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How should you treat the newly diagnosed hypertensive patient?
IT DEPENDS ON THE PATIENT’S RISK FACTORS, physical condition, and preferences. All hypertensive patients can potentially benefit from lifestyle interventions, including weight reduction, aerobic physical activity, the dietary approaches to stop hypertension (DASH) diet, and moderation of alcohol use (strength of recommendation [SOR]: A, systematic reviews).
Although lifestyle interventions are effective for some patients, they haven’t been proven to provide long-term control and don’t lower blood pressure as much as medications (SOR: B, systematic review of inconsistent randomized controlled trial [RCT]). For specific high-risk patients, pharmacologic therapy is recommended at the time of diagnosis (SOR: C, expert opinion).
When considering lifestyle changes and medication, it’s important to assess patient preferences as well as overall cardiovascular risks, presence of target organ damage, and clinical cardiovascular disease, because lifestyle modification and medication can both affect quality of life (SOR: C, expert opinion).
Evidence summary
The prevalence of hypertension is increasing. Twenty-seven percent of adult Americans are hypertensive; 31% have prehypertension (TABLE).1 Among adults older than 50 years, the risk of developing high blood pressure approaches 90% if they live to age 80 or older.2 Cardiovascular risk rises along with blood pressure readings. Blood pressure values in the range of 130/85 to 139/89 mm Hg are associated with a more than 2-fold increase in cardiovascular disease risk compared with values below 120/80 mm Hg.2
Even small reductions in blood pressure, when applied to the population as a whole, produce significant improvements in patient-oriented outcomes. A drop in systolic blood pressure of 3 mm Hg can decrease stroke mortality by 8% and coronary artery disease by 5%.2
Lifestyle interventions for treating hypertension
Lifestyle interventions for hypertensive patients include:
- Striving to maintain or achieve an ideal body weight (body mass index of 18-25).2 However, even modest weight reductions in overweight and obese hypertensive patients significantly lower blood pressure and overall cardiovascular risk. A 10-kg decrease in body weight can lower systolic blood pressure by 5 to 20 mm Hg.2
- Adopting the DASH diet.1 Consuming a diet rich in fruits, vegetables, and lowfat dairy products and limiting saturated and total fat intake can reduce systolic blood pressure by 2 to 8 mm Hg.
- Engaging in regular physical activity for at least 30 minutes most days of the week. This regimen has been shown to decrease systolic blood pressure by 4 to 9 mm Hg.2
- Limiting daily alcohol intake, if the patient drinks, to 2 servings for men and 1 for women and lower-weight individuals.2 Restricting alcohol consumption may lower systolic blood pressure by 2 to 4 mm Hg.
Randomized controlled trials have consistently demonstrated that patients who combine multiple lifestyle interventions achieve the greatest benefits.3-5 Success obviously requires patient motivation. Health care providers need to continually assess motivation and encourage adherence.
Most patients need medication, too
Lifestyle changes alone haven’t been shown to achieve the same long-term reductions in blood pressure as medication.5 Although some motivated patients can control their blood pressure solely by adjusting their lifestyle, few succeed in reaching and maintaining blood pressure goals. Continued attention to lifestyle should be encouraged both to control blood pressure and reduce overall cardiovascular risk, but most patients with hypertension need medication.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) doesn’t specify whether to offer a trial of therapeutic lifestyle change before starting medication.2 Clinicians should negotiate interventions based on each patient’s preferences, risk factors, and the presence or absence of clinical cardiovascular disease or target organ damage. Lifestyle changes and medication both can affect quality of life. Immediate pharmacologic treatment with 2 medications has been recommended in addition to lifestyle interventions for patients with stage 2 hypertension (TABLE).2
TABLE
JNC7 classifications of blood pressure in adults
| Blood pressure classification | Blood pressure (mm Hg) | Recommended follow-up |
|---|---|---|
| Normal | Systolic <120 AND diastolic <80 | 2 y |
| Prehypertension | Systolic 120-139 OR diastolic 80-89 | 1 y |
| Stage 1 hypertension | Systolic 140-159 OR diastolic 90-99 | 2 mo |
| Stage 2 hypertension | Systolic ≥160 OR diastolic ≥100 | 1 mo* |
| JNC7, Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. *For people with higher values (>180/110 mm Hg), evaluate and treat immediately or within 1 week, depending on clinical situation. Source: Chobanian AV, et al. Hypertension. 2003.2 | ||
Recommendations
The European Society of Hypertension provides recommendations for the duration of lifestyle interventions before trying medication. The recommendations are based on a complex scheme of overall cardiovascular risk assessment that takes into account traditional Framingham risks and other factors (such as obesity, C-reactive protein, and micro albuminuria), as well as the stage of hypertension.6 The Society recommends starting drug therapy immediately in people with blood pressure >180/110 mm Hg. This blood pressure threshold drops in patients with increasing numbers of risk factors. For patients with lower, but still elevated, blood pressure, the recommendations call for “lifestyle changes for several months, then drug treatment if BP is uncontrolled.”
