See the separate Hypertension and Hypertension in Pregnancy articles. This article is based primarily on current guidelines in the UK from the National Institute for Health and Care Excellence (NICE), namely the Clinical Guideline, the Hypertension Pathway and the Quality Standard for hypertension in adults[1, 2, 3].
Clinical Editor's comments (October 2017)
Dr Hayley Willacy recommends this recent consensus paper from European Cardiovascular societies looking at risk scoring in people with high blood pressure. Risk stratification in hypertensive patients is of crucial importance to manage treatment and prevent adverse events. Asymptomatic involvement of different organs in patients affected by hypertension represents an independent determinant of CV risk and the identification of target organ damage is recommended to further reclassify patients’ risk. Non-invasive CV imaging is progressively being used and continues to provide new technological opportunities to evaluate end-organ damage at early stage. The paper provides those managing these people with an update on appropriate and justified use of non-invasive imaging tests in the growing population of hypertensive patients.
Discuss lifestyle measures in patients undergoing assessment for, or treatment of, hypertension. Inform about any local initiatives, and supplement advice with leaflets or audiovisual information.
Advice from NICE includes:
- Weight reduction should be suggested if necessary, to maintain an ideal body mass index (BMI) of 18.5-24.9 kg/m2. Offer a diet sheet and/or dietetic appointment. Dietary self-help (eg, dieting clubs, for which there may be local referral options) may be appropriate. Encourage physical activity alongside dietary changes. NICE guidelines for obesity make further recommendations about pharmaceutical and surgical options where appropriate.
- Use of wholegrain varieties of starchy food (eg, rice, pasta, bread) where possible.
- Reduction of saturated fats, and increasing mono-unsaturated fats, using olive or rapeseed oils and spreads.
- Reduction in sugar intake and that of foods containing refined sugars.
- Eating at least five portions of fruit and vegetables per day.
- Eating at least two portions of fish per week, including a portion of oily fish.
- Eating at least 4-5 portions of unsalted nuts, seeds and legumes per week.
- Reducing any excessive caffeine consumption.
- Low dietary salt (see section below).
- Keeping alcohol within current national recommended levels. (Currently no more than 14 units per week for men and women, spread through the week, with at least two days alcohol-free.)
- Calcium, magnesium or potassium supplements are not recommended.
Patients should stop smoking (offer help ± nicotine replacement therapy). See the separate Smoking Cessation article.
- 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.
- Salt reduction to 4.4 g per day results in a reduction of ~4/2 mm Hg in blood pressure (BP).
- Guidelines recommend that we should have no more than 5-6 grams of salt per day.
- Patients should be advised not to 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.
- 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.
Hypertension treatment should be commenced in people 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 CVD risk ≥20%. Treatment in mild hypertension without target-organ damage or cardiovascular risk remains contentious.
Treatment should be started in all patients (any age) with stage 2 hypertension. Treat isolated systolic hypertension in the same way.
Initial antihypertensive choices
|If the patient is young (≤55 years) and non-black, start with:||If the patient is aged >55 years or a black person of African or Caribbean family origin, use:|
Step 2 choices
Step 3 choices
Step 4 choices
Dr Sarah Jarvis, March 2019.
Dual therapy in black African patients with hypertension
A new study in the New England Journal of Medicine (NEJM) has compared the efficacy of A, C and D combinations in patients of black African origin. The drugs used were ACE inhibitor (perindopril), Calcium-channel blocker (amlodipine) and Diuretic (hydrochlorothiazide).
The results showed that using these agents, A+C or C+D was more effective than A+D at controlling 24-hour systolic blood-pressure, office and ambulatory diastolic blood pressures, overall blood-pressure control and response rates.
The combination of an ACE inhibitor with an AIIRA is not recommended for the treatment of hypertension.
The PATHWAY-2 trial, published in 2015, suggested that spironolactone is the most effective fourth-line agent for resistant hypertension. A drug safety update from the Medicines and Healthcare products Regulatory Agency (MHRA) in 2016 warns of the risk of hyperkalaemia when an ACE inhibitor or AIIRA is combined with spironolactone. Routine use of this combination is not recommended but where it is, the lowest possible dose should be used and electrolytes monitored closely.
Hypertension treatment targets
- 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 the separate Lipid-regulating Drugs (including Statins) article. Further ABPM/HBPM may be needed to avoid overtreatment due to 'white coat hypertension'.
Recent research tends to suggest more aggressive hypertension treatment targets may be appropriate in future.
- The Systolic Blood Pressure Intervention Trial (SPRINT) study, published in 2015, showed that a target of below 120 mm Hg rather than below 140 mm Hg for systolic blood pressure led to significant reduction in deaths and cardiovascular events, albeit with an increased incidence of adverse events.
- A systematic review and meta-analysis published in the Lancet in 2016 (but not including the SPRINT study) also showed a significant reduction in cardiovascular events with more intensive treatment.
Benefits of hypertension treatment
Research continues to demonstrate the significant benefits of lowering high blood pressure. A large 2016 systematic review and meta-analysis showed:
- Each 10 mm Hg reduction of systolic blood pressure was associated with an overall relative reduction in risk of major cardiovascular event of 20%, and a reduction of mortality of 13%.
