How can I manage a blood pressure reading of 144/43?

Management of Blood Pressure 144/43 mmHg

Immediate Concern: Wide Pulse Pressure

Your blood pressure of 144/43 mmHg represents isolated systolic hypertension with a dangerously wide pulse pressure (101 mmHg), which requires urgent medical evaluation to rule out secondary causes before initiating standard antihypertensive therapy. 1

The extremely low diastolic pressure (43 mmHg) is abnormal and suggests potential underlying pathology such as:

• Aortic regurgitation - the most common cause of wide pulse pressure with low diastolic readings 1
• Severe arterial stiffness - particularly in elderly patients 1
• Hyperthyroidism - increases cardiac output and lowers diastolic pressure 1
• Anemia or other high-output states 1

Diagnostic Workup Required

Before treating the elevated systolic pressure, screening for secondary hypertension is recommended when clinical findings suggest underlying pathology, particularly with resistant or unusual presentations 1:

• Cardiac auscultation - listen for diastolic murmur of aortic regurgitation 1
• Thyroid function tests - TSH and free T4 to exclude hyperthyroidism 1
• Echocardiogram - assess for valvular disease and left ventricular function 1
• Complete blood count - rule out severe anemia 1
• Renal function tests - serum creatinine and urinalysis to exclude renal parenchymal disease 1

Confirm Blood Pressure Accuracy

Before any treatment decisions, verify proper blood pressure measurement technique and confirm readings with home monitoring 1:

• Avoid smoking, caffeinated beverages, or exercise within 30 minutes before measurement 1
• Ensure 5 minutes of quiet rest before readings 1
• Sit with back supported, feet flat on floor, legs uncrossed 1
• Keep arm supported at heart level 1
• Take at least 2 readings 1 minute apart, in morning before medications and evening before supper 1
• Use validated automated devices with appropriate cuff size 1
• Home blood pressure target is <135/85 mmHg (corresponding to clinic <140/90 mmHg) 1, 2

Treatment Approach After Secondary Causes Excluded

If No Secondary Cause Identified:

The systolic pressure of 144 mmHg meets criteria for Stage 1 hypertension and warrants antihypertensive therapy, but medication selection must account for the low diastolic pressure 1, 2:

• Target blood pressure: <130/80 mmHg for most adults, though the low baseline diastolic requires careful monitoring 3, 2
• Aim to reduce blood pressure by at least 20/10 mmHg initially 3, 2

First-Line Medication Selection:

Start with a low-dose calcium channel blocker (amlodipine 2.5-5 mg once daily) or ACE inhibitor/ARB at low doses, as these are less likely to cause excessive diastolic lowering compared to diuretics or beta-blockers 3, 2:

• For non-Black patients: ACE inhibitor, ARB, or calcium channel blocker 2
• For Black patients: calcium channel blocker or thiazide-type diuretic 2
• Avoid beta-blockers initially as they may worsen wide pulse pressure 2

Monitoring Strategy:

• Reassess blood pressure within 2-4 weeks after starting medication 3, 4
• Target control should be achieved within 3 months 3, 2
• Monitor for symptoms of hypoperfusion (dizziness, syncope, fatigue) given the low diastolic baseline 1
• If diastolic pressure drops below 40 mmHg or symptoms develop, medication adjustment is needed 1

Lifestyle Modifications (Concurrent with Medical Workup):

• Sodium restriction to <2 g/day - can reduce blood pressure by 5-10 mmHg 3
• Weight loss if BMI >25 kg/m² with target BMI 20-25 kg/m² 3
• Regular aerobic exercise 3
• Limit alcohol consumption 3

Referral Indications:

Refer to a hypertension specialist or cardiologist if 3:

• Wide pulse pressure persists despite workup 1
• Blood pressure remains ≥160/100 mmHg despite four-drug therapy 3
• Suspected secondary hypertension confirmed 1, 3
• Symptomatic hypotension develops with treatment 1

Critical Pitfall to Avoid:

Do not aggressively treat the systolic hypertension without first investigating the cause of the extremely low diastolic pressure - standard antihypertensive therapy could dangerously lower the diastolic pressure further, potentially causing coronary or cerebral hypoperfusion 1. The wide pulse pressure (>60 mmHg) is an independent cardiovascular risk factor and requires careful evaluation before treatment 1.