Treatment of Elevated Diastolic Blood Pressure
For patients with confirmed hypertension (BP ≥140/90 mmHg), initiate combination therapy immediately with a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide diuretic, preferably as a fixed-dose single-pill combination, targeting systolic BP of 120-129 mmHg if well tolerated. 1
Initial Assessment and Confirmation
Before initiating treatment, confirm the diagnosis using out-of-office measurements rather than relying solely on clinic readings 2:
- Home BP monitoring ≥135/85 mmHg confirms hypertension 2
- 24-hour ambulatory BP ≥130/80 mmHg confirms hypertension 2
- Perform baseline investigations including urine analysis, serum electrolytes, creatinine, blood glucose, lipid profile, and ECG 2
First-Line Pharmacological Treatment
Combination Therapy as Initial Treatment
Start with two-drug combination therapy immediately for confirmed hypertension (BP ≥140/90 mmHg), not monotherapy 1, 2. The evidence demonstrates superior BP control with combination therapy versus monotherapy 1.
Preferred initial combinations 1:
- RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker (e.g., amlodipine) 1, 3
- RAS blocker + thiazide/thiazide-like diuretic (e.g., chlorthalidone or hydrochlorothiazide) 1, 3
Use fixed-dose single-pill combinations when available to improve adherence 1, 2.
Exceptions to Combination Therapy
Consider monotherapy only for 1:
- Patients aged ≥85 years
- Symptomatic orthostatic hypotension
- Moderate-to-severe frailty
- Elevated BP (systolic 120-139 mmHg or diastolic 70-89 mmHg) with concomitant indication for treatment
Blood Pressure Targets
Target systolic BP of 120-129 mmHg in most adults if treatment is well tolerated 1. This represents the most recent and highest quality evidence from the 2024 ESC guidelines.
Minimum target of <140/90 mmHg for all hypertensive patients 1, 2.
If achieving 120-129 mmHg is not tolerated, target systolic BP "as low as reasonably achievable" (ALARA principle) 1.
Escalation to Triple Therapy
If BP remains uncontrolled on two-drug combination, escalate to three-drug combination 1:
- RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic 1, 3
- Preferably use a single-pill combination 1
This triple therapy targets complementary mechanisms: renin-angiotensin system blockade, vasodilation, and volume reduction 3.
Resistant Hypertension (Fourth-Line Agent)
If BP remains uncontrolled on optimized triple therapy, add spironolactone 25-50mg daily as the preferred fourth-line agent 3, 4. The evidence demonstrates significant additional BP reductions when spironolactone is added to triple therapy 3.
Alternative fourth-line agents if spironolactone is contraindicated 3, 4:
- Amiloride
- Doxazosin
- Eplerenone
- Clonidine
- Beta-blocker (only if compelling indication exists)
Lifestyle Modifications (Concurrent with Pharmacotherapy)
Initiate lifestyle modifications simultaneously with pharmacological treatment—never delay drug therapy while attempting lifestyle changes alone in confirmed hypertension 2.
Essential lifestyle interventions 1, 2, 5, 6:
- Dietary sodium restriction to <2g/day 1, 2
- Weight reduction to BMI 20-25 kg/m² 2, 5
- Regular aerobic exercise 30-60 minutes, 4-7 days per week 2, 6
- Alcohol limitation to <100g/week 1
- DASH diet emphasizing fruits, vegetables, low-fat dairy products 6
- Increased dietary potassium intake 5, 6
These lifestyle modifications provide additive BP reductions of 10-20 mmHg 3.
Monitoring and Follow-Up
Reassess BP within 2-4 weeks after any medication adjustment 3, 4.
Achieve target BP within 3 months of treatment initiation or modification 2, 4.
Monitor serum potassium and creatinine 2-4 weeks after initiating RAS blockers or diuretics 3, 2.
See patients frequently (every 1-3 months) until BP is controlled 2.
Critical Pitfalls to Avoid
Never use monotherapy as initial treatment for confirmed hypertension (BP ≥140/90 mmHg)—combination therapy is mandatory from the outset 1, 2.
Never combine two RAS blockers (ACE inhibitor + ARB)—this increases adverse events without additional benefit 1, 3, 2.
Never add beta-blockers as routine antihypertensive therapy unless compelling indications exist (angina, post-MI, heart failure with reduced ejection fraction, or heart rate control) 1, 3.
Never delay treatment intensification—prompt action reduces cardiovascular risk 3.
Always verify medication adherence before adding additional agents, as non-adherence is the most common cause of apparent treatment resistance 3, 4.
Special Populations
Black Patients
For Black patients, the combination of calcium channel blocker + thiazide diuretic may be more effective than calcium channel blocker + RAS blocker 3.
Young Adults (Diagnosed Before Age 40)
Perform comprehensive screening for secondary hypertension causes, except in obese young adults where obstructive sleep apnea evaluation should be prioritized 1.
Pregnancy
In pregnant women with chronic or gestational hypertension, initiate drug treatment when confirmed office BP ≥140/90 mmHg 1.
Target BP <140/90 mmHg but not below 80 mmHg diastolic 1.
Use dihydropyridine calcium channel blockers (preferably extended-release nifedipine), labetalol, or methyldopa as first-line agents 1.
Medication Timing
Take medications at the most convenient time of day to establish habitual patterns and improve adherence 1. The evidence does not support mandatory evening dosing.
Lifelong Treatment
Maintain BP-lowering drug treatment lifelong, even beyond age 85 years, if well tolerated 1.