For patients with diabetes, the American Diabetes Association (ADA) recommends a blood pressure goal of <130/80 mm Hg and drug therapy in addition to lifestyle and behavioral therapy for patients with systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg.7 Like the JNC7, the ADA notes that a combination of medications is often required to achieve blood pressure targets. The ADA recommendations also state that patients with diabetes and a systolic blood pressure of 130 to 139 mm Hg or a diastolic blood pressure of 80 to 89 mm Hg should pursue lifestyle and behavioral interventions alone for a maximum of 3 months, then start drug therapy if they don’t achieve their blood pressure goals.
The American Heart Association and American College of Cardiology offer evidence-based guidelines for secondary prevention in patients with atherosclerosis.8 They set blood pressure goals of <140/90 mm Hg for all patients and <130/80 mm Hg for patients with diabetes or chronic kidney disease. All patients are encouraged to initiate or maintain lifestyle modifications. If a patient’s blood pressure is ≥140/90 mm Hg (>130/80 mm Hg for patients with chronic kidney disease or diabetes), medications should be titrated to goal, beginning with beta-blockers or angiotensin-converting enzyme inhibitors.
1. Appel LJ, Brands MW, Daniels SR, et al. Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension. 2006;47:296-308.
2. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252.
3. Burke V, Beilin LJ, Cutt HE, et al. Effects of a lifestyle programme on ambulatory blood pressure and drug dosage in treated hypertensive patients: a randomized controlled trial. J Hypertens. 2005;23:1241-1249.
4. Elmer PJ, Obarzanek E, Vollmer WM, et al. Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. Ann Intern Med. 2006;144:485-495.
5. Nicolson DJ, Dickinson HO, Campbell F, et al. Lifestyle interventions or drugs for patients with essential hypertension: a systematic review. J Hypertens. 2004;22:2043-2048.
6. European Society of Hypertension-European Society of Cardiology Task Force on the Management of Arterial Hypertension. 2007 ESH-ESC practice guidelines for the management of arterial hypertension. J Hypertens. 2007;25:1751-1762.
7. American Diabetes Association. Standards of medical care in diabetes 2010. Diabetes Care. 2010;33(suppl 1):S11-S61.Available at: http://care.diabetesjournals.org/content/33/Supplement_1. Accessed March 1, 2010.
8. American Hospital Association, American College of Cardiology. AHA-ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation. 2006;113:2363-2372.
IT DEPENDS ON THE PATIENT’S RISK FACTORS, physical condition, and preferences. All hypertensive patients can potentially benefit from lifestyle interventions, including weight reduction, aerobic physical activity, the dietary approaches to stop hypertension (DASH) diet, and moderation of alcohol use (strength of recommendation [SOR]: A, systematic reviews).
Although lifestyle interventions are effective for some patients, they haven’t been proven to provide long-term control and don’t lower blood pressure as much as medications (SOR: B, systematic review of inconsistent randomized controlled trial [RCT]). For specific high-risk patients, pharmacologic therapy is recommended at the time of diagnosis (SOR: C, expert opinion).
When considering lifestyle changes and medication, it’s important to assess patient preferences as well as overall cardiovascular risks, presence of target organ damage, and clinical cardiovascular disease, because lifestyle modification and medication can both affect quality of life (SOR: C, expert opinion).
