Management of elevated Diastolic Blood Pressure (DBP)

From the Guidelines

Elevated Diastolic Blood Pressure (DBP) management should primarily focus on lifestyle modifications and pharmacological treatment to reduce BP and cardiovascular disease (CVD) risk.

Key Components of Management

• Lifestyle modifications:
  • Weight loss of as little as 10 lbs (4.5 kg) can reduce BP and/or prevent hypertension 1
  • Adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan, which is rich in fruits, vegetables, and low-fat dairy products 1
  • Reduction of dietary sodium to no more than 100 mmol per day (2.4 g of sodium) 1
  • Regular aerobic physical activity, such as brisk walking, at least 30 minutes per day, most days of the week 1
  • Limitation of alcohol intake to no more than 1 oz (30 mL) of ethanol per day in most men and no more than 0.5 oz of ethanol per day in women and lighter weight persons 1
• Pharmacological treatment:
  • Initiation of antihypertensive treatment in adults with an SBP persistently ≥150 mm Hg to achieve an SBP <150 mm Hg, with the possibility of a lower target in some individuals 1
  • Use of ACE inhibitors, calcium channel blockers, angiotensin receptor blockers, and thiazide diuretics for management of hypertension, as included in the WHO Essential Medicines List 1
  • Consideration of single-pill combination antihypertensive medications, which were added to the WHO Essential Medicines List in June 2019 1

Treatment Targets

• BP target: SBP/DBP <140/90 mm Hg, although some guidelines recommend a higher target of <150/90 mm Hg for adults ≥60 years 1

Healthcare Provider Role

• Primary care health care providers, including family physicians, cardiologists, nephrologists, and any providers who manage hypertension, play a crucial role in the management of hypertension in routine, primary care settings 1

From the Research

Management of Elevated Diastolic Blood Pressure (DBP)

• The management of elevated DBP is crucial in reducing the risk of cardiovascular disease (CVD) events and death 2.
• First-line therapy for hypertension, including elevated DBP, is lifestyle modification, consisting of weight loss, dietary sodium reduction and potassium supplementation, healthy dietary pattern, physical activity, and limited alcohol consumption 2.
• When drug therapy is required, first-line therapies are thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and calcium channel blockers 2, 3.
• The goal of treatment is to achieve a diastolic blood pressure (DBP) of less than 80 mmHg, with a systolic blood pressure (SBP) of less than 130 mmHg for adults under 65 years and SBP of less than 130 mmHg for adults 65 years and older 2.
• Reducing DBP to 80 mmHg or less has been shown to reduce coronary revascularization and heart failure in patients with coronary artery disease, but may increase the risk of hypotension 4.
• The optimal achieved DBP at a controlled SBP of 120-140 mmHg is between 70-80 mmHg, with lower and higher DBP associated with a higher risk of cardiovascular outcomes 5.

Treatment Options

• Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have been shown to be effective in improving measures of diastolic function and are recommended as first-line agents in the control of hypertension in patients with diastolic heart failure 3.
• Beta-blockers, calcium channel blockers, and diuretics have also shown some efficacy in improving indices of diastolic filling, but their independent impact on prognosis and outcome in diastolic dysfunction has yet to be clarified 3.
• Thiazide or thiazide-like diuretics, such as hydrochlorothiazide or chlorthalidone, are recommended as initial drug therapy for hypertension, including elevated DBP 2, 6.

Considerations

• The decision to initiate antihypertensive medication should be based on the level of BP and the presence of high atherosclerotic CVD risk 2.
• The choice of initial drug therapy should be influenced by the particular clinical situation, with consideration of coexisting contraindications or co-indications for particular drugs 6.
• Combination therapy is frequently required and can be effective and well tolerated if carefully chosen 6.