Management of mild hypertension in adults

Elevated blood pressure is a common risk factor for cardiovascular disease and affects one in three adults. Blood pressure lowering drugs substantially reduce the risk of stroke, coronary heart disease, heart failure, and premature death, but most clinical trials showing benefits have primarily included patients with moderate to severe hypertension, known cardiovascular disease, or elevated risk of cardiovascular disease. The benefits of treating mild hypertension in patients without cardiovascular disease are less clear, but recent meta-analyses offer some insights. Pooled data from trials that include a large percentage of participants with mild hypertension show significant reductions in stroke, death from cardiovascular disease, and total mortality. Meta-analyses comparing lower blood pressure targets also suggest a benefit of treating patients with mild hypertension, although net benefits are greater for patients at higher absolute levels of cardiovascular disease risk. Before starting drug treatment, most patients should have out-of-office monitoring to confirm hypertension. Lifestyle modifications for reducing blood pressure are appropriate for all patients and may be recommended while delaying drug treatment for those at lower absolute levels of cardiovascular disease risk. Patient level control of blood pressure is supported by home monitoring and by once daily, low cost drug. Control of blood pressure for a population of patients is enhanced by system level interventions such as registries, implementation of evidence based protocols, drug titration visits, and performance metrics.