What is the recommended treatment for a blood pressure reading of 145/100 mmHg (Hypertension)?

Treatment Recommendation for Blood Pressure 145/100 mmHg

You should start antihypertensive medication immediately alongside lifestyle modifications, as your blood pressure of 145/100 mmHg represents Grade 1 hypertension (systolic 140-159 mmHg) with diastolic ≥100 mmHg, which meets criteria for immediate pharmacological intervention. 1

Immediate Actions Required

Confirm the Diagnosis

• Before starting treatment, confirm your hypertension diagnosis with out-of-office measurements using home blood pressure monitoring or 24-hour ambulatory monitoring, as office readings can overestimate true blood pressure 2
• However, given your diastolic pressure of 100 mmHg (Grade 2 range for diastolic), immediate treatment initiation is warranted even while confirming the diagnosis 1

Initial Workup

Obtain the following tests to assess cardiovascular risk and screen for organ damage 2:

• Serum creatinine and estimated glomerular filtration rate (eGFR) to evaluate kidney function
• Urine albumin-to-creatinine ratio to detect early kidney damage
• 12-lead electrocardiogram to identify left ventricular hypertrophy or prior myocardial infarction
• Fasting lipid panel and glucose to calculate 10-year cardiovascular disease risk

Pharmacological Treatment

First-Line Drug Therapy

Start combination therapy immediately with two medications 1, 2:

For non-Black patients:

• Begin with a low-dose ACE inhibitor (such as enalapril) or ARB (such as losartan 50 mg daily) 1, 3
• Plus a dihydropyridine calcium channel blocker (such as amlodipine) 1, 4
• Alternatively, combine with a thiazide/thiazide-like diuretic (such as chlorthalidone) instead of the calcium channel blocker 1, 4

For Black patients:

• Begin with a low-dose ARB plus a dihydropyridine calcium channel blocker 1
• Or use a dihydropyridine calcium channel blocker plus a thiazide/thiazide-like diuretic 1

Dose Titration Strategy

• Increase to full doses of both medications if blood pressure remains ≥140/90 mmHg after 3-4 weeks 1
• Add a third agent (thiazide diuretic if not already used, or the alternative between calcium channel blocker/diuretic) if blood pressure remains uncontrolled on dual therapy after 3 months 1, 2
• Consider spironolactone as fourth-line therapy, or if not tolerated use amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Important caveat: Never combine an ACE inhibitor with an ARB, as this increases adverse events without additional benefit 5

Blood Pressure Targets

Your target blood pressure is 120-129 mmHg systolic and <80 mmHg diastolic (but not <70 mmHg) 1, 2:

• This lower target (compared to older guidelines recommending <140/90 mmHg) is based on recent evidence showing improved cardiovascular outcomes 1, 2
• If you are ≥65 years old, target systolic blood pressure to 130-139 mmHg 1
• Achieve target blood pressure within 3 months of treatment initiation 1, 2

The 2024 ESC guidelines represent the most recent high-quality evidence and recommend more aggressive targets than older guidelines, which improves outcomes for stroke, myocardial infarction, and cardiovascular mortality 1, 2.

Lifestyle Modifications (Start Immediately)

Implement all of the following evidence-based interventions 2, 6, 4:

Dietary changes:

• Restrict sodium intake to approximately 2 g/day (about 5 g of salt) 2, 6
• Adopt a Mediterranean or DASH dietary pattern emphasizing fruits, vegetables, and low-fat dairy products 2, 6, 4
• Increase potassium intake through dietary sources 6, 4

Weight management:

• Achieve and maintain a healthy BMI of 20-25 kg/m² 2
• Even modest weight loss (5-10 kg) significantly reduces blood pressure 6, 7

Physical activity:

• Perform moderate-intensity aerobic exercise ≥150 minutes/week 2, 4
• Supplement with resistance training 2-3 times/week 2

Alcohol limitation:

• Limit alcohol to <100 g/week of pure alcohol (approximately 7 standard drinks for men, 5 for women), or preferably avoid entirely 2, 4

Smoking cessation:

• If you smoke, cessation is essential as tobacco independently increases cardiovascular mortality 2

Monitoring and Follow-Up

• Reassess blood pressure and medication tolerance within 2-4 weeks of treatment initiation 2
• Use home blood pressure monitoring for ongoing assessment and improved adherence 2
• Continue treatment lifelong if tolerated, as blood pressure control reduces stroke, coronary events, and kidney disease risk 5
• Perform annual cardiovascular risk reassessment, including lipid management and diabetes screening 2

Common Pitfalls to Avoid

Do not delay treatment: With diastolic blood pressure of 100 mmHg, you meet criteria for immediate drug therapy regardless of age or cardiovascular risk factors 1. Waiting 3-6 months for lifestyle modification alone is only appropriate for lower-risk patients with blood pressure 140-159/90-99 mmHg 1.

Do not use monotherapy: Most patients with your blood pressure level require at least two medications to achieve target 1, 4. Starting with combination therapy improves adherence and achieves control faster 1.

Do not undertitrate: A systolic blood pressure reduction of 10 mmHg decreases cardiovascular event risk by approximately 20-30% 4. Achieving the target of 120-129 mmHg systolic provides maximum benefit 1, 2.