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Hypertension: Investigations, Treatment Initiation and Non-Pharmacological Treatment

Essentials

  • The diagnosis of hypertension is based on levels measured in the surgery (preferably by a nurse) and, additionally, at home or by ambulatory monitoring.
  • Identify risk factors and concomitant diseases and, in primary prevention in ‘healthy' people, calculate overall risk using a risk calculator appropriate for the local population.
  • The aim is to reduce cardiovascular disease risk through effective lifestyle guidance and medication (statins, in particular), as necessary.
  • Exclude secondary hypertension.
  • Drug treatment is recommended if, despite lifestyle interventions, the systolic BP level is ≥ 140 mmHg or the diastolic BP level is ≥ 90 mmHg as measured in the surgery, and the BP level measured at home or the daytime level during ambulatory blood pressure monitoring is ≥ 135/85 mmHg.
  • The goal of treatment is to reduce systolic BP to below 140 mmHg and diastolic pressure to below 90 mmHg (home measurements < 135/85 mmHg). For persons over 80 years of age the goal is < 150/90 mmHg (home measurements < 140/85 mmHg). The target is lower if there is a high risk of disease or the patient has diabetes or a renal disease and the target can be achieved without harmful effects.

General remarks Blood Pressure Lowering for Prevention of Dementia in Patients Without Prior Cerebrovascular Disease

  • As BP becomes more elevated cardiovascular morbidity and mortality both increase without a definite cut off value.
  • Measurement at home reflects the usual blood pressure level and risk of target organ damage and predicts arterial disease events and deaths better than measurement in the surgery.
  • The threshold values (in mmHg) for diagnosing hypertension are considered to be: systolic pressure ≥ 140 and/ or diastolic pressure ≥ 90, which corresponds to a home measurement of 135/85.
    • Optimal BP: systolic < 120 and diastolic < 80 (home measurement < 120/80).
      • Check every 5 years
    • Normal BP: < 130/85 (home measurement < 125/80).
      • Check every 2 years
    • Satisfactory (high normal) level: systolic 130-139 and/or diastolic 85-89 (home measurement 125-134/80-84).
      • Check once a year
      • If latent hypertension is possible, the matter should be investigated by measurements outside the surgery (at home, for instance).
  • Isolated systolic hypertension refers to systolic BP of ≥ 140 mmHg whilst diastolic BP is < 90 mmHg.
  • For corresponding BP values obtained in the surgery, at home and by ambulatory monitoring, see table T2.

Blood pressure measurement Home Blood Pressure (Bp) Measurement Compared to Office Bp

Choosing an adult cuff

CuffBladder widthCircumference of upper arm
Small adult cuff12 cm26-32 cm
Standard adult cuff15 cm33-41 cm
Large adult cuff18 cmover 41 cm

