part 2: recommendations for hypertension treatment

2007

Part 2: Recommendations

for Hypertension Treatment

January 2007

2007 Canadian Hypertension Education Program Recommendations 2

Assess blood pressure at all appropriate visits. Almost one half of those with blood pressure 130-139/85-89 will develop hypertension within 2 years. They require annual reassessment.Assess global cardiovascular risk in all hypertensive patients. Lifestyle modification is the cornerstone for the prevention and management of hypertension and CVD.

Key CHEP messages for the management of hypertension



Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease). To achieve targets sustained lifestyle modification and more than one drug is usually required.Follow patients with uncontrolled blood pressure at least monthly until blood pressure targets are achieved.Strategies to improve patient adherence to lifestyle modifications and antihypertensive therapy need to be incorporated in every patients management


• A red flaghas been posted where recommendations were updated for 2007.

• A slide kit for medical education can be downloaded (English and French versions) fromhttp://www.hypertension.ca

2007 Canadian Hypertension Education Program


Treatment Approaches:• Lifestyle• Pharmacological




What's New for 2007

• Approximately 95% of Canadians will develop hypertension if they live an average lifespan

• Most overweight patients with high normal blood pressure (130-139/85-89 mmHg) will develop hypertension within 4 years and almost 1/2 within 2 years.

• Annual follow-up of patients with high normal blood pressure is recommended.



What's New for 2007 • Up to 17% of hypertension can be

attributed to high sodium diets • Reduce sodium intake to less than

100 mmol in normotensive patients to prevent hypertension


Recommendations 2007Table of contents

I. Indications for drug therapyII. Goal for therapyIII. AdherenceIV. LifestyleV. UncomplicatedVI. CV – IHDVII. CHFVIII. Cerebrovascular / StrokeIX. LVHX. Chronic kidney diseaseXI. RenovascularXII. DiabetesXIII. SmokingXIV. Global risk reduction


Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension

Condition Initiation

SBP or DBP mmHg

• Systolic or Diastolic hypertension 140/90

• Diabetes• Chronic Kidney Disease

130/80

I. Indications for Pharmacotherapy


I. Indications for Pharmacotherapy

• In low risk patients with stage 1 hypertension (140-159/90-99 mmHg) lifestyle modification can be the sole therapy.

• Over 90% of Canadians with hypertension have other risk factors and pharmacotherapy should be considered in these patients if blood pressure remains equal to or above 140/90 mmHg with lifestyle modification.

• Patients with target organ damage (e.g. left ventricular hypertrophy) are recommended to be treated with pharmacotherapy if blood pressure is equal to or above 140/90

• Patients with known atherosclerotic disease (e.g. past stroke) are recommended to be treated with pharmacotherapy even if the blood pressure is normal (see compelling indications)

• Patients with diabetes or chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmHg


Blood pressure target values for treatment of hypertension

Condition Target

SBP and DBP mmHg

Isolated systolic hypertension <140

Systolic/Diastolic Hypertension• Systolic BP • Diastolic BP

<140<90

Diabetes• Systolic • Diastolic

<130<80

Chronic Kidney disease• Systolic • Diastolic

<130<80

II. Goals of Therapy


II. Goals of Therapy

• To optimally reduce cardiovascular risk reduce the blood pressure to specified targets.• This usually requires two or more drugs and

lifestyle changes• The systolic target is more difficult to

achieve however controlling systolic blood pressure is as important if not more important than controlling diastolic blood pressure


Follow-up of blood pressure above targets

• Patients with blood pressure at target are recommended to be followed at least every 2nd month

• Follow-up visits are used to increase the intensity of lifestyle and drug therapy, monitor the response to therapy and assess adherence

2007

Part 2: Recommendations

for Hypertension Treatment

January, 2007

2007

IV. Lifestyle management


To reduce the possibility of becoming hypertensive,

Restriction of sodium intake to less than 100 mmol (2300 mg) / day

Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt in accordance with Canada's Guide to Healthy Eating.

Regular physical activity: accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity 4-7/week

Low risk alcohol consumption (≤2 standard drinks/day and less than 14/week for men and less than 9/week for women)

Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)

Waist Circumference< 102 cm for men< 88 cm for women

Smoke free environment

Lifestyle Recommendations for Prevention of Hypertension for NON-Hypertensive Individuals.


Lifestyle Recommendations for the Treatment of Hypertension

Restriction of sodium intake to less than 100 mmol (2300 mg) / day

Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt in accordance with Canada's Guide to Healthy Eating.

