I have a systolic blood pressure (BP) of 120 mmHg but difficulty getting my diastolic blood pressure below 90-100 mmHg, what should I do?

Isolated Diastolic Hypertension Management

You need to confirm this blood pressure pattern with out-of-office measurements and then initiate combination pharmacological therapy targeting a diastolic BP of 70-79 mmHg, as your current diastolic BP of 90-100 mmHg represents true hypertension requiring treatment regardless of your controlled systolic BP. 1

Confirm Your Blood Pressure Pattern

• Verify measurements outside the office using home BP monitoring or 24-hour ambulatory monitoring, as office readings alone should not guide treatment decisions 1
• Your pattern (systolic 120 mmHg with diastolic 90-100 mmHg) represents isolated diastolic hypertension, which still carries cardiovascular risk and requires treatment 1
• Diastolic BP ≥90 mmHg meets the threshold for confirmed hypertension regardless of systolic values 1

Treatment Strategy

Immediate Pharmacological Therapy

Start combination BP-lowering medication immediately since your diastolic BP is ≥90 mmHg, which defines hypertension requiring prompt treatment 1:

• Preferred initial combination: A RAS blocker (ACE inhibitor like lisinopril OR ARB) plus either a dihydropyridine calcium channel blocker (like amlodipine) or a thiazide/thiazide-like diuretic 1, 2, 3
• Use fixed-dose single-pill combinations when available to improve adherence 1
• These medications reduce cardiovascular events, not just BP numbers 1, 3

Target Blood Pressure Goals

Your diastolic BP target is 70-79 mmHg 1:

• A diastolic BP target of <80 mmHg is recommended for all hypertensive patients 1
• Since your systolic BP is already at goal (120 mmHg), intensifying treatment specifically to lower diastolic BP to 70-79 mmHg may reduce cardiovascular risk 1
• Critical safety threshold: Do not allow diastolic BP to fall below 70 mmHg, as this may compromise coronary perfusion and cause myocardial damage 4, 5

Escalation if Needed

If diastolic BP remains ≥80 mmHg on two-drug combination 1:

• Escalate to three-drug combination: RAS blocker + dihydropyridine calcium channel blocker + thiazide/thiazide-like diuretic, preferably as single-pill combination 1
• If still uncontrolled, add spironolactone as the fourth agent 1

Concurrent Lifestyle Modifications

Implement these measures simultaneously with medication (not as a delay to pharmacological treatment) 1:

• Dietary changes: Adopt Mediterranean or DASH diet patterns 1
• Sodium restriction: Reduce dietary sodium intake 1
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Alcohol reduction: Limit to <100 g/week of pure alcohol, or preferably avoid entirely 1
• Physical activity: 150 minutes/week moderate-intensity aerobic exercise plus resistance training 2-3 times/week 1
• Smoking cessation: If applicable 1

Important Clinical Caveats

The Diastolic "J-Curve" Concern

Be cautious about excessive diastolic lowering 5:

• Diastolic BP <60 mmHg is associated with subclinical myocardial damage (elevated troponin) and increased coronary heart disease events, particularly when systolic BP ≥120 mmHg 5
• The combination of normal-to-low systolic BP with very low diastolic BP creates high pulse pressure, indicating arterial stiffness and potential coronary perfusion compromise 5
• Practical threshold: When titrating medications, ensure diastolic BP does not fall below 70 mmHg, and especially not below 60 mmHg 4, 5

Monitoring Strategy

• Follow-up every 1-3 months until BP is controlled 1
• Achieve control within 3 months of treatment initiation 1
• Use out-of-office BP measurements to confirm on-treatment targets are met 1
• If lifestyle changes effectively lower BP, medications may be down-titrated 1

Rule Out Secondary Causes

Consider screening for secondary hypertension if 1:

• You are under age 40 (unless obese, in which case evaluate for obstructive sleep apnea first) 1
• BP remains resistant to three-drug therapy 1

Why This Matters

Your diastolic BP of 90-100 mmHg represents true cardiovascular risk 1, 6:

• Elevated diastolic pressure increases cardiovascular risk on a continuous scale 3, 7
• Treatment of hypertension (including isolated diastolic hypertension) substantially decreases cardiovascular events 1, 3
• The relationship between BP and cardiovascular risk is continuous and graded—there is no "safe" level of hypertension 7
• Diastolic BP reflects arterial resistance and remains an important treatment target, particularly in younger and middle-aged adults 8, 6

Bottom line: Your blood pressure pattern requires pharmacological treatment now, not watchful waiting, with careful attention to achieving diastolic BP of 70-79 mmHg while avoiding excessive lowering below 70 mmHg.