Advise lifestyle measures in patients with hypertension and high normal blood pressure (BP), ie clinic BP 130-139/85-89 mm Hg. Inform about any local initiatives, and supplement advice with leaflets or audiovisual information.
Preventing or treating obesity
Weight reduction should be suggested if necessary, to maintain ideal body mass index (BMI) of 20-25 kg/m2. Offer a diet sheet and/or dietetic appointment. Dietary self-help, eg dieting clubs, may be appropriate.
- The National Institute for Health and Clinical Excellence (NICE) recommends basing meals on starchy foods (potatoes, bread, rice and pasta) - using wholegrain bread, and brown rice if possible, but watch the portion size of meals and cut down on snacks.
- Eat foods rich in fibre, ie cereals, pulses (beans, peas, lentils, grains, seeds), fruit and vegetables.
- Have at least five portions of fruit and vegetables a day.
- Select low-fat foods - avoid foods containing a lot of fat and sugar (eg fried food, sweetened drinks, crisps, confectionery).
- Reduce any excessive caffeine consumption and have a low dietary sodium intake (reduce or substitute any sodium salt). Calcium, magnesium or potassium supplements are not recommended.
- Ensure you eat breakfast.
- Cut alcohol intake to no more than 21 units (male) or 14 units (female) of alcohol per week. Be careful not to take too many calories in the form of alcohol.
See the Dietary Approaches to Stop Hypertension (DASH) eating plan.
Patients should stop smoking (offer help ± nicotine replacement therapy) - see separate article Smoking Cessation.
- Make physical activities part of everyday life (eg walk or cycle to work, use stairs instead of lift, walk at lunchtime), and build in enjoyable activities to leisure time every week (e.g walking, cycling, gardening, swimming, aerobics, etc.) .
- Minimise sedentary activities, e.g limit television watching or sitting at a computer or playing video games.
- Once more, look for local activities, join a sporting group, take advantage of taster sessions and get used to exercising regularly, ideally several times a week.
Consider treating immediately if BP in clinic is ≥180/110 mm Hg; otherwise, consider after results of ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), blood tests and cardiovascular risk assessment are available.
- Stage 1 hypertension - clinic readings ≥140/90 mm Hg and ABPM/HBPM ≥135/85 mm Hg.
- Stage 2 hypertension - clinic readings ≥160/100 mm Hg and ABPM/HBPM ≥150/95 mm Hg.
Drug treatment should be commenced in patients aged under 80 years with stage 1 hypertension plus signs of end organ damage (known cardiovascular or renal disease), or with diabetes mellitus or a 10-year cardiovascular disease (CVD) risk ≥20%.
Treatment should be started in all patients (any age) with stage 2 hypertension. Treat isolated systolic hypertension in the same way.
Initial Drug Choices
|If the patient is young (≤55 years) and non-black, start with:
||If the patient is aged >55 years or a black person of African or Caribbean family origin, use:
Stage 2 Drug Choices
Stage 3 Drug Choices
Stage 4 Drug Choices
The combination of angiotensin-converting enzyme (ACE) inhibitor with an angiotensin-II receptor antagonist (AIIRA) is not recommended for the treatment of hypertension.
- People aged <80 years: clinic <140/90 mm Hg, ABPM/HBPM <135/85 mm Hg.
- People aged ≥80 years: clinic <150/90 mm Hg, ABPM/HBPM <145/85 mm Hg.
Monitor regularly with BP checks plus appropriate blood tests (eg U&E and renal function on ACE inhibitor). Consider cholesterol-lowering treatment if CVD risk is ≥20% (see separate article Lipid-regulating Drugs). Further ABPM/HBPM may be needed to avoid overtreatment due to 'white coat hypertension'.
Refer if hypertension is difficult to control in spite of the steps above.
Consider seeking specialist evaluation of patients aged <40 years who appear to have stage 1 hypertension without target organ damage or diabetes, either for exclusion of secondary causes of hypertension or a more detailed assessment of cardiovascular risk, as standard assessments can underestimate the lifetime risk in these people. 
Further reading & references
- Hypertension in pregnancy, NICE Clinical Guideline (August 2010)
- Hypertension: management of hypertension in adults in primary care, NICE Clinical Guideline (August 2011)
- Hypertension, NICE Pathway (August 2011)
- Obesity, NICE Clinical Guideline (2006)
- DASH (Dietary Approaches to Stop Hypertension) Diet
|Original Author: Dr Huw Thomas||Current Version: Dr Huw Thomas||Peer Reviewer: Dr Hannah Gronow|
|Last Checked: 28/09/2011||Document ID: 486 Version: 24||© EMIS|
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