Regular physical activity: accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity 4-7/week

Low risk alcohol consumption (≤2 standard drinks/day and less than 14/week for men and less than 9/week for women)

Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)

Weight loss (> 5 Kg) in those who are over weight (BMI>25)


Smoke free environment


Dietary Sodium

Restrict to target range of 65-100 mmol/day(Most of the salt in food is hidden and comes

from processed food)

Dietary PotassiumIf required, daily dietary intake

>80 mmol

Calcium supplementationNo conclusive studies for hypertension

Magnesium supplementationNo conclusive studies for hypertension

Lifestyle Recommendations for Hypertension: Dietary

• High in fresh fruits• High in vegetables• High in low fat

dairy products• High in dietary and

soluble fibre• High in plant

protein• Low in saturated

fat and cholesterol

http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html


Recommendations for daily salt intake

Less than:• 100 mmol sodium (Na) • or 2,3 g sodium (Na) • or 5,8 g of salt (NaCl)• or 1 teaspoon of table salt

2,300 mg sodium = 1 teaspoon of table salt


Salt 2007: Meta-analyses

HypertensivesReduction of BP 5.1 / 2.7 mmHg with a average reduction of 78 mmol sodium/day (162 to 87mmol/day)

7.2/3.8 mmHg with a average reduction of 100 mmol sodium/day

Normotensives Reduction of BP 2.0 / 1.0 mmHg with a average reduction of sodium 74 mmol/day3.6/1.7 mmHg with a average reduction of 100 mol/day sodium

The Cochrane Library 2006;3:1-41;


Salt 2007: Meta analysis on different reduction in sodium on blood pressure

0

2

4

6

8

10

12

52 104 156

mmol reduction in sodium

BP

red

uct

ion

SBP hyper

DBP hyper

SBP normo

DBP normo

Hypertension 2003;42:1093-1099


Epidemiologic impact on mortality of blood pressure reduction in the population

Reduction in SBP

(mmHg)

% Reduction in Mortality

Stroke CHD Total

2 -6 -4 -3

3 -8 -5 -4

5 -14 -9 -7Adapted from Whelton, P. K. et al. JAMA 2002;288:1882-1888

AfterIntervention

BeforeIntervention

Reduction in BPP

revale

nce

%


Exercise should be prescribed as adjunctive to pharmacological therapy

Lifestyle Recommendations for Hypertension. Physical Activity

Should be prescribed to reduce blood pressure

Type cardiorespiratory activity- Walking, jogging- Cycling- Non-competitive swimming

Time - 30-60 minutes

Intensity - Moderate

Frequency - Four to seven days per weekF

I

T

T


Lifestyle Recommendations for Hypertension: Alcohol

Low risk alcohol consumption

• Women: maximum of 9 standard drinks/week

• Men: maximum of 14 standard drinks/week

• 0-2 standard drinks/day

A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or 12 oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).


Lifestyle Recommendations for Hypertension Stress Management

Hypertensive patientsin whom stress appears to be an important issue

Individualized cognitive behavioral interventions are more likely to be effective when relaxation techniques are employed.

Stress management

Behavior Modification


Lifestyle Recommendations for Hypertension Weight Loss

Height, weight, and waist circumference (WC) should be measured and body mass index (BMI) calculated for all adults.

Hypertensive and all patientsBMI over 25 - Encourage weight reduction- Healthy BMI: 18.5-24.9 kg/m2


For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects. Weight loss strategies should employ a multidisciplinary approach and include dietary education, increased physical activity and behavioural modification


Courtesy J.P. Després 2006

Mid distance

Last rib margin

Iliac crest

Waist circumference measurement


Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults

Intervention Amount SBP/DBP

Reduce foods with added sodium 1.8g or 78 mmol/d -5.1 / -2.7

Weight loss per kg lost -1.1 / -0.9

Alcohol intake - 3.6 drinks/day -3.9 / -2.4

Aerobic exercise 120-150 min/week -4.9 / -3.7

Dietary patternsDASH diet

HypertensiveNormotensive

-11.4 / -5.5-3.6 / -1.8

Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat hypertension Padwal R. et al. CMAJ ･ SEPT. 27, 2005; 173 (7) 749-751


Lifestyle Therapies in Hypertensive Adults: Summary

Intervention Target

Reduce foods with added sodium < 100 mmol/day

Weight loss BMI <25 kg/m2

Alcohol restriction Less or equal to 2 drinks/day

Exercise at least 4 times/week

Dietary patterns DASH diet

Smoking cessation Smoke free environment


2007

Pharmacotherapy



I. Indications for drug therapyII. Goal for therapyIII. AdherenceIV. LifestyleV. UncomplicatedVI. CV – IHDVII. CHFVIII. Cerebrovascular / StrokeIX. LVHX. Chronic kidney diseaseXI. RenovascularXII. DiabetesXIII. SmokingXIV. Global risk reduction

Table of contents


V. Choice of Pharmacological Treatment Uncomplicated

Associated risk factors?or

Target organ damage/complications?or

Concomitant diseases/conditions?

