When is medication needed for high blood pressure? Risk stratification and decision-making guidelines.

Does high blood pressure always require medication? When should medication be started?

Whether medication should be started immediately depends not only on the degree of high blood pressure, but also on whether there are other risk factors for cardiovascular and cerebrovascular diseases, or whether there has been a history of such diseases. In other words, a comprehensive understanding and assessment of the patient's overall condition is necessary to determine whether immediate medication is appropriate. Atherosclerosis and cardiovascular and cerebrovascular diseases are the result of multiple factors, with blood pressure being a major one. If, in addition to hypertension, there are other risk factors for cardiovascular and cerebrovascular diseases, and the more factors present, the greater the likelihood of cardiovascular and cerebrovascular events and the worse the prognosis, requiring more aggressive treatment. Therefore, for hypertensive patients, it is essential to understand whether they have other cardiovascular and cerebrovascular risk factors besides hypertension, conduct a comprehensive assessment, and then decide whether to start medication immediately.

After a preliminary diagnosis of hypertension, therapeutic lifestyle interventions should be initiated immediately. High-risk patients should begin antihypertensive medication immediately. Intermediate-risk and low-risk patients can be followed up for 1 month and 3 months, respectively. If blood pressure remains ≥140 mmHg and/or ≥90 mmHg after multiple measurements, antihypertensive medication is recommended or considered.

After a diagnosis of hypertension, all patients should adhere to long-term non-pharmacological treatment (lifestyle interventions), while most patients require long-term antihypertensive medication. The former is the cornerstone of hypertension treatment, and the latter is crucial for achieving target blood pressure; both are complementary and indispensable.

Non-pharmacological treatment includes promoting a healthy lifestyle and eliminating behaviors and habits detrimental to mental and physical health, thereby controlling hypertension and reducing the risk of other cardiovascular and cerebrovascular diseases.

Non-pharmacological treatments have a clear, mild blood pressure-lowering effect. For example, in obese individuals, a 10kg weight loss can lower systolic blood pressure by 5–20 mmHg; dietary salt restriction (<6g/day) can lower systolic blood pressure by 2–8 mmHg; regular exercise and limiting alcohol consumption can also lower blood pressure. For hypertensive patients and susceptible populations, regardless of whether they are already receiving drug treatment, non-pharmacological treatment is necessary and should be consistently maintained. Salt restriction is an important and effective non-pharmacological measure for the prevention and treatment of hypertension.

The 2014 "Guidelines for Primary Care Management of Hypertension in China" emphasizes the following:

(1) The basic goal of hypertension treatment is to achieve target blood pressure to minimize the overall risk of cardiovascular and cerebrovascular disease incidence and mortality. my country is a high-incidence area for stroke, and the main goal of hypertension treatment is stroke prevention.

(2) Target Blood Pressure: For general hypertensive patients, blood pressure should be reduced to below 140/90 mmHg; for elderly hypertensive patients (≥65 years old), blood pressure should be reduced to below 150/90 mmHg, and if tolerated, further reduced to below 140/90 mmHg. For general patients with diabetes or chronic kidney disease, the target blood pressure can be appropriately lowered.

(3) Hypertension is a "cardiovascular syndrome" characterized by persistently elevated blood pressure. While treating hypertension, comprehensive intervention should be implemented for all coexisting risk factors and clinical diseases.

(4) Time to Achieve Target Blood Pressure: If tolerated by the patient, early achievement of target blood pressure is recommended, and long-term adherence to the target is advised. After 2–4 weeks of treatment, assess whether blood pressure has reached the target. If the target is achieved, maintain treatment; if not, adjust the medication regimen promptly. For grade 1–2 hypertension, the target is generally achieved 4–12 weeks after treatment; if the patient has poor treatment tolerance or is elderly, the time to achieve the target can be appropriately extended.

Simply put, in addition to looking at blood pressure levels, other cardiovascular risk factors should also be considered. After a comprehensive evaluation and risk stratification, a treatment plan can be determined.