Hypertension Management
Hypertension Classification
Stage and Criteria
| Stage | Criteria |
|---|
| Stage 1 | Clinic BP ≥ 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP ≥ 135/85 mmHg |
| Stage 2 | Clinic BP ≥ 160/100 mmHg and subsequent ABPM daytime or HBPM average BP ≥ 150/95 mmHg |
| Stage 3 | Clinic BP ≥ 180 mmHg, or clinic diastolic BP ≥ 110 mmHg |
Keys:
- ABPM: Ambulatory Blood Pressure Monitoring
- HBPM: Home Blood Pressure Monitoring
Note: Clinic BP is usually higher than ABPM and HBPM because some people get stressed or anxious while at a clinic, causing a slight increase in BP.
Management of Hypertension
Lifestyle Advice
- Low salt diet
- Reduce caffeine intake
- Stop smoking
- Drink less alcohol
- Eat a balanced diet rich in fruits and vegetables
- Exercise more
- Lose weight
When to Treat Stage 1 Hypertension
- Treat if the patient’s age is < 80 years and has any of the following:
- Target organ damage
- Established cardiovascular disease
- Renal disease
- Diabetes
- A 10-year cardiovascular risk equivalent to 20% or more
Note: If a patient has stage 1 hypertension but is otherwise healthy, recommend lifestyle and diet modifications with regular follow-up.
When to Treat Stage 2 Hypertension
- Always treat if ABPM or HBPM confirms hypertension with BP ≥ 150/95 mmHg
- For patients < 40 years with stage 2 hypertension or higher, consider specialist referral to exclude secondary causes of hypertension
Initial Treatment Steps Based on Age and Ethnicity
| Patient Group | Step 1 Management |
|---|
| Patients < 55 years | Start with ACE inhibitor (ACEi) or ARB |
| Patients ≥ 55 years or Afro-Caribbean origin (any age) | Start with Calcium channel blocker (CCB) |
| White < 55 years | Start with ACEi or ARB |
| White ≥ 55 years | Start with CCB |
| Afro-Caribbean (any age) | Start with CCB |
Stepwise Management
- Step 1:
- Patients < 55 years: Start with ACEi or ARB
- Patients ≥ 55 years or Afro-Caribbean: Start with CCB
- Step 2:
- If still hypertensive after step 1, combine ACEi or ARB with CCB (A + C)
- Step 3:
- If still hypertensive after step 2, add a thiazide diuretic (A + C + D)
- Examples:
- ACEi: Enalapril
- CCB: Amlodipine
- Thiazide diuretics: Chlorthalidone, Indapamide
- Step 4 (Resistant Hypertension):
- Consider further diuretic treatment
- If potassium < 4.5 mmol/L, add spironolactone (25 mg once daily)
- If potassium > 4.5 mmol/L, add a higher-dose thiazide-like diuretic
- If further diuretic therapy is not tolerated, consider alpha- or beta-blockers
- Refer to a specialist if hypertension remains uncontrolled with four drugs
