Posted: January 13th, 2020
Improving Management of Hypertension in Primary Care
Improving Management of Hypertension in Primary Care
Hypertension, or high blood pressure, is a common condition that affects about one in four adults worldwide. It is a major risk factor for cardiovascular diseases such as heart attack, stroke, heart failure and kidney disease. Hypertension can also cause damage to other organs such as the eyes, brain and nerves. Therefore, it is important to diagnose and treat hypertension effectively to prevent these complications and improve the quality of life of patients.
In this blog post, we will discuss some of the best practices for improving the management of hypertension in primary care settings, based on the latest evidence and guidelines from various sources. We will cover the following topics:
– How to diagnose hypertension using accurate blood pressure measurement techniques
– How to assess the cardiovascular risk and target organ damage of patients with hypertension
– How to start and monitor antihypertensive drug treatment according to the recommended treatment steps
– How to advise patients on lifestyle interventions that can lower blood pressure and reduce cardiovascular risk
– How to refer patients to specialist care when needed
The diagnosis of hypertension is based on the average of two or more blood pressure readings taken on at least two separate occasions, using a validated device and an appropriate cuff size. The blood pressure should be measured after the patient has rested for at least five minutes, in a seated position, with their arm supported at heart level. The patient should avoid smoking, caffeine, alcohol and exercise for at least 30 minutes before the measurement. The blood pressure should be measured in both arms at the first visit, and the higher arm should be used for subsequent measurements.
The normal blood pressure range for adults is less than 120/80 mmHg. Hypertension is defined as a systolic blood pressure of 140 mmHg or higher, or a diastolic blood pressure of 90 mmHg or higher, or both. However, some patients may have different blood pressure thresholds depending on their age, comorbidities and other factors. For example, patients with diabetes or chronic kidney disease should aim for a blood pressure target of less than 130/80 mmHg. Patients with postural hypotension, which is a drop in blood pressure when standing up, should have their blood pressure measured in both sitting and standing positions.
Some patients may have a discrepancy between their clinic blood pressure and their home or ambulatory blood pressure. This can be due to white coat hypertension, which is a transient elevation of blood pressure in the clinic setting due to anxiety or stress, or masked hypertension, which is a normal blood pressure in the clinic but a high blood pressure outside the clinic. These conditions can be detected by using home or ambulatory blood pressure monitoring devices, which can provide more accurate and representative readings over a period of time. Home or ambulatory blood pressure monitoring is recommended for patients who have borderline or variable clinic blood pressure readings, or who are suspected of having white coat or masked hypertension.
Assessing cardiovascular risk and target organ damage
Patients with hypertension should have a comprehensive assessment of their cardiovascular risk and target organ damage at diagnosis and periodically thereafter. This can help to stratify patients into different risk categories and guide the choice and intensity of treatment.
Cardiovascular risk factors include age, sex, smoking status, family history of premature cardiovascular disease, diabetes, dyslipidemia, obesity and physical inactivity. These factors can be used to calculate the 10-year risk of developing a cardiovascular event using validated tools such as the Framingham Risk Score or the QRISK3 score. Patients with a high risk (more than 20%) or a moderate risk (10-20%) should be offered more aggressive treatment than those with a low risk (less than 10%).
Target organ damage refers to the structural or functional changes in the heart, vessels, kidneys or eyes that are caused by hypertension. These changes can be detected by performing various tests such as electrocardiogram (ECG), echocardiogram (ECHO), urine analysis, serum creatinine, estimated glomerular filtration rate (eGFR), albumin-to-creatinine ratio (ACR), fundoscopy or retinal photography. Patients with evidence of target organ damage should also be offered more aggressive treatment than those without.
Starting and monitoring antihypertensive drug treatment
Patients with hypertension should be offered antihypertensive drug treatment if their blood pressure is persistently above 140/90 mmHg (or 130/80 mmHg for patients with diabetes or chronic kidney disease), or if they have a high or moderate cardiovascular risk or target organ damage regardless of their blood pressure level.
