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Table 3 Impact of lifestyle on blood pressure 8
Modification Recommendation Potential SBP reduction Reduce weight
Adopt DASH diet
Maintain normal body weight ( BMI of 18.5-24.9kg / m 2 )
Rich in fruit , vegetables and low-fat dairy ; reduced saturated and total fat content
by the GP practice ( see tip 10 ). A hypertension diagnosis will usually happen in primary care , mostly in general practice , although pilot programmes are taking place in community pharmacies across England . 6
Ambulatory BP monitoring ( ABPM ) remains the gold standard for diagnosis but home BP monitoring ( HBPM ) should be initiated if ABPM is unsuitable or the patient is unable to tolerate it . For example , anticoagulated patients may be at an increased risk of bruising with ABPM ; the BIHS recommends they be advised to discontinue it if this happens . Readings that are required to confirm a diagnosis are outlined in Table 1 . 3
Note that this can be a point where patients ‘ slip through the net ’ and the opportunity for a diagnosis is missed . The Primary Care Network Directed Enhanced Service is incentivising practices to follow up raised BP readings through the Investment and Impact Fund . 7
Record the diagnosis accurately
5Once the clinic reading and daytime average readings from ABPM / HBPM are available , a diagnosis of hypertension can be made or excluded , according to the classification described in Table 2 . 8
It ’ s essential that both clinic and home readings are taken into account and that the information is entered in the patient ’ s clinical record . The appropriate diagnostic code should place the patient on the practice hypertension register to ensure full assessment of cardiovascular ( CVD ) risk , monitoring for target organ damage , appropriate interventions and annual review .
Involve patients in their management plan
6Patients should be involved in deciding how to manage their condition . All patients should be offered information on lifestyle changes to reduce BP and given details of patient organisations such as Blood Pressure UK that can support them . 1
At stage 1 hypertension , consider two questions : has the raised BP caused a problem yet , and is it likely to .
The first question is answered through tests to assess for target organ damage , including blood and urine tests to check kidney function and diabetes status , fundoscopy to assess for retinal damage and a 12-lead ECG to assess for left ventricular hypertrophy . The second question requires a full assessment of CVD risk using a recognised
3-20mmHg
8-14mmHg
Reduce dietary sodium < 100 mmol ( 2.4g )/ day 2-8mmHg Increase physical activity
Reduce to moderate alcohol consumption
Aerobic activity > 30 min / day most days of the week
Men : ≤2 drinks / day Women : ≤1 drink / day
4-9mmHg
2-4mmHg
References 1 Blood Pressure UK . bloodpressureuk . org 2 British and Irish Hypertension Society . Blood pressure measurement . Edinburgh : BIHS , 2007 . bit . ly / 3Owlq5S 3 NICE . Hypertension in adults : diagnosis and management . London : NICE , 2019 . nice . org . uk / ng136 4 . Share the Pressure . sharethepressure . com 5 . NHS Health Check . Heart age test . bit . ly / 3Xk7ZK2 6 NHS England . Advanced service specification : NHS community pharmacy hypertension case finding advanced service . London : NHSE , 2021 . bit . ly / 3Owknms 7 NHS England . Network contract directed enhance service : contract specification 2022 / 23 – PCN requirements and entitlements . London : NHSE , 2022 . bit . ly / 3EReuNx 8 Chobanian A et al . The seventh report of the Joint National Committee on prevention , evaluation and treatment of high blood pressure . JAMA 2003 ; 289:2560-2572 9 Hippisley-Cox J et al . Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease : prospective cohort study . BMJ 2017 ; 357 : j2099 . 10 NICE . CKS . Hypertension : Risk factors . London : NICE , 2022 . bit . ly / 3AxMJXJ 11 NICE . Hypertension in adults : diagnosis and management . Visual summary . London : NICE , 2019 . bit . ly / 3GA395M tool such as QRISK ® 3 . 9 If there are signs of target organ damage or an estimated CVD risk of 10 % or more , discuss antihypertensive medication with the patient . Always consider age , as pharmacological intervention would not usually be indicated in newly diagnosed stage 1 hypertension in the over-80s . 3 At stage 2 and severe hypertension , all patients should be offered medication .
Lifestyle changes really can lower BP
7While there are non-modifiable risk factors such as ethnicity and genetics , lifestyle can make a real difference . Smoking , excessive alcohol consumption , excess dietary salt , unhealthy diet , obesity and physical inactivity are all modifiable risk factors and addressing them can sometimes be more effective than medication . Examples of reported benefits are shown in Table 3 .
While lifestyle changes aren ’ t easy , behavioural techniques such as motivational interviewing can increase the chances of success . 10 Remember , maintaining changes can be difficult and slipping back into old ways can see BP rise again , so monitoring should continue .
Make the most of medications
8Effective use of the ‘ ACD ’ algorithm – where A is an ACE inhibitor or angiotensin receptor blocker , C a calcium channel blocker and D a thiazide-like diuretic – will successfully control BP in most cases but it may take time . 11 The physiological mechanisms driving high BP may need different pharmacological approaches , and many people will require combination therapy .
Target levels vary according to age and comorbidities such as chronic kidney disease or previous stroke . For most people , the target clinic BP will be < 140 / 90mmHg or < 150 / 90 for over-80s . 3 Remember , those with postural hypotension , over-80s and patients with type 2 diabetes should have their BP measured while standing , and be treated to target based on their standing BP . 3
It ’ s worth making patients aware that it may take some time to get the right combination of medication , and adherence is vital . Shared decision making using validated tools and resources can support this process and empower patients to take control of their condition . 3
If target is not achieved , look at further options
9If BP is not controlled through a combination of three ACD medications in an adherent patient , treatment-resistant hypertension should be assumed . 3 It is then sensible to repeat ABPM or HBPM to confirm the readings and rule out a ‘ white coat ’ effect .
The first-line fourth agent is low-dose spironolactone in a person with a potassium level of ≤4.5 mmol / L , or an a- or β-blocker if their potassium level is > 4.5mmol / L . 3 If BP remains uncontrolled on optimal tolerated therapy with four different agents , refer for specialist assessment .
Know when to review and refer adults under 40 with a confirmed diagnosis , consider routine referral for specialist 10For
investigation . 3 Always review newly detected severe hypertension ( ≥180 / 120mmHg ), with consideration of same-day intervention . 3 Severe hypertension with signs of retinal haemorrhage or papilloedema , chest pain , new-onset confusion , signs of heart failure or acute kidney injury , or suspected phaeochromocytoma should prompt referral for same-day assessment and treatment . 3