I have a blood pressure of 133/99 mm Hg; how should I manage this hypertension?

Management of Blood Pressure 133/99 mmHg

Classification and Immediate Action

Your blood pressure of 133/99 mmHg represents Grade 1 (mild) hypertension and requires treatment initiation. 1

According to the British Hypertension Society classification, your diastolic pressure of 99 mmHg falls into the Grade 1 hypertension range (90-99 mmHg), while your systolic pressure of 133 mmHg is in the high-normal range (130-139 mmHg). 1 The higher value determines your classification, placing you in Grade 1 hypertension. 1

Confirmation Before Treatment

Before starting medication, confirm this diagnosis with repeated measurements over multiple visits or home blood pressure monitoring. 1

• Take the average of two readings at each of several visits to guide treatment decisions. 1
• Home blood pressure monitoring is diagnostic if readings are ≥135/85 mmHg. 1
• 24-hour ambulatory monitoring confirms hypertension if values are ≥125/80 mmHg. 1
• Remove tight clothing, support your arm at heart level, ensure relaxation, and avoid talking during measurement. 1

Risk Assessment Determines Treatment Intensity

The decision to start medication depends on your cardiovascular risk profile, not blood pressure alone. 1

Start medication immediately if you have ANY of:

• Target organ damage (left ventricular hypertrophy, retinopathy, proteinuria, elevated creatinine) 1
• Established cardiovascular disease (prior stroke, heart attack, angina) 1
• Diabetes mellitus 1
• 10-year coronary heart disease risk >15% (calculate using Joint British Societies risk chart) 1

If none of the above apply:

• Continue monitoring blood pressure and reassess cardiovascular risk. 1
• Implement lifestyle modifications aggressively (see below). 1
• Recheck blood pressure in 1-3 months. 1

First-Line Medication Choice

If treatment is indicated, start with a low-dose thiazide diuretic or calcium channel blocker as first-line therapy. 1, 2

The British Hypertension Society guidelines recommend low-dose thiazide diuretics or β-blockers as preferred first-line treatment for the majority of hypertensive patients in the absence of contraindications. 1 However, more recent evidence from 2022 supports thiazide or thiazide-like diuretics (such as chlorthalidone), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and calcium channel blockers as first-line options. 2

Specific recommendations:

• Chlorthalidone 12.5-25 mg once daily (preferred thiazide-like diuretic) 3, 2
• Amlodipine 5-10 mg once daily (calcium channel blocker alternative) 3, 2
• ACE inhibitor or ARB (e.g., lisinopril 10 mg or losartan 50 mg) if you have diabetes, chronic kidney disease, heart failure, or coronary disease 3, 2

Blood Pressure Targets

Your treatment goal is systolic <140 mmHg and diastolic <85 mmHg (optimal target). 1

• Minimum acceptable control: <150/<90 mmHg 1
• Optimal target: <140/<85 mmHg 1
• For higher-risk patients (diabetes, chronic kidney disease, cardiovascular disease): <130/80 mmHg 2

Lifestyle Modifications (Essential for All)

Non-pharmacological measures must be implemented regardless of whether you start medication. 1

Dietary changes:

• Reduce sodium intake to <2 g/day (approximately 5 g salt/day) – yields 5-10 mmHg systolic reduction 3, 2
• Adopt DASH dietary pattern (high in fruits, vegetables, whole grains, low-fat dairy; low in saturated fat) – reduces BP by ~11/5.5 mmHg 3, 2
• Increase potassium intake through diet 2

Weight and exercise:

• Lose weight if BMI ≥25 kg/m² – losing 10 kg reduces BP by ~6/4.6 mmHg 3, 2
• Regular aerobic exercise ≥30 minutes most days (≥150 minutes/week moderate intensity) – lowers BP by ~4/3 mmHg 3, 2

Alcohol and smoking:

• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women 3, 2
• Stop smoking completely 1

Monitoring and Follow-Up

Reassess blood pressure within 1 month of starting treatment. 4

• If BP remains ≥140/90 mmHg after 1 month, add a second agent from a different class. 4
• Goal: achieve target BP within 3 months of treatment initiation. 3, 4
• When adding a thiazide diuretic, check serum potassium and creatinine 2-4 weeks later to detect hypokalemia or renal changes. 3

Escalation Strategy if Initial Treatment Fails

If blood pressure remains uncontrolled on one medication, add a second agent rather than increasing the dose. 3, 5

Recommended two-drug combinations:

• Thiazide diuretic + calcium channel blocker 3
• Thiazide diuretic + ACE inhibitor or ARB 3
• Calcium channel blocker + ACE inhibitor or ARB 3

If still uncontrolled on two drugs:

• Add a third agent to create triple therapy (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic). 3

For resistant hypertension (uncontrolled on three drugs):

• Add spironolactone 25-50 mg daily as the preferred fourth-line agent – provides additional 20-25/10-12 mmHg reduction. 3

Critical Pitfalls to Avoid

• Do not delay treatment if you have target organ damage, cardiovascular disease, diabetes, or high cardiovascular risk – these require immediate medication. 1
• Do not combine an ACE inhibitor with an ARB – this increases adverse events (hyperkalemia, acute kidney injury) without added benefit. 3
• Do not add a beta-blocker as second or third agent unless you have angina, prior heart attack, heart failure, or atrial fibrillation – beta-blockers are less effective for stroke prevention. 3
• Do not assume treatment failure without first confirming medication adherence – non-adherence is the most common cause of apparent treatment resistance. 3
• Do not ignore lifestyle modifications – they provide additive 10-20 mmHg systolic reduction and enhance medication efficacy. 3, 2