Classification of BP levels

  • BP measurement in the surgery is primarily used for screening.
  • If blood pressure is elevated when measured in the surgery, the diagnosis of hypertension should be confirmed by measurement outside the surgery.
  • If other measurement is unsuccessful, classification should be based on measurement in the surgery.
    • Mean of readings obtained by duplicate measurement preferably made by a nurse on 4 days
  • Home measurement is the most recommended way of following up blood pressure.
    • For BP values obtained with different types of measurement, see Table T2.
  • Home measurements should be performed in the sitting position, before taking the medication, using an automatic upper arm device; two readings should be taken both in the morning (at 6-9 a.m.) and in the evening (at 6-9 p.m.) for a period of 4-7 days.
    • The home BP level should be determined by calculating the means of the morning and evening readings and of all the readings. Readings obtained during 4 days are sufficient for assessing the treatment.
    • Higher levels measured in the morning than in the evening may suggest sleep apnoea or excessive alcohol consumption.
  • 24-hour ambulatory BP monitoring may be indicated for the investigation of resistance to drug treatment (at least 3 drugs in use), hypotensive episodes during drug treatment, paroxysmal increase or decrease in BP, nocturnal BP, or a significant discrepancy between measurements obtained at home and in the surgery.
  • In white coat hypertension http://www.dynamed.com/approach-to/high-blood-pressure-differential-diagnosis#GUID-3CF25157-7745-49F9-9FC4-1D0B78510C12, the patient's BP is elevated when measured by a doctor or nurse in a clinic (in the surgery), but home BP or daytime ambulatory BP readings are within the normal range.
    • White coat hypertension is predictive of the development of sustained hypertension and warrants regular follow-up to assess the need for drug treatment.
    • Treatment decisions should be based on either home BP or ambulatory BP measurements.
  • In latent hypertension http://www.dynamed.com/approach-to/high-blood-pressure-differential-diagnosis#GUID-9458A52F-1E7F-40E6-A99D-1BE940B09396, the home BP level or the daytime level of ambulatory BP is elevated but the BP is normal when measured in the surgery.
    • If the systolic BP measured in the surgery is 130-139 mmHg or the diastolic BP 85-89 mmHg and the patient has other risk factors for arterial disease, the possibility of latent hypertension should be investigated by home measurement or ambulatory BP monitoring.
    • Treatment decisions should be based on either home BP or ambulatory BP measurements and on the patient's risk factors.
  • In pseudohypertension http://www.dynamed.com/approach-to/high-blood-pressure-differential-diagnosis#PSEUDOHYPERTENSION, blood pressure is elevated and reacts poorly to medication, but target organ damage does not occur.
    • Patients are usually elderly. Pseudohypertension is caused by calcification of the brachial artery; BP measurements with an external cuff yield values that are falsely higher than the real intra-arterial pressure.
    • Pseudohypertension may be clinically suspected and reduction of medication tried if in an elderly person striving for reaching the recommended target blood pressure causes dizziness or falls.
    • The diagnosis can be confirmed by intra-arterial blood pressure measurement, but in practice this is only possible in few cases.

Corresponding BP values (mmHg) obtained with different types of measurement. Source: Finnish Current Care guideline on hypertension, 2020 (modified).

SurgeryHomeAmbulatory
24 hDayNight
120/80120/80115/75120/80100/65
130/80125/80125/75130/80110/65
140/90135/85130/80135/85120/70
150/90140/85
160/100145/90

Initial investigations in primary care

  • A patient with high BP should undergo basic examinations as well as evaluations of cardiovascular risk factors and target organ damage. In primary prevention in ‘healthy' people, the overall cardiovascular risk can be evaluated using a calculator appropriate for the local population. The evaluation results, together with the BP level, should be used in treatment planning.
  • Medical history: see table T3
  • Physical examination
    • Auscultation of the heart and lungs, bruits (carotid artery, abdominal artery, renal artery, femoral artery)
    • Palpation of the arteries (the radial, femoral, dorsalis pedis and posterior tibial arteries) and the abdomen (liver and kidneys), left ventricular apex beat, leg oedema
    • Weight, height, BMI, waist circumference Metabolic Syndrome
    • Examination of optic fundi if diastolic BP is over 120 mmHg (fundus photography is most reliable)
  • Laboratory investigations http://www.dynamed.com/condition/hypertension#TESTING_FOR_ALL_PATIENTS_WITH_HYPERTENSION and imaging studies
    • Plasma creatinine (eGFR calculator: Gfr Calculator), potassium (hypokalaemia - primary hyperaldosteronism Primary Hyperaldosteronism (Pha)) and sodium
    • Basic blood count with platelet count, fasting blood glucose, plasma total cholesterol, HDL-cholesterol, LDL-cholesterol and triglycerides
    • Chemical urinalysis (protein, haemoglobin) and urine albumin/creatinine ratio
      • Increased albuminuria and decreased GFR are early signs of target organ damage.
      • Increased albuminuria: urine albumin/creatinine ratio 3-30 mg/mmol, or albumin in 24-hour urine 30-300 mg/24 h
      • Proteinuria (macroalbuminuria): urine albumin/creatinine ratio > 30 mg/mmol, or 24-hour urine albumin > 300 mg/24 h
      • Urine dipstick tests give a positive result (+) only when the albumin concentration is 200-300 mg/l.
    • Plasma NT-proBNP (in suspected heart failure)
    • ECG
    • Chest x-ray (in suspected heart failure)
    • Echocardiography if indicated (ECG difficult to interpret [LBBB] and not suitable for the evaluation of LVH, or cardiac insufficiency of unknown origin, unspecified valvular defect, atrial fibrillation not previously investigated or other significant arrhythmia).
    • Renal ultrasonography if indicated (if GFR < 30 ml/min/1.73 m2 or the patient has proteinuria [urine albumin/creatinine ratio > 30 mg/mmol or urine albumin level > 300 mg/24 h])
  • If secondary hypertension http://www.dynamed.com/approach-to/high-blood-pressure-differential-diagnosis#GUID-39DF68F1-F87C-4A5E-8557-54D891917C8D is suspected Secondary Hypertension, additional investigations http://www.dynamed.com/condition/hypertension#ADDITIONAL_TESTING_FOR_SELECTED_PATIENTS should be carried out according to the suspected aetiology and local protocols, consulting specialized care, as necessary.
    • TSH and free T4 (thyroid diseases)
    • Plasma renin and serum aldosterone (after night rest in sitting position, at least 5 min sitting before sampling) and their ratio in any patient if treatment goal is not reached, irrespective of potassium level (primary aldosteronism); for more information see Primary Hyperaldosteronism (Pha)
    • Short 1.5 mg dexamethasone test (Cushing's syndrome) Cushing's Syndrome
    • Serum metanephrine and normetanephrine (pheochromocytoma) Rare Endocrine Tumours
    • Plasma ionised calcium (hyperparathyroidism) Hypercalcaemia and Hyperparathyroidism.