IndividualizedTreatment

(and compelling indications)

YES

Treatment in theabsence of specific

indication

NO


V. Choice of Pharmacological Treatment

1. Treatment of Systolic/Diastolic hypertension without other compelling indications

2. Treatment of Isolated Systolic hypertension without other compelling indications


V. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling Indications

TARGET <140/90 mmHgINITIAL TREATMENT AND MONOTHERAPY

* BBs are not indicated as first line therapy for age 60 and above

Beta-blocker*

Long-actingCCB

Thiazide ACE-I ARB

Lifestyle modificationtherapy

ACEI and ARB are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential


V. Considerations Regarding the Choice of First-Line Therapy

• ACE inhibitors and ARBs are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential

• Beta adrenergic blockers are not recommended for patients age 60+ without another compelling indication

• Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent

• ACE-I are not recommended (as monotherapy) for black patients without another compelling indication


Major Congenital Malformations after First Trimester Exposure to ACE

inhibitors• Cardiovascular and neurological defects• ACEI risk ratio 2.71 (1.72-4.27) vs. other

drugs 0.66 (0.25-1.75) vs. no drug

NEJM 2006;354:2443-51


V. Add-on Therapy for Systolic/Diastolic Hypertension without Other Compelling Indications

CONSIDER

• Nonadherence?• Secondary HTN?• Interfering drugs or lifestyle?• White coat effect?• Resistant Hypertension?

If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers or centrally acting agents).

2. Triple or Quadruple Therapy

1. Add-on Therapy

If partial response to monotherapy


Drug Combinations

• When combining drugs, use first-line therapies

• Two drug combinations of beta blockers, ACE inhibitors and angiotensin receptor blockers have not been proven to have additive hypotensive effects.

• Therefore these potential two drug combinations should not be used unless there is a compelling (non blood pressure lowering) indication such as ischemic heart disease, post myocardial infarction, congestive heart failure or chronic kidney disease with proteinuria.


Drug Combinations cont’d

• Caution should be exercised in combining a non dihydropyridine CCB and a beta blocker to reduce the risk of bradycardia or heart block.

• Monitor creatinine and potassium when combining K sparing diuretics, ACE inhibitors and/or angiotensin receptor blockers.

• If a diuretic is not used as first or second line therapy, triple dose therapy should include a diuretic, when not contraindicated.


Most HTN Pts need more than 1 drug (data from ALLHAT)


Most HTN Pts need more than 1 drug

0

1

2

3

4

5

UKPDS

ABCD

MDRD

HOT

AASKID

NT

ALLHAT

Nu

mb

er o

f d

rug

s


BP Effects from antihypertensive therapy

Law. BMJ 2003 (SR of 354 RCTs)• Dose response curves for efficacy

are relatively flat

• 80% of the BP lowering efficacy is achieved at half-standard dose

• Combinations of high standard dose have additive blood pressure lowering effects


V. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications

CONSIDER

• Nonadherence?• Secondary HTN?• Interfering drugs or

lifestyle?• White coat effect?

Dual Combination

Triple or Quadruple Therapy


Thiazidediuretic ACE-I Long-acting

CCBBeta-

blocker*

TARGET <140/90 mmHg

ARB

* Not indicated as first line therapy over 60

ACEI and ARB are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential


V. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications

INITIAL TREATMENT AND MONOTHERAPY

Thiazide diuretic

Long-actingDHP CCB


ARB

TARGET <140 mmHg


V. Add-on therapy for Isolated Systolic Hypertension without Other Compelling Indications

CONSIDER



If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha adrenergic blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).

If partial response to monotherapy

Long-actingDHP CCB

Triple therapy

Thiazide diuretic

ARB

Dual combinationCombine first line agents


V. Summary: Treatment of Isolated Systolic Hypertension without Other Compelling Indications

CONSIDER



Thiazide diuretic

Long-actingDHP CCB

Dual therapy

Triple therapy


ARB

TARGET <140 mmHg

*If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).


