Hypertension Treatment Guidelines

ICD 10 code = I10.

Key Points on Hypertension Treatment

Hypertension control has significant benefit for patients.

Detect and treat co-existent risk factors.

Assess cardiovascular risk.

Lifestyle modification and patient education is essential for all patients.

Medicine treatment is needed for SBP ≥140 mmHg and DBP ≥90 mmHg despite lifestyle modification. See medicine treatment choices below.

Immediate medicine treatment is needed for DBP ≥110 mmHg and/or SBP ≥180 mmHg (defined as severe hypertension) or for patients with 3 or more risk factors, target organ damage and/or associated clinical conditions.

Patients should be evaluated for cardiovascular risk factors, target organ damage and associated clinical conditions.

Other major risk factors for ischaemic cardio- and cerebrovascular disease, check Ischaemic heart disease and atherosclerosis, prevention.

Target organ damage (TOD)

• Left ventricular hypertrophy,
• Hypertensive retinopathy,
• Microalbuminuria, or positive dipsticks for albuminuria or elevated albumin/creatinine ratio, or
• Elevated creatinine level (or eGFR <60 mL/minute).

Associated clinical conditions:

• Ischaemic heart disease,
• Heart failure,
• Stroke or transient ischaemic attack,
• Chronic kidney disease,
• Peripheral arterial disease.

Investigations

If overweight, record body weight and waist circumference at each visit when BP is measured.

Central obesity is defined as waist circumference of 102 cm in men and 88 cm in women.

Do urine test strip analysis for protein, blood and glucose at presentation.

• If normal, repeat urine test strip every 6 months.
• If abnormal, do spot urine ACR. Repeat yearly.
• If haematuria >1+, investigate further.
• If glycosuria, exclude diabetes mellitus.

Other important investigations to do:

• If known diabetic, HbA1c.
• Random total cholesterol.
• Perform a resting ECG to exclude left ventricular hypertrophy or ischaemia.
• Assess renal function (serum creatinine and eGFR).

Goal of Hypertension treatment: Aim for SBP < 140 mmHg and DBP < 90 mmHg.

General Measures

All persons with hypertension should be encouraged to make the following lifestyle changes as appropriate.

Lifestyle Modification

• Maintain ideal weight, i.e. BMI <25 kg/m2. Weight reduction in the overweight patient.
• Salt restriction with increased potassium intake from fresh fruits and vegetables (e.g. remove the salt from the table, gradually reduce added salt in food preparation and avoid processed foods). Dietician’s advice recommended.
• Reduce alcohol intake to no more than 2 standard drinks per day for males and 1 for females.
• Follow a prudent eating plan i.e. low fat, high fibre and unrefined carbohydrates, with adequate fresh fruit and vegetables. Dietician’s advice recommended.
• Regular moderate aerobic exercise, e.g. 40 minutes brisk walking at least 3 times a week.

Medicine Treatment of Hypertension

Initial medicine choice in patients qualifying for treatment is dependent on the presence of compelling indications (see section); the severity of the BP elevation; and the presence of target organ damage, cardiovascular risk factors, and associated clinical conditions.

Check adherence to antihypertensive therapy by doing pill counts and questioning family members.

The use of fixed dose combination medication for control of hypertension provides greater adherence and such agents should be used when they are available.

There is emerging evidence that taking the total daily dose of antihypertensive medication at bedtime rather than on awaking provides both better control of hypertension and a significant reduction in important cardiovascular events.

Monitor patients monthly and adjust therapy if necessary until the BP is controlled.

After target BP is achieved, patients can be seen at 3–6 monthly intervals.

Medicine Treatment Choices without Compelling Indications

Stepped-care approach to BP treatment is as follows:

If lifestyle modification failed to achieve BP control: Counsel patient on the risk of major cardiovascular events associated with elevated BP; and initiate monotherapy.

If BP control is suboptimal: Up titrate treatment (maximise dose of current antihypertensive and/or add additional medicine).

Evidence suggests that treatment inertia contributes to suboptimal BP control with patients remaining on monotherapy and/or suboptimal doses.

Initiate combination medicine therapy in cases of severe hypertension and hypertensive urgency.

BP 140-159/90-99 mmHg

For < 3 risk factors, no target organ damage or associated clinical conditions:

• Lifestyle modification for 3–6 months.
• Start antihypertensive therapy with a single medicine if target BP not achieved.

For ≥ 3 risk factors, target organ damage and/or associated clinical conditions:

• Start antihypertensive therapy immediately (together with lifestyle modification).

BP 160-179/100-109 mmHg

Even in absence of risk factors, or target organ damage or associated clinical conditions:

Start antihypertensive therapy (together with lifestyle modifications) with a combination of two medicines.

BP ≥180/100 mmHg: this is severe hypertension, see article.

Medicines used in Hypertension treatment

Initial antihypertensive medicine:

• Hydrochlorothiazide, oral, 12.5 mg daily.
• Caution in patients with gout.
• Less effective in impaired renal function.
• Caution in patients with a history or family history of skin cancer; and counsel all patients on sun avoidance and sun protection.

If target BP is not reached after one month despite adequate adherence (or immediately in patients with BP160-179/100-109 mmHg), add one of the following: ACE-inhibitor or calcium channel blocker.

Long-acting calcium channel blocker, e.g.:

Amlodipine, oral, 5 mg at night.

OR

ACE-inhibitor, e.g.:

Enalapril, oral, 10 mg at night.

If ACE-inhibitor intolerant, i.e. intractable cough:

Angiotensin receptor blocker (ARB), e.g. Losartan, oral, 50 mg daily. Specialist initiated.

If target BP is not reached after one month despite adequate adherence on two medicines, add one of ACE-inhibitor or calcium channel blocker, whichever has not already been used.

If target BP is still not achieved after one month despite adequate adherence, increase the dose of medication, one medicine every month, to their maximal levels: amlodipine 10 mg daily, enalapril 20 mg daily (losartan 100 mg daily) hydrochlorothiazide 25 mg daily.

If target BP is not reached after one month despite adequate adherence, ADD:

Spironolactone, oral 25–50 mg daily.

For refractory hypertension, ADD:

β-blocker , e.g.:

Atenolol, oral, 50 mg at night.

Note: In 60–80% of patients a combination of the above antihypertensive therapy is needed. Combination therapy, i.e. hydrochlorothiazide plus a calcium channel blocker or ACE-inhibitor should be considered at the outset in patients with BP >160/100 mmHg.

Medicine treatment choices with compelling indications

Referral

Referrals or consultation with a specialist are indicated when:

• Patients are adherent to therapy, and BP is refractory, i.e. >140/90 mmHg, while on medicines from 3-4 different classes at appropriate dose, one of which is a diuretic.
• All cases where secondary hypertension is suspected.
• Complicated hypertensive urgency e.g. malignant/accelerated hypertension, severe heart failure with hypertension and hypertensive emergency.

More reading on Hypertension is here.