Medical history of a hypertensive patient

Subsections to be consideredDetails
Family history
  • Parents
  • Siblings
  • Hypertension
  • Type 2 diabetes
  • Dyslipidaemia
  • Early coronary and cerebrovascular events
    • Men under 55 years
    • Women under 65 years
Other cardiovascular diseases
  • Coronary heart disease, history of myocardial infarctions (MI)
  • Cerebrovascular disease
    • Stroke (cerebral infarction, intracerebral haemorrhage, subarachnoid haemorrhage)
    • TIA
  • Peripheral vascular disease
  • Left ventricular dysfunction
    • Post MI
    • Cardiomyopathies
  • Heart failure
  • Significant valvular defects
  • Aortic disease (dilatation, dissection)
  • Arrhythmias
Other conditions influencing treatment
  • Diabetes
  • Renal disease or damage
  • Asthma
  • Gout
Clinical course of hypertensionOnset, progress, severity
Medication use
Lifestyle
  • Diet
    • Salt intake
    • Type of fats
    • Vegetable, berry and fruit intake
  • Weight and its fluctuations
  • Exercise and other physical activity
  • Products containing liquorice extract (such as liquorice, salmiac (ammonium chloride) products)
  • Alcohol (AUDIT Audit)
  • Smoking
  • Illicit drugs (particularly amphetamine, cocaine and other stimulants)
StressStressful emotional and social factors

Indications for consulting specialized care

  • Hypertensive emergency - treat as a medical emergency
  • Gestational hypertension Antenatal Clinics and Specialist Care: Consultations, Referrals, Treatment Guidelines Elevated Blood Pressure in Pregnancy (Gestational Hypertension, Pre-Eclampsia)
  • Suspicion of secondary hypertension Secondary Hypertension
    • A young patient (under 30 years)
    • Systolic BP over 220 mmHg or diastolic BP over 120 mmHg
    • Hypertension with sudden onset or rapid progression
    • Treatment goals not achieved even with at least triple drug treatment (of which one a diuretic)
    • Symptoms or findings suggestive of secondary causes of hypertension
    • Significant target organ damage (LVH, albuminuria, funduscopic findings)
    • Renal disease
    • Hypokalaemia (spontaneous or due to a diuretic)
  • Difficulty in finding suitable medication
  • Impairing of renal function despite using an ACE inhibitor or an angiotensin-receptor blocker (ARB)
    • GFR decreasing during monitoring by 25% or into level < 30 ml/min or
    • increasing albuminuria (U-Alb/Crea > 30 mg/mmol or 24-hour urinary protein excretion > 500 mg).
  • Development of a differential diagnostic problem or significant treatment problem.

