Primary Hypertension control guidelines

Primary Hypertension control guidelines ( not secondary hypertension)

It is lifelong condition like most of chronic diseases. Treatment need to be tailored to patient preferences and needs and patient need to make informed decision.

For non-UK trainees that is ultimately important as it is not part of our training, you need to think patient is your partner that you need to work alongside him and you need to make sure he is on board otherwise your treatment plan would not be successful. Just think of your role as a doctor is actually a facilitator, to guide the patient to achieve what is best for his health.

First question Why?

Patients with persistent high pressure have higher risks of cardiovascular events (heart failure, Ischemic heart disease), cerebrovascular events (stroke), end organ damage and higher incidence of comorbidities.

Targets

Two Blood pressure readings above 140/90 are essential to confirm the diagnosis. The current recommendation is not to start antihypertensives till readings of 160/100 but once started you should aim for 140/90.

Work up needed for all patients

 Urine test for protein (using test strip)

 Plasma glucose, electrolytes, creatinine, serum total cholesterol and HDL cholesterol

12-lead electrocardiography

That will help you to assess the cardiovascular risk and guide the decision of starting pharmacological agents

Life style changes

It is ultimately important to get the patient to join in, Life style changes alone can be enough measure to bring BP below 160/100 back to normal levels.

Again remember that normal blood pressure decrease the risk of cardiovascular events and death.

Changes to consider

Exercise, Exercise, Exercise………….  Regular moderate intensity exercise, walking 20-30 mins 5 days a week

Maintain low salt, low fat diet

Decrease caffeine intake, that include soda drinks and tea

When to Treat

Patients with BP reading above 160/100

Patient with BP reading above 140/90 with other cardiovascular risk factors ( existing cardiovascular disease, end organ damage, 10 years CVD risk of 20%or more )

Pharmacological interventions

That is the easy bit

Different categories

Patients older than 55 years or from black origin

Thiazides

Calcium channel blockers

Patient younger than 55 years and not from black origin

Angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin-II receptor antagonist if

an ACE inhibitor is not tolerated).

The Combination of ACE and CaChB is a good combination

You can combine the whole three to achieve better blood pressure control.

B-blockers and alpha blockers should be reserved for patients with persistently high blood pressure after using the whole three combined together.

Other pharmacological intervention

Aspirin 75mg, big debate about usage for primary prevention and current guidance is not in favour in UK.  I would recommend it though if you are sure there are no contraindications (Peptic ulcers and chronic kidney disease).

Statins should be considered for all of those patients with high cholesterol.

 Next antihypertensive medications, how to start, titrate doses and when to review for response

Please feel free to leave any comments

Please if you have a topic you want me to cover please leave me a note

Reference SIGN guidelines for hypertension management

Note that there would be new guidelines coming from NICE at the end of the year, I will give you an update as appropriate