The choice of antihypertensive drug treatment depends on several factors such as age, ethnicity, comorbidities and contraindications. The main classes of antihypertensive drugs are angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), beta-blockers, diuretics and others. The following table summarizes the recommended treatment steps for different patient groups, based on the NICE guideline on hypertension in adults:
| Patient group | Step 1 | Step 2 | Step 3 | Step 4 |
| Under 55 years | ACEI or ARB | ACEI or ARB + CCB | ACEI or ARB + CCB + diuretic | Add further diuretic or alpha-blocker or beta-blocker or potassium-sparing agent |
| Over 55 years or black African or Caribbean origin of any age | CCB | CCB + ACEI or ARB | CCB + ACEI or ARB + diuretic | Add further diuretic or alpha-blocker or beta-blocker or potassium-sparing agent |
| With type 2 diabetes | ACEI or ARB | ACEI or ARB + CCB or diuretic | ACEI or ARB + CCB + diuretic | Add further diuretic or alpha-blocker or beta-blocker or potassium-sparing agent |
| With chronic kidney disease | ACEI or ARB | ACEI or ARB + CCB | ACEI or ARB + CCB + diuretic | Add further diuretic or alpha-blocker or beta-blocker or potassium-sparing agent |
Patients should be advised to take their antihypertensive drugs regularly and to report any side effects to their healthcare provider. They should also be monitored for their blood pressure response, adherence, adverse effects and renal function. The frequency of monitoring depends on the severity of hypertension, the risk of complications and the stability of control. Generally, patients should have their blood pressure checked every month until it is controlled, then every 3 to 6 months thereafter. Patients should also have their renal function checked at baseline, within 1 to 2 weeks of starting or changing an ACEI or an ARB, then every 6 to 12 months thereafter.
The blood pressure target for most patients with hypertension is less than 140/90 mmHg (or less than 135/85 mmHg for home or ambulatory measurements). However, some patients may have different blood pressure targets depending on their age, comorbidities and other factors. The following table summarizes the blood pressure targets for different patient groups, based on various guidelines:
| Patient group | Blood pressure target (clinic) | Blood pressure target (home/ambulatory) |
| Under 80 years with hypertension only | <140/90 mmHg | <135/85 mmHg |
| Over 80 years with hypertension only | <150/90 mmHg | <145/85 mmHg |
| With type 1 diabetes | <130/80 mmHg | <125/75 mmHg |
| With type 2 diabetes | <130/80 mmHg | <130/80 mmHg |
| With chronic kidney disease (eGFR <60 ml/min/1.73 m2) | <140/90 mmHg (or <130/80 mmHg if proteinuria >1 g/day) | <135/85 mmHg (or <125/75 mmHg if proteinuria >1 g/day) |
If the blood pressure target is not achieved after following the treatment steps, patients should be referred to specialist care for further assessment and management.
Advising on lifestyle interventions
Patients with hypertension should be advised on lifestyle interventions that can lower blood pressure and reduce cardiovascular risk. These include:
– Eating a healthy diet that is low in salt, saturated fat and sugar, and high in fruits, vegetables, whole grains and lean protein
– Reducing alcohol intake to no more than 14 units per week for both men and women, and avoiding binge drinking
– Quitting smoking and avoiding exposure to secondhand smoke
– Increasing physical activity to at least 150 minutes of moderate intensity exercise per week, or 75 minutes of vigorous intensity exercise per week, or a combination of both
– Losing weight if overweight or obese, and maintaining a healthy body mass index (BMI) of 18.5 to 24.9 kg/m2
– Managing stress and practicing relaxation techniques such as meditation, yoga or breathing exercises
Lifestyle interventions can have a significant impact on blood pressure and cardiovascular risk. For example, reducing salt intake by 6 g per day can lower systolic blood pressure by about 5 mmHg; reducing alcohol intake by 50% can lower systolic blood pressure by about 4 mmHg; quitting smoking can lower systolic blood pressure by about 5 to 10 mmHg; increasing physical activity by.