Non-pharmacological treatment of risk factors for hypertension Magnesium Supplementation and Blood Pressure, Dietary Fiber and Hypertension, Effect of Cocoa on Blood Pressure, Green and Black Tea for the Primary Prevention of Cardiovascular Disease, Relaxation Therapies for the Management of Primary Hypertension in Adults, Coenzyme Q10 for Primary Hypertension, Fermented Milk for Hypertension, Effect of Oral Potassium on Blood Pressure, Lowsodium Salt Substitutes and Blood Pressure

Initiation of drug treatment according to the severity of hypertension

  • In addition to antihypertensive medication, effective lifestyle guidance and, as necessary, pharmacotherapy (statins, in particular) should be used to reduce the overall risk of cardiovascular disease.
  • Most patients need combination therapy to reach the goal. If the baseline BP level is > 160/100 mmHg (home measurement > 145/90 mmHg), it is warranted to start pharmacotherapy using a drug combination.
  • Drugs can be taken once or twice daily, in the morning and/or in the evening. To stabilize blood pressure levels in elderly patients, it may be useful to divide the daily doses into morning and evening doses.
  • In elderly patients, a 3-minute orthostatic test should be performed before starting the medication and after any changes to it.
  • When treating elderly patients, the blood pressure lowering effects of other than antihypertensive medication (such as alpha-receptor blockers used to treat prostatic hyperplasia and Parkinson's disease medication) should also be considered.
  • Choosing the first-line drug: see Drug Treatment for Hypertension

High normal blood pressure

  • BP measured in the surgery 130-139 and/or 85-89 mmHg
  • BP measured at home 125-134 and/or 80-84 mmHg
  • Explore any risk factors and provide lifestyle advice.
  • If BP measured in the surgery is at this level and the patient has other risk factors for arterial disease, the possibility of latent hypertension should be investigated by home measurement or ambulatory BP monitoring.
  • In latent hypertension, BP measured in the surgery is normal (less than 140/90 mmHg), but self-measurements or the daytime level in ambulatory monitoring are elevated (135/85 mmHg or more).
    • Intensify lifestyle intervention and consider drug treatment of high-risk patients.
  • BP measurement every 12 months

Mild hypertension Pharmacotherapy for Mild Hypertension

  • BP measured in the surgery 140-159 and/or 90-99 mmHg
  • BP measured at home 135-144 and/or 85-89 mmHg
  • Provide lifestyle guidance and confirm the BP level and BP classification by home measurement or ambulatory BP monitoring.
  • Drug treatment should be started immediately if the patient has
    • a renal disease
    • symptomatic cardiovascular disease
    • target organ damage associated with hypertension.
  • Otherwise, antihypertensive medication should be started after 3-6 months' lifestyle treatment if the BP goal set for treatment has not been achieved.

Moderate hypertension

  • BP measured in the surgery 160-179 and/or 100-109 mmHg
  • BP measured at home ≥ 145 and/or ≥ 90 mmHg
  • Provide lifestyle guidance and confirm the BP level and BP classification by home measurement or ambulatory BP monitoring.
  • At such BP levels measured at home, antihypertensive medication should be started immediately and BP levels should reach the goal within 3 months.
  • If the BP measured in the surgery is at this level, immediate antihypertensive treatment is recommended if the patient has a renal disease, symptomatic cardiovascular disease or target organ damage associated with hypertension. The target BP level should be reached within 3 months.

Significant hypertension

  • BP measured in the surgery 180-199 and/or 110-129 mmHg
  • Provide lifestyle guidance and confirm the BP level and BP classification by home measurement or ambulatory BP monitoring.
  • Start antihypertensive medication immediately. The target BP level must be reached within 3 months.

