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 |
Note: For a patient with both hypertension and diabetes, an ACE inhibitor like Lisinopril is advisable regardless of age, gender and origin due to its beneficial effects on kidney function, which is crucial as diabetes can lead to nephropathy.
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
NICE Guidelines on HTN
