How are elevated systolic and diastolic blood pressures managed and treated?

Management of Elevated Systolic vs Diastolic Blood Pressure

Treatment Approach Based on Blood Pressure Pattern

Both elevated systolic and diastolic blood pressure should be treated with the same initial approach: combination pharmacotherapy plus lifestyle modifications for confirmed hypertension ≥140/90 mmHg, with the primary goal being to lower both values to target ranges (<130/80 mmHg for most adults). 1, 2, 3

Initial Assessment and Confirmation

• Confirm blood pressure measurements on separate occasions before initiating treatment, using home or ambulatory monitoring when possible to avoid white-coat hypertension 1, 2
• Assess for orthostatic hypotension before starting treatment, particularly in patients with wide pulse pressure (high systolic with low diastolic) 1
• Evaluate cardiovascular disease risk factors including diabetes, chronic kidney disease, age, frailty status, and comorbidities to guide treatment intensity 1, 2

Treatment Targets

For Most Adults

• Target systolic blood pressure to 120-129 mmHg if well tolerated 1, 3
• Target diastolic blood pressure to <80 mmHg for all hypertensive patients 1, 2
• When systolic BP is at target (120-129 mmHg) but diastolic remains ≥80 mmHg, consider further lowering diastolic to 70-79 mmHg if tolerated 1, 2

Special Populations

• For patients with diabetes or chronic kidney disease, maintain BP <130/80 mmHg 4, 2
• For elderly patients (≥85 years), those with moderate-to-severe frailty, or limited life expectancy, consider more lenient targets (<140/90 mmHg) 1
• Lower blood pressure gradually in elderly patients to avoid complications 4

Pharmacological Management

Initial Drug Therapy for Confirmed Hypertension (≥140/90 mmHg)

Start with combination therapy using two drugs immediately rather than monotherapy 1, 2, 3:

1. First-line combination: ACE inhibitor or ARB PLUS either:

   • Dihydropyridine calcium channel blocker (CCB), OR
   • Thiazide/thiazide-like diuretic 1, 2, 3, 5, 6

2. Use single-pill combinations when possible to improve adherence 1, 2, 3

3. For patients with diabetes, ACE inhibitors or ARBs are preferred as they provide additional renal protection 4, 2

Escalation Strategy

• If BP not controlled with two drugs, escalate to three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 2, 3
• Multiple-drug therapy is generally required to achieve blood pressure targets 4
• Monitor renal function and potassium within first 3 months when using ACE inhibitors, ARBs, or diuretics, then every 6 months if stable 4, 2

Special Considerations for Wide Pulse Pressure (High Systolic, Low Diastolic)

When diastolic BP is already low (<60-70 mmHg) but systolic remains elevated:

• Start with lower doses to avoid excessive diastolic reduction 1
• Titrate medications more gradually with more frequent follow-up 1
• Monitor closely for symptoms of hypoperfusion including dizziness, falls, confusion 1
• Consider administering antihypertensives at bedtime to reduce nocturnal BP and cardiovascular events 1
• Avoid aggressive BP lowering when diastolic is already <60 mmHg 1

Lifestyle Modifications

Implement lifestyle changes immediately for all patients with BP >120/80 mmHg, regardless of whether pharmacotherapy is initiated 1, 2, 3, 7:

Dietary Interventions

• Adopt DASH or Mediterranean dietary pattern emphasizing fruits, vegetables, fish, nuts, unsaturated fatty acids, and low-fat dairy products 4, 1, 2, 8
• Restrict sodium to 1200-2300 mg/day (equivalent to 3000-6000 mg sodium chloride) 4, 1, 2, 9
• Increase dietary fiber intake to 14g per 1000 calories consumed 4
• Moderate total fat intake to 25-35% of total calories, primarily from monounsaturated or polyunsaturated sources 4

Weight Management

• Achieve and maintain BMI 20-25 kg/m² with waist circumference <94 cm in men, <80 cm in women 1, 2
• Even modest weight loss provides cardiovascular benefits 4, 8

Physical Activity

• Engage in ≥150 minutes of moderate-intensity aerobic exercise weekly or 75 minutes of vigorous exercise, distributed over at least 3 days per week 4, 1, 2, 7
• Add resistance training 2-3 times weekly 1, 2
• Physical activity effects on BP are comparable or superior to other lifestyle changes 7, 9

Alcohol and Tobacco

• Limit alcohol to <14 units/week for men, <8 units/week for women, or avoid completely 1, 2
• Complete smoking cessation with referral to cessation programs and pharmacotherapy as needed 4, 1, 2

Follow-Up and Monitoring

• Reassess BP in 2-4 weeks after initiating therapy 3
• Measure blood pressure at every routine visit 4
• Use home BP monitoring to improve control and patient engagement 2
• Schedule more frequent visits during treatment initiation and titration 1, 3
• Refer to hypertension specialist if target BP not achieved despite multiple-drug therapy 4

Common Pitfalls to Avoid

• Never use monotherapy for Stage 2 hypertension (≥140/90 mmHg) - start with combination therapy 1, 2, 3
• Never combine ACE inhibitor with ARB - increased risk without additional benefit 1, 3
• Avoid beta-blockers as first-line therapy for uncomplicated hypertension 3
• Do not delay treatment intensification if BP remains uncontrolled at follow-up (therapeutic inertia) 3
• Never aggressively lower BP in patients with already low diastolic (<60 mmHg) 1
• Do not discontinue treatment prematurely - BP-lowering should be maintained lifelong if tolerated 1
• Avoid inadequate lifestyle counseling - patients who receive health professional advice are significantly more likely to attempt behavior changes 10