Volume 1 Guidelines Management of Hypertension

MANAGEMENT OF HYPERTENSION

Non-pharmacological treatment

Non-pharmacological treatment should be employed in all hypertensives. It may be fully effective, or may reduce the dose of drug required.

It is the appropriate treatment for patients with diastolic pressure 90 - 94 mmHg and without target organ damage. It comprises:

reduction of obesity

a decrease in dietary sodium to 60 - 100 mmol/day (3.5 - 5.5 g per day as sodium chloride)

curtailed intake of alcohol

These measures are all of proven benefit, though individual response varies.

The effects tend to be additive and are of useful extent.

The goal for blood pressure reduction is:

systolic pressure 140 mmHg or less

diastolic pressure 85 - 90 mmHg or less; but after the age of 75 this goal should be less ambitious

Drug treatment
Drug treatment commences with monotherapy, using:

Thiazide diuretics:

preferably at low dosage (e.g. hydrochlorothiazide 6 - 12 mg/day) which may lessen side effects

thiazides should be avoided in diabetics, in hyperlipidaemia and in those with low HDL cholesterol, since these conditions may be worsened

clinical trial evidence of reduced cardiovascular disease

Beta-blockers (especially if angina is also present):

can adversely affect triglyceride and HDL levels

side effects are less frequent with cardioselective and vasodilator beta-blockers and those with intrinsic sympathomimetic activity

clinical trial evidence of reduced cardiovascular disease

ACE inhibitors (especially if left ventricular hypertrophy or cardiac failure is present):

relatively well tolerated

no adverse lipid effects

renal function must be tested before commencing treatment with an ACE inhibitor as it can worsen rapidly if renal artery stenosis is present (suspect if peripheral vascular disease is present)

Calcium channel blockers:

relatively well tolerated

no adverse lipid effects

may have antiatherogenic action

Two or more drugs are needed in 50% of hypertensives, e.g. ACE inhibitor with low-dose thiazide or calcium antagonist; or beta-blocker with calcium antagonist or low-dose thiazide.

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