Patients with untreated stage 1 hypertension should be prescribed medication if their blood pressure does not decrease after six months of guideline-recommended lifestyle therapy, according to a new scientific statement from the American Heart Association.

Published in the Association's journal Hypertension, the recommendation fills a gap in current guidance by addressing how to manage untreated, stage 1 high blood pressure, which is levels of 130-139/80-89mmHg.

The 2017 American College of Cardiology/American Heart Association Blood Pressure Management Guidelines' recommendation for patients with stage 1 hypertension and a low (<10%) risk for having a heart attack or stroke within 10 years is to first treat with healthy lifestyle changes and then repeat the blood pressure check in six months. For patients with stage 1 hypertension and a high (>10%) 10-year risk for heart attack or stroke, the guidelines recommend anti-hypertensive medication in addition to healthy lifestyle.

The new scientific statement suggests clinicians should consider medication for patients with a low ten-year risk if the blood pressure goals (<130/80mmHg) are not met after six months of sustained healthy lifestyle changes. 

Cornerstone of cardiovascular disease prevention

Many patients who have stage 1 high blood pressure are adults under the age of 40. Randomised controlled trials following these patients for cardiovascular disease risk are lacking, therefore, the statement writing committee relied on other forms of evidence including observational studies focused on the relationship between blood pressure and cardiovascular disease.

Professor Daniel W. Jones, chair of the statement writing group, professor and dean emeritus at the University of Mississippi School of Medicine in Jackson, Mississippi, said: "We know that people with blood pressure lower than 130/80mmHg have fewer markers of cardiovascular risk like elevated coronary calcium, enlargement of the heart, or buildup of fatty deposits called atherosclerosis in arteries of the neck. There is strong evidence that treating high blood pressure saves lives by reducing the risks for heart attack and stroke."

Healthy lifestyle changes to lower blood pressure include achieving ideal body weight, exercising (30 minutes on most days of moderate to vigorous physical activity, if possible), limiting dietary sodium, enhancing potassium intake and following the Dietary Approaches to Stop Hypertension (DASH) diet (combination diet of fruits and vegetables with low-fat dairy products and reduced saturated fat and total fat). In addition, patients should be recommended to limit alcohol and not smoke. These remain the cornerstone of cardiovascular disease prevention.

"If after six months with lifestyle changes, blood measure does not improve, clinicians should consider adding medications to control blood pressure," said Jones. "That's an important message for patients to hear as well because they should check their blood pressure regularly to monitor progress. If they don't achieve average daily systolic blood pressure less than 130mmHg, it's probably time to initiate a conversation with their doctor about practical next steps, which may include adding medication, to manage their blood pressure."