- There was no evidence of a level of BP reduction below which there is not further benefit.
- There was no evidence of increased risk at lower BP levels.
- CCBs were most effective in reducing the risk of stroke, whereas diuretics were most effective in reducing the risk of heart failure.
Self-monitoring may result in better BP control.
Refer if hypertension is difficult to control in spite of the steps above.
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, 9].
Hypertension in the context of multimorbidity
Multimorbidity is increasingly the norm. One UK-based study found that two thirds of people with hypertension have a co-morbidity. Those with multimorbidity tend to be excluded from trials, making it difficult to determine optimum management. Management needs to be tailored to the individual, and NICE has developed guidelines to aid in the assessment and management of those with multimorbidity.
A 2016 paper in the British Medical Journal (BMJ) collates advice from the disease-specific NICE guidelines to make recommendations about choices in these conditions, which may represent different choices from those in the hypertension NICE guidelines:
- Chronic heart failure: people would normally already be on A and a beta-blocker. Add D, and if still not controlled, refer for specialist advice to consider spironolactone.
- Diabetes: A is first-line in type 1 and type 2. Add D as second-line and C as third-line. For type 2 diabetes, if of black African or Caribbean origin, use A + D or A + C first-line.
- Atrial fibrillation: if rate control is needed, add a beta-blocker (but not sotalol) or a rate-limiting CCB such as diltiazem. If on amlodipine, change to a rate-limiting CCB such as diltiazem.
- Chronic kidney disease: treatment depends on whether there is diabetes or not and on the albumin:creatinine ratio (ACR). A would normally be the first choice.
Further reading and references
Hypertension in pregnancy; NICE Clinical Guideline (August 2010, updated 2011)
Falaschetti E, Mindell J, Knott C, et al; Hypertension management in England: a serial cross-sectional study from 1994 to 2011. Lancet. 2014 May 31383(9932):1912-9. doi: 10.1016/S0140-6736(14)60688-7.
Hypertension: management of hypertension in adults in primary care; NICE Clinical Guideline (August 2011)
Hypertension overview; NICE Pathway, August 2011
Hypertension; NICE Quality Standards, March 2013
Non-invasive cardiovascular imaging for evaluating subclinical target organ damage in hypertensive patients: A consensus paper from the European Association of Cardiovascular Imaging (EACVI), the European Society of Cardiology Council on Hypertension, and the European Society of Hypertension (ESH) (Sept 2017)
Obesity: identification assessment and management of overweight and obesity in children young people and adults; NICE Clinical Guideline (November 2014)
Alcohol Guidelines Review – Report from the Guidelines development group to the UK Chief Medical Officers; Department of Health, January 2016
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 3346:f1325. doi: 10.1136/bmj.f1325.
Guidelines for the management of arterial hypertension; ESH/ESC Clinical Practice Guidelines, European Society of Cardiology (2013)
Diao D, Wright JM, Cundiff DK, et al; Pharmacotherapy for mild hypertension. Cochrane Database Syst Rev. 2012 Aug 158:CD006742. doi: 10.1002/14651858.CD006742.pub2.
Wiysonge CS, Bradley HA, Volmink J, et al; Beta-blockers for hypertension. Cochrane Database Syst Rev. 2012 Nov 1411:CD002003. doi: 10.1002/14651858.CD002003.pub4.
Comparison of combinations of blood pressure-lowering drugs in black African patients with hypertension; New England Journal of Medicine (NEJM)
Williams B, MacDonald TM, Morant S, et al; Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015 Nov 21386(10008):2059-68. doi: 10.1016/S0140-6736(15)00257-3. Epub 2015 Sep 20.
Drug Safety Update; Medicines and Healthcare products Regulatory Agency (MHRA) February 2016
Wright JT Jr, Williamson JD, Whelton PK, et al; A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015 Nov 26373(22):2103-16. doi: 10.1056/NEJMoa1511939. Epub 2015 Nov 9.
Xie X, Atkins E, Lv J, et al; Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016 Jan 30387(10017):435-43. doi: 10.1016/S0140-6736(15)00805-3. Epub 2015 Nov 7.
Ettehad D, Emdin CA, Kiran A, et al; Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016 Mar 5387(10022):957-67. doi: 10.1016/S0140-6736(15)01225-8. Epub 2015 Dec 24.
McManus RJ, Mant J, Haque MS, et al; Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial. JAMA. 2014 Aug 27312(8):799-808. doi: 10.1001/jama.2014.10057.
Myat A, Redwood SR, Qureshi AC, et al; Resistant hypertension. BMJ. 2012 Nov 20345:e7473. doi: 10.1136/bmj.e7473.
Brilleman SL, Purdy S, Salisbury C, et al; Implications of comorbidity for primary care costs in the UK: a retrospective observational study. Br J Gen Pract. 2013 Apr63(609):e274-82. doi: 10.3399/bjgp13X665242.
Multimorbidity: clinical assessment and management; NICE Guidance (September 2016)
Kennard L, O'Shaughnessy KM; Treating hypertension in patients with medical comorbidities. BMJ. 2016 Feb 16352:i101. doi: 10.1136/bmj.i101.