What are the next steps for a patient on lisinopril (angiotensin-converting enzyme inhibitor) 5 mg with a blood pressure reading of 138/84 mmHg?

Management of Blood Pressure 138/84 mmHg on Lisinopril 5 mg

Next Steps: Intensify Treatment Now

You should increase lisinopril to 10 mg once daily immediately, as this patient has confirmed hypertension (≥140/90 mmHg systolic) requiring treatment intensification. 1, 2

Rationale for Dose Escalation

• The current blood pressure of 138/84 mmHg represents elevated BP (systolic 120-139 mmHg), which requires pharmacological treatment when combined with cardiovascular risk factors 1
• Lisinopril 5 mg is below the recommended initial dose of 10 mg for hypertension, and the usual therapeutic range is 20-40 mg daily 2
• The 2024 ESC guidelines recommend achieving blood pressure control within 3 months, preferably targeting <130/80 mmHg for most patients 1

Stepwise Treatment Algorithm

Step 1: Optimize Current Monotherapy

• Increase lisinopril from 5 mg to 10 mg once daily 2
• Reassess blood pressure in 2-4 weeks 1

Step 2: If BP Remains ≥140/90 mmHg After Dose Optimization

• Add a calcium channel blocker (amlodipine 5-10 mg daily) OR a thiazide-like diuretic (hydrochlorothiazide 12.5-25 mg or chlorthalidone 12.5-25 mg) 1, 2
• The 2024 ESC guidelines strongly recommend combination therapy with a RAS blocker (ACE inhibitor) plus either a dihydropyridine calcium channel blocker or thiazide diuretic, preferably as a single-pill combination 1

Step 3: If BP Remains Uncontrolled on Two-Drug Combination

• Escalate to triple therapy: ACE inhibitor + calcium channel blocker + thiazide diuretic 1
• This represents the guideline-recommended three-drug combination for uncontrolled hypertension 1

Step 4: If BP Remains Uncontrolled on Triple Therapy

• Add spironolactone 25-50 mg daily as the preferred fourth-line agent for resistant hypertension 1

Blood Pressure Targets

• Minimum target: <140/90 mmHg for all hypertensive patients 1
• Optimal target: <130/80 mmHg if well tolerated, particularly for patients with diabetes, cardiovascular disease, or chronic kidney disease 1
• Aim to achieve target within 3 months of treatment initiation or modification 1

Monitoring Parameters

• Recheck blood pressure within 2-4 weeks after any dose adjustment 1
• Consider home blood pressure monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) to confirm office readings 1
• Monitor serum potassium and creatinine when uptitrating ACE inhibitors or adding additional agents, particularly diuretics 1

Critical Pitfalls to Avoid

• Do not delay treatment intensification when blood pressure remains above target—this increases cardiovascular risk unnecessarily 1
• Do not combine two RAS blockers (ACE inhibitor + ARB)—this increases adverse events without additional benefit 1
• Do not add a beta-blocker as second-line therapy unless there are compelling indications (heart failure, post-MI, angina, or rate control needs) 1
• Confirm medication adherence before assuming treatment failure—non-adherence is the most common cause of apparent resistant hypertension 1

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Explaining Systolic and Diastolic Blood Pressure

Simple Explanation for Patients

Systolic pressure (the top number, 138) represents the pressure in your arteries when your heart beats and pushes blood out. Think of it as the maximum pressure during the heart's pumping action.

Diastolic pressure (the bottom number, 84) represents the pressure in your arteries when your heart relaxes between beats. This is the minimum pressure that's always present in your blood vessels.

Clinical Significance

• Systolic pressure is the stronger predictor of cardiovascular events, especially in patients over 50 years old 1
• Your systolic reading of 138 mmHg falls in the "elevated BP" category, indicating increased cardiovascular risk that warrants treatment 1
• The diastolic reading of 84 mmHg is also in the elevated range (normal is <70 mmHg by strict ESC criteria, though <80 mmHg is more commonly used) 1

Why Both Numbers Matter

• Systolic hypertension (elevated top number) increases risk of stroke, heart attack, and heart failure 1
• Diastolic hypertension (elevated bottom number) indicates increased vascular resistance throughout the body 1
• Treating both components reduces overall cardiovascular risk by 20-30% for stroke and 15-20% for coronary events 1

Lifestyle Modifications to Emphasize

• Sodium restriction to <2 g/day can reduce BP by 5-10 mmHg 1
• Weight loss (target BMI 20-25 kg/m²) can reduce BP by 5-20 mmHg 1
• Regular aerobic exercise (150 minutes/week) can reduce BP by 5-8 mmHg 1
• Alcohol limitation to <100 g/week can reduce BP by 2-4 mmHg 1

These lifestyle changes are crucial and may allow subsequent down-titration of medication, but should be implemented concurrently with pharmacological therapy, not as a substitute for it. 1