page125
changes to reduce blood pressure or cardiovascular risk;
these
include
smoking
cessation,
weight
reduction,
reduction of
excessive intake of
alcohol,
reduction of
dietary salt, reduction of total and saturated fat, increas-
ing exercise,
and increasing fruit and vegetable intake.
Thresholds and targets for treatment
The follow-
ing thresholds for treatment
1
are recommended:
.
Severe
hypertension
with
acute
target-organ
damage,
or
severe hypertension (systolic
blood
pressure 180 mmHg
or
diastolic
110 mmHg)
without acute target-organ damage, treat promptly
(see Hypertensive crises,
p.
106)
.
When the initial
blood pressure is systolic 160–
179 mmHg
or
diastolic 100–109 mmHg,
and
the
patient
has
cardiovascular
complications,
target-
organ damage (e.g.
left
ventricular
hypertrophy,
renal
impairment)
or diabetes mellitus (type 1 or
2), confirm over 3–4 weeks then treat if these values
are sustained;
.
When the initial
blood pressure is systolic 160–
179 mmHg
or
diastolic 100–109 mmHg,
but
the
patient
has
no
cardiovascular
complications,
no
target-organ damage, or no diabetes, advise lifestyle
changes, reassess weekly initially and treat if these
values are sustained on repeat measurements over
4–12 weeks;
.
When the initial
blood pressure is systolic 140–
159 mmHg
or
diastolic
90–99 mmHg
and
the
patient
has
cardiovascular
complications,
target-
organ
damage
or
diabetes,
confirm within
12
weeks and treat if these values are sustained;
.
When the initial
blood pressure is systolic 140–
159 mmHg
or
diastolic 90–99 mmHg and
no
cardi-
ovascular complications,
no target-organ damage,
or no diabetes,
advise lifestyle changes and reas-
sess monthly;
treat persistent mild hypertension if
the 10-year cardiovascular disease risk is 20% or
more.
2
A target systolic blood pressure < 140 mmHg
and
dia-
stolic blood pressure < 90 mmHg is suggested. A lower
target systolic blood pressure < 130 mmHg
and
diasto-
lic blood pressure < 80 mmHg should be considered for
those with established atherosclerotic cardiovascular
disease,
diabetes,
or
chronic renal
failure.
In some
individuals
it
may not
be possible to reduce blood
pressure below the suggested targets despite the use
of appropriate therapy.
Drug treatment of hypertension
Response to drug
treatment
for
hypertension may be affected by the
patient’s age and ethnic background. An ACE inhibitor
(section 2.5.5.1) or an angiotensin-II receptor antago-
nist (section 2.5.5.2) may be the most appropriate initial
drug in younger Caucasians;
however a beta-blocker
may be considered if
an ACE inhibitor
or
an angio-
tensin-II receptor antagonist is not tolerated or is con-
tra-indicated
(see
also
Hypertension
in
Pregnancy,
p.
106).
Afro-Caribbean patients and those aged over
55 years respond less well to ACE inhibitors and angio-
tensin-II receptor antagonists, therefore a thiazide (sec-
tion 2.2.1) or a calcium-channel blocker (section 2.6.2)
may be chosen for initial treatment.
Beta-blockers,
especially when combined with a thia-
zide diuretic,
should be avoided for the routine treat-
ment
of
uncomplicated hypertension in patients with
diabetes or in those at high risk of developing diabetes.
A single antihypertensive drug is often not adequate and
other
antihypertensive drugs are usually added in a
step-wise manner until
control
is achieved.
Unless it is
necessary to lower
the blood pressure urgently,
an
interval of at least 4 weeks should be allowed to deter-
mine response.
When two antihypertensive drugs are needed,
an ACE
inhibitor
or
an angiotensin-II receptor antagonist can be
combined with
either
a thiazide
or
a calcium-channel
blocker.
If control
is inadequate with 2 drugs,
a thiazide
and
a
calcium-channel blocker can be added. The addition of
an
alpha-blocker
(section
2.5.4),
spironolactone,
another diuretic, or a beta-blocker should be considered
in resistant
hypertension.
In patients
with
primary
hyperaldosteronism
,
spironolactone (section 2.2.3)
is
effective.
Other
measures to reduce cardiovascular
risk
Aspirin (section 2.9) in a dose of
75 mg daily reduces
the risk of cardiovascular events and myocardial infarc-
tion.
Unduly high blood pressure must
be controlled
before aspirin is given.
Unless contra-indicated,
aspirin
is recommended for all patients with established cardi-
ovascular disease. Use of aspirin in primary prevention,
in those with or without diabetes, is of unproven benefit
(see also section 2.9).
Lipid-regulating drugs can also be of benefit in cardio-
vascular
disease or
in those who are at
high risk of
developing cardiovascular disease (section 2.12).
Hypertension in the elderly
Benefit from antihyper-
tensive therapy is evident up to at least 80 years of age,
but it is probably inappropriate to apply a strict age limit
when deciding on drug therapy.
Patients who reach 80
years of age while taking antihypertensive drugs should
continue treatment,
provided that it continues to be of
benefit and does not cause significant side-effects.
The
thresholds for treatment are diastolic pressure averaging
90 mmHg
or
systolic
pressure
averaging
160 mmHg over 3 to 6 months’
observation (despite
appropriate lifestyle interventions).
Treatment
with a
low dose of
a thiazide or
a dihydropyridine calcium-
channel
blocker
is effective.
An ACE inhibitor (or
an
angiotensin-II
receptor antagonist)
(section 2.5.5)
can
be added if necessary.
Isolated systolic hypertension
Isolated systolic
hypertension (systolic pressure 160 mmHg,
diastolic
pressure < 90 mmHg)
is associated with an increased
cardiovascular disease risk,
particularly in those aged
over
60
years.
Systolic
blood
pressure
averaging
160 mmHg or higher over 3 to 6 months (despite appro-
priate lifestyle interventions) should be lowered in those
over 60 years,
even if diastolic hypertension is absent.
Treatment with a low dose of
a thiazide or a dihydro-
pyridine calcium-channel
blocker is effective.
An ACE
inhibitor (or an angiotensin-II receptor antagonist) (sec-
1.
Thresholds
and targets
for
treatment
based on blood
pressure measured in clinic may not apply to ambulatory
or
home blood-pressure monitoring,
which usually give
lower values.
2.
Cardiovascular disease risk may be determined from the
chart issued by the Joint British Societies (
Heart
2005;
91
(Suppl
V):
v1–v52)—see inside
back cover.
The Joint
British Societies’
‘Cardiac Risk Assessor’
computer
pro-
gramme may also be used to determine cardiovascular
disease risk.
BNF 61
2.5 Hypertension and heart failure
105
2
Cardiovascular system