How to manage high systolic and low diastolic blood pressure?

Management of High Systolic and Low Diastolic Blood Pressure

For patients with high systolic blood pressure (≥140 mmHg) and low diastolic blood pressure, initiate combination pharmacotherapy targeting systolic BP to 120-129 mmHg while carefully monitoring for symptoms of hypoperfusion, using lower starting doses and more gradual titration than standard protocols. 1

Initial Assessment and Risk Stratification

Before initiating treatment, confirm blood pressure measurements on separate occasions to ensure accurate diagnosis. 1 This is particularly critical in patients with wide pulse pressure (the difference between systolic and diastolic BP), as single measurements may be misleading.

Assess for orthostatic hypotension before starting or intensifying treatment, as patients with wide pulse pressure are at higher risk for symptomatic hypotension. 1 Measure BP in both sitting and standing positions, waiting 1-3 minutes after standing.

Evaluate cardiovascular disease risk using validated tools, and consider age, frailty status, and comorbidities when determining treatment targets. 1 Screen older adults for frailty using validated clinical tests, as this significantly impacts treatment decisions. 2

Blood Pressure Targets

Target systolic BP to 120-129 mmHg for most adults to reduce cardiovascular disease risk, provided treatment is well tolerated. 2, 1 This aggressive target is supported by the highest quality evidence for reducing cardiovascular events. 3

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

However, use more lenient systolic BP targets (<140 mmHg) for specific high-risk populations: 2, 1

• Patients with pre-treatment symptomatic orthostatic hypotension
• Age ≥85 years
• Moderate to severe frailty at any age
• Limited life expectancy (<3 years)

For older patients aged 65-84 years without significant frailty, target systolic BP to 130-139 mmHg. 2

Lifestyle Modifications (First-Line for All Patients)

Implement lifestyle changes for all patients with BP >120/80 mmHg before or alongside pharmacotherapy. 1, 3

Weight management: Achieve and maintain BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women). 2 Weight loss alone can reduce systolic BP by approximately 5-20 mmHg per 10 kg lost. 4

Dietary modifications: 2, 1

• Adopt a DASH-style diet emphasizing fruits, vegetables, low-fat dairy products, fish, nuts, and unsaturated fatty acids (olive oil)
• Restrict sodium intake to <100 mEq (2.3 g) per 24 hours, ideally <1.5 g/day. 2 In resistant hypertension, sodium restriction lowered systolic/diastolic BP by 9/8 mmHg. 2
• Increase potassium intake by 0.5-1.0 g/day through potassium-enriched salt (75% sodium chloride, 25% potassium chloride) or potassium-rich foods, unless contraindicated by CKD or potassium-sparing medications. 2

Physical activity: Exercise for minimum 30 minutes on most days of the week, targeting 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous aerobic exercise plus resistance training 2-3 times/week. 2, 1 Regular aerobic exercise reduces systolic BP by 4 mmHg and diastolic BP by 3 mmHg. 2

Alcohol restriction: Limit to <14 units/week for men and <8 units/week for women, with preferential avoidance for best health outcomes. 2

Pharmacological Management

Initiate combination therapy with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic for confirmed hypertension (≥140/90 mmHg). 2, 1, 3 Single-pill combinations improve adherence and should be used when possible. 1

Special Considerations for Wide Pulse Pressure

Start with lower doses than standard protocols to avoid excessive diastolic BP reduction. 1 For example, if initiating amlodipine/losartan combination, consider starting at 2.5 mg/25 mg rather than 5 mg/50 mg.

Titrate medications more gradually than usual, with more frequent follow-up visits. 1 Schedule follow-up every 2-4 weeks during titration rather than the standard 4-8 weeks.

Monitor closely for symptoms of hypoperfusion: 1

• Dizziness or lightheadedness
• Falls
• Confusion or cognitive changes
• Fatigue
• Syncope

Consider administering one or more antihypertensive medications at bedtime to reduce nocturnal BP and cardiovascular events, particularly in patients with wide pulse pressure. 1

Medication Selection

First-line agents include: 2, 3

• ACE inhibitors or ARBs (e.g., enalapril, losartan, candesartan) - reduce cardiovascular events and provide renal protection. 5, 3
• Calcium channel blockers (e.g., amlodipine) - particularly effective in isolated systolic hypertension. 3
• Thiazide/thiazide-like diuretics (e.g., chlorthalidone, indapamide, hydrochlorothiazide) - proven mortality benefit. 2, 3

Do not combine two RAS blockers (ACE inhibitor plus ARB), as this increases adverse events without additional benefit. 2, 1

If BP remains uncontrolled on three-drug combination, add spironolactone 25 mg daily as fourth-line agent. 2 If spironolactone is not tolerated, consider eplerenone, amiloride, or a beta-blocker (if not already indicated). 2

Monitor serum creatinine/eGFR and potassium levels when using ACE inhibitors, ARBs, or diuretics. 2

Management of Resistant Hypertension

If BP remains ≥140/90 mmHg despite three-drug combination (including a diuretic): 2, 1

1. Reinforce lifestyle measures, especially sodium restriction to <100 mEq/24 hours. 2
2. Add low-dose spironolactone (12.5-25 mg daily) to existing treatment. 2
3. If spironolactone not tolerated, add eplerenone, amiloride, higher-dose thiazide/thiazide-like diuretic, or loop diuretic. 2
4. Consider adding bisoprolol or doxazosin as fifth-line agents. 2
5. Screen for and treat secondary causes: obstructive sleep apnea, primary aldosteronism, renal artery stenosis, pheochromocytoma. 2

For obstructive sleep apnea, CPAP use (averaging 4-5.5 hours/night) reduced systolic BP by 9-14 mmHg in resistant hypertension. 2

Common Pitfalls to Avoid

Do not aggressively lower BP in patients with diastolic BP already <60 mmHg, as this increases risk of myocardial and cerebral hypoperfusion. 1 If diastolic BP falls below 60 mmHg during treatment, consider dose reduction or medication adjustment.

Do not delay combination therapy in patients with confirmed hypertension ≥140/90 mmHg. 1 Monotherapy is inadequate for most patients and delays achieving target BP.

Do not discontinue treatment prematurely. BP-lowering treatment should be maintained lifelong, even beyond age 85 years, if well tolerated. 2, 1

Do not ignore medication adherence. Simplify regimens to once-daily dosing, use single-pill combinations, provide appointment reminders, and collaborate with pharmacists and nurses to improve adherence. 1

Follow-Up and Monitoring

Schedule more frequent follow-up visits during treatment initiation and titration (every 2-4 weeks). 1 Once BP is controlled and stable, follow up at least yearly for BP and cardiovascular risk factor assessment. 2

Use home BP monitoring to confirm office readings and detect white-coat or masked hypertension. 2 Home BP readings are typically 10/5 mmHg lower than office readings. 2