How should an adult patient with elevated diastolic blood pressure (hypertension) be managed?

Management of Diastolic Blood Pressure of 110 mmHg

For an adult patient with a diastolic blood pressure of 110 mmHg, you should initiate prompt pharmacological treatment with combination therapy (two antihypertensive agents from different classes) along with lifestyle modifications, with the goal of gradually lowering blood pressure over days to weeks—not during a single visit. 1

Immediate Assessment: Rule Out Hypertensive Emergency

First, determine if this is a hypertensive urgency (severely elevated BP without acute end-organ damage) versus a hypertensive emergency (with acute end-organ damage). 1, 2

Screen for acute end-organ damage:

• Neurologic: New or worsening headache, altered mental status, visual changes, focal deficits, seizures 2
• Cardiac: Chest pain, acute heart failure symptoms, pulmonary edema 2
• Renal: Acute kidney injury, hematuria 2
• Vascular: Aortic dissection symptoms 2

If NO acute end-organ damage is present (hypertensive urgency):

• Do NOT rapidly lower blood pressure in the emergency department or acute care setting 1
• Rapidly lowering BP in asymptomatic patients is unnecessary and may be harmful 1
• Initiating treatment in the ED is not necessary when patients have follow-up 1

If acute end-organ damage IS present (hypertensive emergency):

• Admit to intensive care unit for immediate IV antihypertensive therapy 2
• Use short-acting titratable IV agents (labetalol, nicardipine, clevidipine, fenoldopam) 2
• Avoid hydralazine, immediate-release nifedipine, and use sodium nitroprusside with caution 2

For Asymptomatic Hypertensive Urgency (DBP 110 mmHg without end-organ damage)

Confirm the diagnosis:

• One-third of patients with diastolic BP >95 mmHg normalize before arranged follow-up 1
• Recheck BP after 5 minutes of rest, seated position, feet on floor, arm supported at heart level 3
• Consider out-of-office BP monitoring (home or ambulatory) to exclude white-coat hypertension 3, 4

Screen for secondary hypertension:

• In adults diagnosed before age 40, comprehensive screening for secondary causes is required 3
• Measure renin and aldosterone levels to screen for primary aldosteronism in all adults with confirmed BP ≥140/90 mmHg 3
• Evaluate for obstructive sleep apnea, especially in obese patients 3

Initiate combination pharmacological therapy:

For stage 2 hypertension (DBP ≥100 mmHg or SBP ≥160 mmHg), initiate TWO antihypertensive agents from different classes promptly 1

Preferred initial combination: 1, 3, 4

• RAS blocker (ACE inhibitor OR ARB) PLUS dihydropyridine calcium channel blocker 1, 3, 4
• Alternative: RAS blocker PLUS thiazide/thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide) 1, 4
• Use fixed-dose single-pill combination to improve adherence 3, 4

Specific first-line agents: 1, 5

• Thiazide-like diuretics: Chlorthalidone 12.5-25 mg daily or indapamide 1.5 mg modified-release daily 1
• ACE inhibitors: Lisinopril, enalapril 6, 5
• ARBs: Candesartan, losartan 5
• Calcium channel blockers: Amlodipine 5

Implement intensive lifestyle modifications:

• Weight management: Target BMI 20-25 kg/m² 1, 3
• Sodium restriction: Limit to <2 g/day (approximately 5 g salt/day) 1, 3, 5
• Potassium supplementation: Increase by 0.5-1.0 g/day through diet or potassium-enriched salt 3
• Restrict free sugar to maximum 10% of energy intake, avoid sugar-sweetened beverages 3
• Moderate-intensity aerobic exercise ≥150 minutes/week plus resistance training 2-3 times/week 4
• Adopt Mediterranean or DASH dietary pattern 4
• Alcohol restriction: <14 units/week for men, <8 units/week for women 1

Treatment Targets and Timeline

Target blood pressure: 1, 4

• First objective: Lower BP to <140/90 mmHg in all patients 1
• Optimal target: Systolic BP 120-129 mmHg and diastolic BP <80 mmHg for most adults, if well tolerated 1, 4
• For adults <65 years: Target <130/80 mmHg 1, 5

Timeline for BP reduction: 1, 3

• Blood pressure should be gradually lowered over days to weeks, NOT normalized during initial visit 1
• Reassess within 2-4 weeks after initiating therapy 3
• Goal is to achieve target BP within 3 months of initiating therapy 3

Follow-Up and Monitoring

• Evaluate within 1 month of initial diagnosis for stage 2 hypertension 1
• Monthly evaluation of adherence and therapeutic response until control is achieved 1
• Monitor serum creatinine/eGFR and potassium when using ACE inhibitors, ARBs, or diuretics 3
• Once BP is controlled and stable, at least yearly follow-up 3

Critical Pitfalls to Avoid

• Do NOT use immediate-release nifedipine for acute BP lowering 2
• Do NOT rapidly lower BP in asymptomatic patients—this may cause harm 1
• Do NOT order routine chest X-rays or ECGs unless clinically indicated for suspected end-organ damage 1
• Do NOT start monotherapy for stage 2 hypertension—combination therapy is required 1, 4
• Do NOT assume this is primary hypertension in young adults (<40 years) without screening for secondary causes 3