V. Choice of Pharmacological Treatment

1. Treatment of systolic-diastolic hypertension without other compelling indications

2. Treatment of isolated systolic hypertension without other compelling indications


Choice of Pharmacological Treatment for Hypertension

Individualized treatment

• Compelling indications:• Ischemic Heart Disease• Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI• Left Ventricular Systolic Dysfunction• Cerebrovascular Disease• Left Ventricular Hypertrophy• Non Diabetic Chronic Kidney Disease• Renovascular Disease• Smoking

• Diabetes Mellitus• With Diabetic Nephropathy• Without Diabetic Nephropathy

• Global Vascular Protection for Hypertensive Patients• Statins if 3 or more additional cardiovascular risks• Aspirin once blood pressure is controlled


VI. Treatment of Hypertension in Patients with Ischemic Heart Disease

• Caution should be exercised when combining a non DHP-CCB and a beta-blocker• If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or

Diltiazem)

1. Beta-blocker2. Long-acting CCBStable angina

ACE-I are recommended for most patients with established CAD*

Short-actingnifedipine

Those at low risk with well controlled risk factors may not benefit from ACEI therapy


VI. Treatment of Hypertension in Patients with Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI

Long-actingDHP CCB

(Amlodipine, Felodipine)

Beta-blocker and ACE-I

Recentmyocardialinfarction

Heart Failure

?

NO

YES

Long-acting CCB

If beta-blocker contraindicated or not effective

An ARB can be used if the patient is intolerant to ACE-I


VII. Treatment of Hypertension with Left Ventricular Systolic Dysfunction

Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol. Physicians who are not yet experienced in the use of beta-blockers should consider initiation of treatment in conjunction with a physician experienced in heart failure management particularly for NYHA Class III-IV patients

If additional therapy is needed:• Diuretic* • for CHF class III-IV: Aldosterone Antagonist

Systoliccardiac

dysfunction

• ACE-I• if ACE-I intolerant: ARB

If ACE-I and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination

If additional antihypertensive therapy is needed: • ACE-I / ARB Combination • Long-acting DHP-CCB (Amlodipine or Felodipine)

Non dihydropyridine

CCB

and Beta-Blocker


VIII. Treatment of Hypertensionfor Patients with Cerebrovascular Disease

Strongly consider blood pressure reduction in all patients after the acute phase of non disabling stroke or TIA .

An ACE-I / diuretic combination is preferred

StrokeTIA


IX. Treatment of Hypertension in Patients with Left Ventricular Hypertrophy

Vasodilators:Hydralazine, Minoxidil can increase LVH

Left ventricularhypertrophy

Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events.

- ACE-I- ARB,- CCB- Thiazide Diuretic- BB (if age below 60)*


X. Treatment of Hypertension in Patients with Non Diabetic Chronic Kidney Disease

Chronic kidney disease and proteinuria *

ACE-I/ARB: Bilateral renal artery stenosis

1. ACE-I2. Alternate if ACE-I not tolerated: ARB

Combination with other agents

Additive therapy: Thiazide diuretic.Alternate: If volume overload: loop diuretic

Target BP: Nondiabetic: < 130/80 mmHg

* albumin:creatinine ratio [ACR] > 30 mg/mmol or urinary protein > 500 mg/24hr

Monitor potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB


XI. Treatment of Hypertension in Patients with Renovascular Disease

Close follow-up and early intervention (angioplasty and stenting or surgery) should be considered for patients with: uncontrolled hypertension despite therapy with three or more drugs, or deteriorating renal function, or bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney), or recurrent episodes of flash pulmonary edema.

Does not imply specific treatment choice

Renovascular disease

Caution in the use of ACE-I/ARB in bilateral renal artery stenosis or unilateral disease with solitary kidney

2007 XII. Treatment

of Hypertension in association with Diabetes

Mellitus


XII. Treatment of Hypertension in association with Diabetes Mellitus

Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg

withNephropathy*

*Urinary albumin to creatinine ration > 2.0 mg/mmol in men or > 2.8mg/mmol in women or chronic kidney disease*

Diabetes

withoutNephropathy**

IsolatedSystolic

Hypertension

Systolic- diastolic

Hypertension

**Urinary albumin to creatinine ratio <2.0 mg/mmol in men or <2.8mg/mmol in women

* based on at least 2 of 3 measurements


XII. Treatment of Hypertension in association with Diabetic Nephropathy

THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

DIABETESwith

Nephropathy

ACE Inhibitoror ARB

IF ACE-I and ARB are contraindicated or not tolerated, SUBSTITUTE• Long-acting CCB or• Thiazide diuretic

Addition of one or more ofThiazide diuretic orLong-acting CCB

3 - 4 drugs combination may be needed



XII. Treatment of Systolic-Diastolic Hypertension without Diabetic Nephropathy

1. ACE-Inhibitor or ARB or

2. Thiazide diuretic or Dihydropyridine CCB

IF ACE-I and ARB and DHP-CCB or Thiazide are contraindicated or not tolerated, SUBSTITUTE• Cardioselective BB* or• Long-acting NON DHP-CCB

