Recommendations
The European Society of Hypertension provides recommendations for the duration of lifestyle interventions before trying medication. The recommendations are based on a complex scheme of overall cardiovascular risk assessment that takes into account traditional Framingham risks and other factors (such as obesity, C-reactive protein, and micro albuminuria), as well as the stage of hypertension.6 The Society recommends starting drug therapy immediately in people with blood pressure >180/110 mm Hg. This blood pressure threshold drops in patients with increasing numbers of risk factors. For patients with lower, but still elevated, blood pressure, the recommendations call for “lifestyle changes for several months, then drug treatment if BP is uncontrolled.”
For patients with diabetes, the American Diabetes Association (ADA) recommends a blood pressure goal of <130/80 mm Hg and drug therapy in addition to lifestyle and behavioral therapy for patients with systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg.7 Like the JNC7, the ADA notes that a combination of medications is often required to achieve blood pressure targets. The ADA recommendations also state that patients with diabetes and a systolic blood pressure of 130 to 139 mm Hg or a diastolic blood pressure of 80 to 89 mm Hg should pursue lifestyle and behavioral interventions alone for a maximum of 3 months, then start drug therapy if they don’t achieve their blood pressure goals.
The American Heart Association and American College of Cardiology offer evidence-based guidelines for secondary prevention in patients with atherosclerosis.8 They set blood pressure goals of <140/90 mm Hg for all patients and <130/80 mm Hg for patients with diabetes or chronic kidney disease. All patients are encouraged to initiate or maintain lifestyle modifications. If a patient’s blood pressure is ≥140/90 mm Hg (>130/80 mm Hg for patients with chronic kidney disease or diabetes), medications should be titrated to goal, beginning with beta-blockers or angiotensin-converting enzyme inhibitors.