Evidence summary
The prevalence of hypertension is increasing. Twenty-seven percent of adult Americans are hypertensive; 31% have prehypertension (TABLE).1 Among adults older than 50 years, the risk of developing high blood pressure approaches 90% if they live to age 80 or older.2 Cardiovascular risk rises along with blood pressure readings. Blood pressure values in the range of 130/85 to 139/89 mm Hg are associated with a more than 2-fold increase in cardiovascular disease risk compared with values below 120/80 mm Hg.2
Even small reductions in blood pressure, when applied to the population as a whole, produce significant improvements in patient-oriented outcomes. A drop in systolic blood pressure of 3 mm Hg can decrease stroke mortality by 8% and coronary artery disease by 5%.2
Lifestyle interventions for treating hypertension
Lifestyle interventions for hypertensive patients include:
- Striving to maintain or achieve an ideal body weight (body mass index of 18-25).2 However, even modest weight reductions in overweight and obese hypertensive patients significantly lower blood pressure and overall cardiovascular risk. A 10-kg decrease in body weight can lower systolic blood pressure by 5 to 20 mm Hg.2
- Adopting the DASH diet.1 Consuming a diet rich in fruits, vegetables, and lowfat dairy products and limiting saturated and total fat intake can reduce systolic blood pressure by 2 to 8 mm Hg.
- Engaging in regular physical activity for at least 30 minutes most days of the week. This regimen has been shown to decrease systolic blood pressure by 4 to 9 mm Hg.2
- Limiting daily alcohol intake, if the patient drinks, to 2 servings for men and 1 for women and lower-weight individuals.2 Restricting alcohol consumption may lower systolic blood pressure by 2 to 4 mm Hg.
Randomized controlled trials have consistently demonstrated that patients who combine multiple lifestyle interventions achieve the greatest benefits.3-5 Success obviously requires patient motivation. Health care providers need to continually assess motivation and encourage adherence.
Most patients need medication, too
Lifestyle changes alone haven’t been shown to achieve the same long-term reductions in blood pressure as medication.5 Although some motivated patients can control their blood pressure solely by adjusting their lifestyle, few succeed in reaching and maintaining blood pressure goals. Continued attention to lifestyle should be encouraged both to control blood pressure and reduce overall cardiovascular risk, but most patients with hypertension need medication.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) doesn’t specify whether to offer a trial of therapeutic lifestyle change before starting medication.2 Clinicians should negotiate interventions based on each patient’s preferences, risk factors, and the presence or absence of clinical cardiovascular disease or target organ damage. Lifestyle changes and medication both can affect quality of life. Immediate pharmacologic treatment with 2 medications has been recommended in addition to lifestyle interventions for patients with stage 2 hypertension (TABLE).2
TABLE
JNC7 classifications of blood pressure in adults
| Blood pressure classification | Blood pressure (mm Hg) | Recommended follow-up |
|---|---|---|
| Normal | Systolic <120 AND diastolic <80 | 2 y |
| Prehypertension | Systolic 120-139 OR diastolic 80-89 | 1 y |
| Stage 1 hypertension | Systolic 140-159 OR diastolic 90-99 | 2 mo |
| Stage 2 hypertension | Systolic ≥160 OR diastolic ≥100 | 1 mo* |
| JNC7, Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. *For people with higher values (>180/110 mm Hg), evaluate and treat immediately or within 1 week, depending on clinical situation. Source: Chobanian AV, et al. Hypertension. 2003.2 | ||
Recommendations
The European Society of Hypertension provides recommendations for the duration of lifestyle interventions before trying medication. The recommendations are based on a complex scheme of overall cardiovascular risk assessment that takes into account traditional Framingham risks and other factors (such as obesity, C-reactive protein, and micro albuminuria), as well as the stage of hypertension.6 The Society recommends starting drug therapy immediately in people with blood pressure >180/110 mm Hg. This blood pressure threshold drops in patients with increasing numbers of risk factors. For patients with lower, but still elevated, blood pressure, the recommendations call for “lifestyle changes for several months, then drug treatment if BP is uncontrolled.”
For patients with diabetes, the American Diabetes Association (ADA) recommends a blood pressure goal of <130/80 mm Hg and drug therapy in addition to lifestyle and behavioral therapy for patients with systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg.7 Like the JNC7, the ADA notes that a combination of medications is often required to achieve blood pressure targets. The ADA recommendations also state that patients with diabetes and a systolic blood pressure of 130 to 139 mm Hg or a diastolic blood pressure of 80 to 89 mm Hg should pursue lifestyle and behavioral interventions alone for a maximum of 3 months, then start drug therapy if they don’t achieve their blood pressure goals.
The American Heart Association and American College of Cardiology offer evidence-based guidelines for secondary prevention in patients with atherosclerosis.8 They set blood pressure goals of <140/90 mm Hg for all patients and <130/80 mm Hg for patients with diabetes or chronic kidney disease. All patients are encouraged to initiate or maintain lifestyle modifications. If a patient’s blood pressure is ≥140/90 mm Hg (>130/80 mm Hg for patients with chronic kidney disease or diabetes), medications should be titrated to goal, beginning with beta-blockers or angiotensin-converting enzyme inhibitors.