More than 3 drugs may be needed to reach target values for diabetic patients

* Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

Combination of first line agents

Addition of one or more of:Cardioselective BB orLong-acting CCB

Diabeteswithout

Nephropathy

DHP: dihydropyridine


XII. Treatment of Hypertension in association with Diabetes Mellitus: Summary

More than 3 drugs may be needed to reach target values for diabetic patients

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

Diabetes

withNephropathy

Combination(Effective

2-drug combination)

ACE Inhibitoror ARB

withoutNephropathy

1. ACE-Inhibitor or ARB

or

2. Thiazide diuretic or DHP-CCB



The benefits of treating smokers with beta-blockersremain uncertain in the absence of a specific

indications like angina or post-MI

Smoking Beta-blocker

XIII. Treatment of Hypertension for Patients Who Use Tobacco

2007 XIV. Global

Vascular Protection for Patients with Hypertension


XIV. Vascular Protection for Hypertensive Patients: Statins

In addition to current Canadian recommendations on management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria:

• Male• Age 55 or older• Smoking• Type 2 Diabetes• Total-C/HDL-C ratio of 6

mmol/L or higher

• Family History of Premature CV disease

• LVH• ECG abnormalities• Microalbuminuria or

Proteinuria

ASCOT-LLA Lancet 2003;361:1149-58


XIV. Vascular Protection for Hypertensive Patients: ASA

Consider low dose ASA

Caution should be exercised if BP is not controlled.


Adherence to anti-hypertensive management can be improved by a multi-pronged approach

• Assess adherence to pharmacological and non-pharmacological therapy at every visit

• Teach patients to take their pills on a regular schedule associated with a routine daily activity e.g. brushing teeth.

• Simplify medication regimens using long-acting once-daily dosing

• Utilize fixed-dose combination pills • Utilize unit-of-use packaging e.g. blister

packaging


Adherence to anti-hypertensive management can be improved by a multi-pronged approach

• Encourage greater patient responsibility/autonomy in regular monitoring their blood pressure

• Educate patients and patients' families about their disease/treatment regimens verbally and in writing


Public translation of CHEP recommendations

Download at www.hypertension.ca


Useful patient information can be obtained in recent publications from the Canadian Hypertension Society.

Available by order from CHS SecretariatCanadian Hypertension Society

Tel: 613-533-3299, Fax: 613-533-6927

E mail: [email protected] .

Coming soon to bookstores near you.

Educate patients and patients' families about their disease/treatment regimens verbally and in writing


Encourage greater patient responsibility/autonomy


Summary I

Regarding the treatment of hypertension, the recommendations endorse: • ASSESSMENT OF BLOOD PRESSURE AT ALL

APPROPRIATE VISITS• Most Canadians will develop hypertension during

their lives. Routine assessment of blood pressure is required for early detection and risk management

• ANNUAL FOLLOW-UP OF PATIENTS WITH HIGH NORMAL BLOOD PRESSURE

• Most overweight patients with high normal blood pressure (130-139/85-89 mmHg) will develop within 4 years and almost 1/2 within 2 years.


Summary II

Regarding the treatment of hypertension, the recommendations endorse:• INDIVIDUALIZING THERAPY

• consider concomitant risk factors and/or concurrent diseases, other patient characteristics and preferences (e.g. age, diabetes, CVD) and other considerations e.g. costs

• LIFESTYLE MODIFICATION• To prevent hypertension• In those with hypertension alone if effective to reach

the goal value or in combination with pharmacological treatment


Summary III

Regarding the treatment of hypertension, the recommendations endorse:

• TREATING TO TARGET BP • treat aggressively using combinations of drugs

and lifestyle modification to achieve individualized target

• PROMOTING ADHERENCE• a multi-faceted approach should be used to

improve adherence with both non pharmacological and pharmacological strategies


Assess blood pressure at all appropriate visits. Almost one half of those with blood pressure 130-139/85-89 will develop hypertension within 2 years. They require annual reassessment.Assess global cardiovascular risk in all hypertensive patients. Lifestyle modification is the cornerstone for the prevention and management of hypertension and CVD.




Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease). To achieve targets sustained lifestyle modification and more than one drug is usually required.Follow patients with uncontrolled blood pressure at least monthly until blood pressure targets are achieved.Strategies to improve patient adherence to lifestyle modifications and antihypertensive therapy need to be incorporated in every patients management

part 2: recommendations for hypertension treatment

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