Management of Hypertension

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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

See also: Medicines for High Blood Pressure written for patients

See related separate articles Hypertension and Hypertension in Pregnancy, and the National Institute for Health and Care Excellence (NICE) Hypertension Pathway Quality Standard.[1][2][3] 

Advise lifestyle measures in patients with hypertension and high normal blood pressure (BP), ie clinic BP 130-139/85-89 mm Hg. Inform about any local initiatives, and supplement advice with leaflets or audiovisual information.

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Preventing or treating obesity[4]

Weight reduction should be suggested if necessary, to maintain an ideal body mass index (BMI) of 20-25 kg/m2. Offer a diet sheet and/or dietetic appointment. Dietary self-help (eg, dieting clubs) may be appropriate.

  • NICE recommends basing meals on starchy foods (potatoes, bread, rice and pasta) - using wholegrain bread, and brown rice if possible, but watch the portion size of meals and cut down on snacks.
  • Eat foods rich in fibre, ie cereals, pulses (beans, peas, lentils, grains, seeds), fruit and vegetables.
  • Have at least five portions of fruit and vegetables a day.
  • Select low-fat foods - avoid foods containing a lot of fat and sugar (eg, fried food, sweetened drinks, crisps, confectionery).
  • Reduce any excessive caffeine consumption and have a low dietary sodium intake (reduce or substitute any sodium salt). Calcium, magnesium or potassium supplements are not recommended.
  • Ensure you eat breakfast.
  • Cut alcohol intake to no more than 21 units (male) or 14 units (female) of alcohol per week. Be careful not to take too many calories in the form of alcohol.

See the Dietary Approaches to Stop Hypertension (DASH) eating plan.[5]

Stopping smoking

Patients should stop smoking (offer help ± nicotine replacement therapy) - see separate article Smoking Cessation.

Encouraging exercise

  • Make physical activities part of everyday life (eg, walk or cycle to work, use the stairs instead of the lift, walk at lunchtime), and build in enjoyable activities to leisure time every week (eg, walking, cycling, gardening, swimming, aerobics, etc).
  • Minimise sedentary activities (eg, limit television watching or sitting at a computer or playing video games).
  • Once more, look for local activities, join a sporting group, take advantage of taster sessions and get used to exercising regularly, ideally several times a week.
  • Vigorous exercise is not advised in severe hypertension.

Salt[6][7] 

  • Salt reduction to 4.4 g per day results in a reduction of ~4/2 mm Hg in blood pressure.
  • Guidelines recommend that we should have no more than 5-6 grams of salt per day.
  • Patients should be advised to not add salt to food and to avoid processed foods.
  • Food labelling is making it easier to determine the salt content of food.

Consider treating immediately if BP in clinic is ≥180/110 mm Hg; otherwise, consider after results of ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), blood tests and cardiovascular risk assessment are available.

Diagnose hypertension if average of ABPM or HBPM readings is ≥135/85 mm Hg, (ignore first day readings and average the rest - see separate article Hypertension).
  • Stage 1 hypertension - clinic readings ≥140/90 mm Hg and ABPM/HBPM ≥135/85 mm Hg.
  • Stage 2 hypertension - clinic readings ≥160/100 mm Hg and ABPM/HBPM ≥150/95 mm Hg.

Drug treatment should be commenced in patients aged under 80 years with stage 1 hypertension plus signs of end organ damage (known cardiovascular or renal disease), or with diabetes mellitus or a 10-year cardiovascular disease (CVD) risk ≥20%. Treatment in mild hypertension without target-organ damage or cardiovascular risk remains contentious.[8] 

Treatment should be started in all patients (any age) with stage 2 hypertension. Treat isolated systolic hypertension in the same way.

Initial Drug Choices[1]
If the patient is young (≤55 years) and non-black, start with:
  • (A) angiotensin-converting enzyme (ACE) inhibitor or low-cost angiotensin-II receptor antagonist (AIIRA).
  • A beta-blocker may be appropriate in younger adults if an ACE is not tolerated, in women who may become pregnant or if there is evidence of increased sympathetic drive.
If the patient is aged >55 years or a black person of African or Caribbean family origin, use:
Stage 2 Drug Choices

  • (A+C) ACE inhibitor or AIIRA with CCB.
  • Use an ACE/AIIRA and a thiazide-like diuretic (D) if CCB is not tolerated (or if there is any evidence of heart failure).
  • If initially started on a beta-blocker, add a CCB rather than a thiazide-like diuretic second-line (reduce diabetic risk).
  • Consider an AIIRA rather than an ACE with a CCB in black (African or Caribbean) patients.
Stage 3 Drug Choices

  • (A+C+D) ACE inhibitor or AIIRA and a CCB and a thiazide-like diuretic (chlortalidone or indapamide).
Stage 4 Drug Choices

  • (A+C+D) ACE inhibitor or AIIRA and a CCB and a thiazide-like diuretic plus a further diuretic (higher-dose thiazide-like diuretic or spironolactone, depending on potassium).
    If the higher-dose diuretic is not tolerated, consider an alpha- or beta-blocker, or seek expert advice.

The combination of an ACE inhibitor with an AIIRA is not recommended for the treatment of hypertension.[1]

Treatment targets[1][7] 

  • People aged <80 years: clinic <140/90 mm Hg, ABPM/HBPM <135/85 mm Hg.
  • People aged ≥80 years: clinic <150/90 mm Hg, ABPM/HBPM <145/85 mm Hg.

Monitor regularly with BP checks plus appropriate blood tests (eg, U&E and renal function on ACE inhibitor). Consider cholesterol-lowering treatment if CVD risk is ≥20% (see separate article Lipid-regulating Drugs). Further ABPM/HBPM may be needed to avoid overtreatment due to 'white coat hypertension'.

  • Doctors and patients can use Decision Aids together to help choose the best course of action to take.
  • Compare the options  

Refer if hypertension is difficult to control in spite of the steps above.[9] 

Consider seeking specialist evaluation of patients aged <40 years who appear to have stage 1 hypertension without target organ damage or diabetes, either for exclusion of secondary causes of hypertension or a more detailed assessment of cardiovascular risk, as standard assessments can underestimate the lifetime risk in these people.[1][7] 

Further reading & references

  1. Hypertension: management of hypertension in adults in primary care; NICE Clinical Guideline (August 2011)
  2. Hypertension overview; NICE Pathway, August 2011
  3. Hypertension; NICE Quality Standards, March 2013
  4. Obesity; NICE Clinical Guideline (December 2006)
  5. DASH (Dietary Approaches to Stop Hypertension) Diet; National Institutes of Health
  6. He FJ, Li J, Macgregor GA; Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ. 2013 Apr 3;346:f1325. doi: 10.1136/bmj.f1325.
  7. Guidelines for the management of arterial hypertension; ESH/ESC Clinical Practice Guidelines, European Society of Cardiology (2013)
  8. Diao D, Wright JM, Cundiff DK, et al; Pharmacotherapy for mild hypertension. Cochrane Database Syst Rev. 2012 Aug 15;8:CD006742. doi: 10.1002/14651858.CD006742.pub2.
  9. Myat A, Redwood SR, Qureshi AC, et al; Resistant hypertension. BMJ. 2012 Nov 20;345:e7473. doi: 10.1136/bmj.e7473.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Huw Thomas
Current Version:
Peer Reviewer:
Dr Helen Huins
Document ID:
486 (v25)
Last Checked:
17/12/2013
Next Review:
16/12/2018

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