IT DEPENDS ON THE PATIENT’S RISK FACTORS, physical condition, and preferences. All hypertensive patients can potentially benefit from lifestyle interventions, including weight reduction, aerobic physical activity, the dietary approaches to stop hypertension (DASH) diet, and moderation of alcohol use (strength of recommendation [SOR]: A, systematic reviews).
Although lifestyle interventions are effective for some patients, they haven’t been proven to provide long-term control and don’t lower blood pressure as much as medications (SOR: B, systematic review of inconsistent randomized controlled trial [RCT]). For specific high-risk patients, pharmacologic therapy is recommended at the time of diagnosis (SOR: C, expert opinion).
When considering lifestyle changes and medication, it’s important to assess patient preferences as well as overall cardiovascular risks, presence of target organ damage, and clinical cardiovascular disease, because lifestyle modification and medication can both affect quality of life (SOR: C, expert opinion).
Evidence summary
The prevalence of hypertension is increasing. Twenty-seven percent of adult Americans are hypertensive; 31% have prehypertension (TABLE).1 Among adults older than 50 years, the risk of developing high blood pressure approaches 90% if they live to age 80 or older.2 Cardiovascular risk rises along with blood pressure readings. Blood pressure values in the range of 130/85 to 139/89 mm Hg are associated with a more than 2-fold increase in cardiovascular disease risk compared with values below 120/80 mm Hg.2
Even small reductions in blood pressure, when applied to the population as a whole, produce significant improvements in patient-oriented outcomes. A drop in systolic blood pressure of 3 mm Hg can decrease stroke mortality by 8% and coronary artery disease by 5%.2
Lifestyle interventions for treating hypertension
Lifestyle interventions for hypertensive patients include:
- Striving to maintain or achieve an ideal body weight (body mass index of 18-25).2 However, even modest weight reductions in overweight and obese hypertensive patients significantly lower blood pressure and overall cardiovascular risk. A 10-kg decrease in body weight can lower systolic blood pressure by 5 to 20 mm Hg.2
- Adopting the DASH diet.1 Consuming a diet rich in fruits, vegetables, and lowfat dairy products and limiting saturated and total fat intake can reduce systolic blood pressure by 2 to 8 mm Hg.
- Engaging in regular physical activity for at least 30 minutes most days of the week. This regimen has been shown to decrease systolic blood pressure by 4 to 9 mm Hg.2
- Limiting daily alcohol intake, if the patient drinks, to 2 servings for men and 1 for women and lower-weight individuals.2 Restricting alcohol consumption may lower systolic blood pressure by 2 to 4 mm Hg.
Randomized controlled trials have consistently demonstrated that patients who combine multiple lifestyle interventions achieve the greatest benefits.3-5 Success obviously requires patient motivation. Health care providers need to continually assess motivation and encourage adherence.
Most patients need medication, too
Lifestyle changes alone haven’t been shown to achieve the same long-term reductions in blood pressure as medication.5 Although some motivated patients can control their blood pressure solely by adjusting their lifestyle, few succeed in reaching and maintaining blood pressure goals. Continued attention to lifestyle should be encouraged both to control blood pressure and reduce overall cardiovascular risk, but most patients with hypertension need medication.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) doesn’t specify whether to offer a trial of therapeutic lifestyle change before starting medication.2 Clinicians should negotiate interventions based on each patient’s preferences, risk factors, and the presence or absence of clinical cardiovascular disease or target organ damage. Lifestyle changes and medication both can affect quality of life. Immediate pharmacologic treatment with 2 medications has been recommended in addition to lifestyle interventions for patients with stage 2 hypertension (TABLE).2
TABLE
JNC7 classifications of blood pressure in adults
| Blood pressure classification | Blood pressure (mm Hg) | Recommended follow-up |
|---|---|---|
| Normal | Systolic <120 AND diastolic <80 | 2 y |
| Prehypertension | Systolic 120-139 OR diastolic 80-89 | 1 y |
| Stage 1 hypertension | Systolic 140-159 OR diastolic 90-99 | 2 mo |
| Stage 2 hypertension | Systolic ≥160 OR diastolic ≥100 | 1 mo* |
| JNC7, Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. *For people with higher values (>180/110 mm Hg), evaluate and treat immediately or within 1 week, depending on clinical situation. Source: Chobanian AV, et al. Hypertension. 2003.2 | ||
Recommendations
The European Society of Hypertension provides recommendations for the duration of lifestyle interventions before trying medication. The recommendations are based on a complex scheme of overall cardiovascular risk assessment that takes into account traditional Framingham risks and other factors (such as obesity, C-reactive protein, and micro albuminuria), as well as the stage of hypertension.6 The Society recommends starting drug therapy immediately in people with blood pressure >180/110 mm Hg. This blood pressure threshold drops in patients with increasing numbers of risk factors. For patients with lower, but still elevated, blood pressure, the recommendations call for “lifestyle changes for several months, then drug treatment if BP is uncontrolled.”
