, labetalol, or methyldopa instead 1