Hypertensive crisis (systolic BP ≥ 200 or diastolic BP ≥ 130 mmHg) Pharmacological Interventions for Hypertensive Emergencies

  • A distinction is made between hypertensive emergency and hypertensive urgency.
    • In hypertensive emergency there are findings consistent with, or symptoms of, target organ involvement (coronary ischaemia, heart failure, cerebral signs, rapidly progressing renal failure, retinal haemorrhage, dissection of the aorta).
      • Requires an emergency referral to specialist care.
      • Intravenous medication is usually required to control BP.
      • In primary care, the first aid treatment consists of intermediate- or long-acting calcium-channel blockers, which must not be chewed.
    • In hypertensive urgency, when the patient is asymptomatic
      • As there is no target organ damage medication may be started in primary care, either immediately or no later than after a monitoring period of a few days if the BP level does not decrease.
      • A combination of 3-4 drugs can be used as the first-line approach, for example amlodipine 5 mg + bisoprolol 5 mg + hydrochlorothiazide 12.5 mg + enalapril 10 mg.
      • Treatment response is assessed within 1-3 days.

Treatment goal Pharmacotherapy for Hypertension in the Elderly, Blood Pressure Targets for Hypertension in Older Adults, Blood Pressure Targets for People with Hypertension and Cardiovascular Disease

  • A patient's blood pressure level is determined by averaging measurements taken on at least 4 separate days - two readings per measurement.
  • The treatment goal (in mmHg) is
    • <140/90 (home measurements < 135/85)
    • <130/80 (home measurements < 125/80) if there is a high risk of disease (= cardiovascular disease or, in asymptomatic patients, high risk according to an appropriate risk calculator) and the goal can be reached without adverse effects
      • In the Finnish FINRISK calculator, 10 % is considered as the threshold for high risk.
    • <140/80 (home measurements < 135/80) if the patient has diabetes. A stricter target of < 130/80 (home measurement < 125/80) should be aimed at if this can be reached without adverse effects.
    • <130/80 (home measurement < 125/80) if the patient has a chronic renal disease (eGFR < 60 ml/min/1.73 m2 ) or diabetic or non-diabetic renal disease associated with albuminuria (urine albumin > 300 mg/24h or urine albumin/creatinine ratio > 30 mg/mmol) and the goal is achievable without adverse effects.
  • Advanced age does not influence treatment goals, but in clinical practice, based on the overall situation, the target BP may be < 150/90 mmHg (home measurements < 140/85) for an individual over 80 years of age Hypertension in Elderly Patients. In an elderly patient with impaired performance capacity, a systolic BP < 130 mmHg may have adverse effects.

Follow-up ASA for Hypertension, Interventions to Improve Control of Blood Pressure in Hypertension, Evening Versus Morning Dosing of Antihypertensive Drugs

  • The aim at follow-up visits is to assess whether treatment goals have been achieved and how the patient tolerates the treatment.
  • Effects can be evaluated 1-2 months after treatment was started or changed, until the disease is under control.
  • The frequency of further follow-up visits should be decided according to the treatment, target organ damage and existing comorbidities.
    • A nurse or public health nurse can be responsible for some contacts, and electronic and telephone contacts can be utilized.
    • If the goal cannot be reached, the patient should be referred to the surgery for investigation of the reasons for the poor response.
  • At the first follow-up visit, the following should be checked:
    • plasma potassium and sodium in patients on diuretics
    • plasma potassium, sodium and creatinine (estimated glomerular filtration rate, eGFR Gfr Calculator) in patients on ACE inhibitors or ARBs.
  • After treatment has been stabilised:
    • General health condition, suitability and realization of planned medication, heart rate, BP level (home measurements) and realization of the treatment goal
    • Realization of lifestyle changes: smoking, weight, exercise, alcohol, diet and salt intake
    • Plasma potassium, sodium and creatinine (eGFR Gfr Calculator) in patients on diuretics, ACE inhibitors or ARBs, in other patients as needed.
    • Target organ complications (urine albumin/creatinine ratio, eGFR Gfr Calculator, ECG) and risk factors for arterial disease (blood glucose, lipids) should be assessed every 1-2 years as considered appropriate on a case by case basis, and in primary prevention the overall risk of arterial disease should be defined using an appropriate calculator.

    References

    • Williams B, Mancia G, Spiering W et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018;39(33):3021-3104. [PubMed]
    • Piepoli MF, Hoes AW, Agewall S et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016;37(29):2315-2381. [PubMed]