For patients with diabetes, the American Diabetes Association (ADA) recommends a blood pressure goal of <130/80 mm Hg and drug therapy in addition to lifestyle and behavioral therapy for patients with systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg.7 Like the JNC7, the ADA notes that a combination of medications is often required to achieve blood pressure targets. The ADA recommendations also state that patients with diabetes and a systolic blood pressure of 130 to 139 mm Hg or a diastolic blood pressure of 80 to 89 mm Hg should pursue lifestyle and behavioral interventions alone for a maximum of 3 months, then start drug therapy if they don’t achieve their blood pressure goals.
The American Heart Association and American College of Cardiology offer evidence-based guidelines for secondary prevention in patients with atherosclerosis.8 They set blood pressure goals of <140/90 mm Hg for all patients and <130/80 mm Hg for patients with diabetes or chronic kidney disease. All patients are encouraged to initiate or maintain lifestyle modifications. If a patient’s blood pressure is ≥140/90 mm Hg (>130/80 mm Hg for patients with chronic kidney disease or diabetes), medications should be titrated to goal, beginning with beta-blockers or angiotensin-converting enzyme inhibitors.
1. Appel LJ, Brands MW, Daniels SR, et al. Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension. 2006;47:296-308.
2. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252.
3. Burke V, Beilin LJ, Cutt HE, et al. Effects of a lifestyle programme on ambulatory blood pressure and drug dosage in treated hypertensive patients: a randomized controlled trial. J Hypertens. 2005;23:1241-1249.
4. Elmer PJ, Obarzanek E, Vollmer WM, et al. Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. Ann Intern Med. 2006;144:485-495.
5. Nicolson DJ, Dickinson HO, Campbell F, et al. Lifestyle interventions or drugs for patients with essential hypertension: a systematic review. J Hypertens. 2004;22:2043-2048.
6. European Society of Hypertension-European Society of Cardiology Task Force on the Management of Arterial Hypertension. 2007 ESH-ESC practice guidelines for the management of arterial hypertension. J Hypertens. 2007;25:1751-1762.
7. American Diabetes Association. Standards of medical care in diabetes 2010. Diabetes Care. 2010;33(suppl 1):S11-S61.Available at: http://care.diabetesjournals.org/content/33/Supplement_1. Accessed March 1, 2010.
8. American Hospital Association, American College of Cardiology. AHA-ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation. 2006;113:2363-2372.
1. Appel LJ, Brands MW, Daniels SR, et al. Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension. 2006;47:296-308.
2. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252.
3. Burke V, Beilin LJ, Cutt HE, et al. Effects of a lifestyle programme on ambulatory blood pressure and drug dosage in treated hypertensive patients: a randomized controlled trial. J Hypertens. 2005;23:1241-1249.
4. Elmer PJ, Obarzanek E, Vollmer WM, et al. Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. Ann Intern Med. 2006;144:485-495.
5. Nicolson DJ, Dickinson HO, Campbell F, et al. Lifestyle interventions or drugs for patients with essential hypertension: a systematic review. J Hypertens. 2004;22:2043-2048.
6. European Society of Hypertension-European Society of Cardiology Task Force on the Management of Arterial Hypertension. 2007 ESH-ESC practice guidelines for the management of arterial hypertension. J Hypertens. 2007;25:1751-1762.
7. American Diabetes Association. Standards of medical care in diabetes 2010. Diabetes Care. 2010;33(suppl 1):S11-S61.Available at: http://care.diabetesjournals.org/content/33/Supplement_1. Accessed March 1, 2010.
8. American Hospital Association, American College of Cardiology. AHA-ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation. 2006;113:2363-2372.
Evidence-based answers from the Family Physicians Inquiries Network