Management of Hypertension in Patients on Antipsychotic Medication

Assessment and Diagnosis

The American Heart Association recommends confirming hypertension by taking at least two blood pressure readings and averaging them, as per international guidelines 1
Hypertension is confirmed if office BP is ≥140/90 mmHg, especially if home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg 1
A validated BP measuring device with appropriate cuff size should be used for accurate readings 1

The European Society of Cardiology recommends starting with lifestyle interventions including reduced salt intake, increased physical activity, weight management, and limited alcohol consumption 1, 2
For pharmacological management, the American Heart Association recommends considering low-dose ACE inhibitor or ARB as first-line therapy for non-black patients 1
For black patients, the American Heart Association recommends considering low-dose ARB with dihydropyridine calcium channel blocker (DHP-CCB) or thiazide/thiazide-like diuretic 1
Beta-blockers (except metoprolol) should be considered if the patient has drug-induced tachycardia from antipsychotic medications 3
RAS inhibitors (ACE inhibitors or ARBs) and diuretics are preferred in patients with psychiatric disorders due to fewer pharmacological interactions with antidepressants 3

The American Heart Association recommends targeting BP reduction of at least 20/10 mmHg with a goal of <130/80 mmHg 1, 2
BP control should be monitored with a goal to achieve target within 3 months 1
Potential drug interactions between antihypertensives and Lybalvi should be monitored 3

If BP remains uncontrolled despite optimal therapy, consideration should be given to referral to a specialist with hypertension expertise 1
For patients with resistant hypertension (BP >140/90 mmHg despite three medications including a diuretic), spironolactone may be considered as a fourth agent if serum potassium <4.5 mmol/L and eGFR >45 ml/min/1.73m² 3
Medication regimens should be simplified with once-daily dosing and single-pill combinations to improve adherence 2
BP targets should be individualized based on frailty, especially in elderly patients 1