From the Guidelines
Elevated Systolic Blood Pressure (SBP) treatment should start with lifestyle measures, and pharmacological therapy should be considered if lifestyle changes are not successful, especially in individuals with high cardiovascular disease risk.
Treatment Approach
- For individuals with elevated BP (120-139/70-89 mmHg), lifestyle measures such as diet, exercise, and weight management should be initiated as the first line of treatment 1.
- If the individual has a 10-year estimated cardiovascular disease (CVD) risk of ≥10%, or high-risk conditions (e.g., established CVD, diabetes, moderate or severe chronic kidney disease), pharmacological therapy should be considered in addition to lifestyle measures 1.
- For those with SBP 130-139 mmHg and a 10-year estimated CVD risk of <10%, lifestyle measures should be initiated, and pharmacological therapy may be considered on an individual basis if lifestyle changes are not successful 1.
Pharmacological Therapy
- Thiazide diuretics, ACE inhibitors, ARBs, and CCBs are recommended as primary agents for the treatment of hypertension, as they have been shown to reduce clinical events 1.
- Combination therapy may be considered for individuals who require multiple agents to reach their blood pressure goals, with the goal of using agents with complementary mechanisms of action 1.
Special Considerations
- Caution should be exercised when treating individuals with orthostatic hypotension, moderate-to-severe frailty, limited life expectancy, or older patients (aged ≥85 years), as they may be less likely to benefit from BP-lowering therapy or may be at increased risk of side effects 1.
- Individualized treatment decisions should be made based on shared decision-making between the patient and clinician, taking into account the patient's preferences, values, and clinical characteristics 1.
From the Research
Treatment for Elevated Systolic Blood Pressure (SBP)
The treatment for elevated SBP involves a combination of lifestyle modifications and pharmacological interventions.
- Lifestyle modifications include:
- Weight loss
- Healthy dietary pattern with low sodium and high potassium intake
- Physical activity
- Moderation or elimination of alcohol consumption as stated in the study 2
- Pharmacological interventions:
- First-line drug therapy consists of a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker
- The choice of initial drug therapy should be influenced by the particular clinical situation, as mentioned in the study 3
- The decision to initiate antihypertensive medication should be based on the level of BP and the presence of high atherosclerotic CVD risk, as stated in the study 2
Target Systolic Blood Pressure
The target SBP varies depending on the individual's risk factors and age.
- For adults <65 years, the target SBP is <130 mm Hg, as stated in the study 2
- For adults ≥65 years, the target SBP is <130 mm Hg, as stated in the study 2
- The study 4 suggests that targeting an SBP <130 mm Hg significantly reduces the risks of major CVD and all-cause mortality
- The study 5 suggests that pharmacological treatment could be activated when SBP reaches 140 mm Hg, and for people with cardiovascular disease or at a higher risk of stroke and heart failure, 130 mm Hg may be a better therapeutic threshold
Benefits and Risks of Antihypertensive Medication
The benefits and risks of antihypertensive medication vary depending on the individual's SBP and risk factors.
- The study 5 found that antihypertensive medications were not associated with major adverse cardiovascular events (MACEs) when the SBP was <140 mm Hg, but increased adverse events (AEs)
- The study 4 found that targeting an SBP <130 mm Hg significantly reduced the risks of major CVD and all-cause mortality, but adverse events were significantly more likely in the intensive SBP target groups
- The study 6 suggests that treatment should be continued and not reduced when treated SBP is <130, especially for the SPRINT-like subset.