What is the recommended management for hypertension?

Management of Hypertension

The recommended management for hypertension includes lifestyle modifications for all patients and pharmacological therapy for those with sustained systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥100 mmHg, or those with lower blood pressure but with target organ damage, cardiovascular disease, diabetes, or high cardiovascular risk. 1

Blood Pressure Thresholds for Treatment

When to Initiate Pharmacological Therapy:

• Immediate treatment required for:

  • Sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg 1
  • Accelerated hypertension (severe hypertension with grade III-IV retinopathy)
  • Particularly severe hypertension (>220/120 mmHg)
  • Impending complications (e.g., TIA, left ventricular failure) 1

• Treatment indicated for sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg when:

  • Target organ damage is present
  • Established cardiovascular disease exists
  • Diabetes is present
  • 10-year cardiovascular disease risk ≥20% 1

• Consider lifestyle modifications alone for 3-6 months in:

  • Grade 1 hypertension (140-159/90-99 mmHg) without complications or high risk 1

Lifestyle Modifications

All patients with hypertension or high-normal blood pressure should implement the following lifestyle changes 1, 2:

1. Weight reduction to achieve ideal body weight

   • Each kg lost can reduce systolic BP by approximately 1 mmHg 2

2. Physical activity

   • 30-60 minutes of moderate aerobic exercise 4-7 days per week
   • Can reduce systolic BP by 3-8 mmHg 2, 3

3. Dietary modifications

   • Reduced sodium intake (can lower systolic BP by 3-6 mmHg)
   • Increased fruit and vegetable consumption
   • Reduced total and saturated fat intake
   • Replacement of saturated fats with monounsaturated fats (olive oil, rapeseed oil)
   • Increased fish consumption 1, 2, 4

4. Alcohol moderation

   • ≤21 units/week for men
   • ≤14 units/week for women 1, 2

5. Smoking cessation 1

These lifestyle modifications can significantly reduce blood pressure and may complement pharmacological therapy, reducing the number or doses of medications required 1, 3, 5.

Pharmacological Therapy

First-Line Medications:

When pharmacological treatment is indicated, the following options are recommended:

1. Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide) 1, 6, 7
2. ACE inhibitors (e.g., lisinopril) 8, 7
3. Angiotensin receptor blockers (ARBs) 2, 7
4. Calcium channel blockers (e.g., amlodipine) 9, 7

The choice between these medications should follow the AB/CD algorithm, considering compelling indications and contraindications for specific patient groups 1.

Treatment Algorithm:

• Step 1: Start with a single agent from the first-line options
• Step 2: If blood pressure remains uncontrolled, add a second agent from a different class
• Step 3: If necessary, add a third agent
• Step 4: Consider resistant hypertension and add a fourth agent or specialist referral 1

Most patients will require at least two antihypertensive medications to achieve target blood pressure goals 8, 9, 7.

Blood Pressure Targets

General Population:

• Target BP ≤140/85 mmHg 1
• Minimum acceptable control (audit standard): <150/90 mmHg 1

High-Risk Patients:

• For patients with diabetes, renal impairment, or established cardiovascular disease:
  • Target BP ≤130/80 mmHg 1, 2
  • Audit standard: <140/80 mmHg 1

Additional Cardiovascular Risk Reduction

Aspirin:

• Recommended for secondary prevention in all patients with established cardiovascular disease
• For primary prevention in patients ≥50 years with controlled BP (<150/90 mmHg) and 10-year cardiovascular risk ≥20% 1

Statins:

• Recommended for all hypertensive patients with established cardiovascular disease
• For primary prevention in patients with 10-year cardiovascular risk ≥20% and total cholesterol ≥3.5 mmol/L 1

Special Considerations

Evaluation for Secondary Causes:

Consider referral for specialist evaluation when:

• Young age (<30 years needing treatment)
• Resistant hypertension (≥3 drugs)
• Sudden onset or worsening of hypertension
• Signs suggesting secondary causes (e.g., hypokalaemia with high normal sodium) 1

Ambulatory Blood Pressure Monitoring:

Indicated for:

• Unusual BP variability
• Possible white coat hypertension
• Resistant hypertension
• Suspected hypotension 1

Follow-Up

• Allow at least four weeks to observe full response to medication changes
• Titrate medication doses according to manufacturers' instructions
• Schedule follow-up visits every 2-4 weeks until BP goal is achieved, then every 3-6 months 2
• Monitor electrolytes, creatinine, and eGFR, particularly when using ACE inhibitors or ARBs 2

By following this structured approach to hypertension management, focusing on appropriate lifestyle modifications and evidence-based pharmacological therapy, mortality and morbidity from cardiovascular disease can be significantly reduced.