PPRNet Practice Guidelines


Heart Disease and Stroke 

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Blood Pressure Management

Practice guidelines: 

The relationship between BP and risk of cardiovascular disease (CVD) events is continuous, consistent, and independent of other risk factors. For individuals aged 40 to 70 years, each increment of 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP doubles the risk of CVD across the entire BP range from 115/75 to 185/115 mm Hg.

In clinical trials, antihypertensive therapy has been associated with 35% to 40% mean reductions in stroke incidence; 20% to 25% in myocardial infarction; and more than 50% in heart failure. It is estimated that in patients with stage 1 hypertension (systolic BP, 140-159 mm Hg and/or diastolic BP, 90-99 mm Hg) and additional cardiovascular risk factors, achieving a sustained 12-mm Hg decrease in systolic BP for 10 years will prevent 1 death for every 11 patients treated. In the presence of CVD or target-organ damage, only 9 patients would require this BP reduction to prevent a death. Because most patients with hypertension, especially those aged at least 50 years, will reach the diastolic BP goal once systolic BP is at goal, the primary focus should be on achieving the systolic BP goal. Treating systolic BP and diastolic BP to targets that are less than 140/90 mm Hg is associated with a decrease in CVD complications. In patients with hypertension with diabetes or renal disease, the BP goal is less than 130/80 mm Hg.  

Click here for more information on BP measurement.

Recommendations from the American Heart Association:

 The auscultator method of BP measurement with a properly calibrated and validated instrument should be used.

Patients should be seated quietly for at least 5 minutes in a chair rather than on an examination table, with feet on the floor and arm supported at heart level.

The patient should be seated comfortably with the back supported and the upper arm bared without constrictive clothing. The legs should not be  crossed.

 The arm should be supported at heart level, and the bladder of the cuff should encircle at least 80% of the arm circumference.

The mercury column should be deflated at 2 to 3 mm/s, and the first and last audible sounds should be taken as systolic and diastolic pressure.  The column should be read to the nearest 2 mm Hg.

Neither the patient nor the observer should talk during the measurement.

             

Adoption of healthy lifestyles by all individuals is critical for the prevention of high BP and an indispensable part of the management of those with hypertension. Major lifestyle modifications shown to lower BP include weight reduction in those individuals who are overweight or obese; adoption of Dietary Approaches to Stop Hypertension (DASH) eating plan, which is rich in potassium and calcium; dietary sodium reduction; physical activity; and moderation of alcohol consumption. Lifestyle modifications decrease BP, enhance antihypertensive drug efficacy, and decrease cardiovascular risk. For example, a 1600-mg sodium DASH eating plan has effects similar to single drug therapy. Combinations of 2 or more lifestyle modifications can achieve even better results.

Strong clinical trial outcome data prove that lowering BP with several classes of drugs, including thiazide-type diuretics, ACE inhibitors, ARBs, B-blockers, and calcium channel blockers, will all reduce the complications of hypertension. Thiazide-type diuretics have been used in most outcome trials. In these trials, including the ALLHAT Trial, diuretics have been virtually unsurpassed in preventing the cardiovascular complications of hypertension.  Diuretics enhance the antihypertensive efficacy of multi-drug regimens, can be useful in achieving BP control, and are more affordable than other antihypertensive agents.

Thiazide-type diuretics should be used as initial therapy for most patients with hypertension, either alone or in combination with 1 of the other classes (ACE inhibitors, ARBs, B-blockers, CCBs) demonstrated to be beneficial in randomized controlled outcome trials.

Most patients with hypertension will require 2 or more antihypertensive medications to achieve their BP goals. Addition of a second drug from a different class should be initiated when use of a single drug in adequate doses fails to achieve the BP goal. When BP is more than 20/10 mm Hg above goal, consideration should be given to initiating therapy with 2 drugs, either as separate prescriptions or in fixed-dose combinations. Initial combination therapy should be used cautiously in those at risk for orthostatic hypotension, such as patients with diabetes, autonomic dysfunction, and some older persons.

Once antihypertensive drug therapy is initiated, most patients should return for follow-up and adjustment of medications at approximately monthly intervals until the BP goal is reached. More frequent visits will be necessary for patients with stage 2 hypertension or with complicating comorbid conditions. Serum potassium and creatinine should be monitored at least 1 to 2 times per year. After BP is at goal and stable, follow-up visits can usually be at 3- to 6-month intervals. Other cardiovascular risk factors should be treated to their respective goals, including tobacco cessation. Low-dose aspirin therapy should be considered only when BP is controlled, because the risk of hemorrhagic stroke is increased in patients with uncontrolled hypertension.

Additional resources: 

Home Monitoring of Glucose and Blood Pressure – From the American Family Physician. http://www.aafp.org/afp/20070715/255.html