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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

8.2 Blood pressure

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 >80

BP should be measured in all adults from 18 years of age (A) at least every two years. BP should be interpreted in the context of an absolute CVD risk assessment after 45 years of age (35 years of age for Aboriginal and Torres Strait Islander peoples; B). Secondary causes of hypertension and ‘white coat’ hypertension should be considered.

Table 8.2.1. Hypertension: Identifying risk
Age and risk groupWhat should be done?How often?
Low absolute risk
<10% cardiovascular disease (CVD) risk Provide lifestyle advice and education (I, B) 34, 39–41

Offer pharmacotherapy if blood pressure (BP) persistently over 160/100 mmHg

Review BP of 140–159 mmHg after two months of lifestyle advice
BP every two years (III, C)
Moderate risk
10–15% absolute CVD risk Provide intensive lifestyle advice (II, B) 34, 38, 42

Consider pharmacotherapy if systolic blood pressure (SBP) is 140–159 mmHg or diastolic blood pressure (DBP) is 90–99 mmHg. If SBP is 130–139 mmHg or DBP is 85–89 mmHg, review BP in six months 11, 36, 37, 41, 43

Offer pharmacotherapy simultaneously with lifestyle intervention if BP persistently over 160/100 mmHg or if family history of premature CVD or patient is of South Asian, Middle Eastern, Maori, Aboriginal, Torres Strait Islander or Pacific Islander descent (III, C)
BP every 6–12 months (III, C)
High risk
  • >15% absolute CVD risk
  • Clinically determined high risk:
    • diabetes and >60 years of age
    • diabetes with microalbuminuria (>20 μg/min or urine the urine albumin-to-creatinine ratio [UACR] >2.5 mg/mmol for males, >3.5 mg/mmol for females)
    • moderate or severe chronic kidney disease (CKD) (persistent proteinuria or estimated glomerular filtration rate [eGFR] >45 mL/min/1.73 m2)
    • previous diagnosis of familial hypercholesterolemia (FH)
    • SBP ≥180 mmHg or DBP ≥110 mmHg
    • serum total cholesterol >7.5 mmol/L
    • Aboriginal and Torres Strait Islander peoples aged >74 years
Provide intensive lifestyle advice (II, B) 34, 43

Commence pharmacotherapy (simultaneously with lipid therapy unless contraindicated)

Treatment goal is BP ≤140/90 mmHg in adults without CVD, or lower (SBP <120 mmHg) in some individuals who tolerate more intensive treatment, and those with CKD (I, B to III, D;* ≤130/80 mmHg in people with diabetes or microalbuminuria or macroalbuminuria UACR ≥2.5 mg/mmol in males and >3.5 mg/mmol in females) 44, 45
BP every 6–12 weeks

(III, C)
Existing CVD (previous event, symptomatic CVD), stroke or transient ischaemic attacks (TIAs) or CKD Provide lifestyle risk factor counselling and commence pharmacotherapy to lower risk (I, A). There is some evidence that a treatment goal (SBP <120 mmHg) in some individuals who tolerate more intensive treatment provides additional benefit. Adverse effects need to be monitored 43, 46 Every six months (III, C)
*D recommendation for clinically determined high risk

BP, blood pressure; CKD, chronic kidney disease; CVD, cardiovascular disease; DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate; FH, familial hypercholesterolaemia; SBP, systolic blood pressure; TIA, transient ischaemic attack;

UACR, urine albumin-to-creatinine ratio
Table 8.2.2. Hypertension: Preventive interventions
Assessment and interventionTechnique
Measure blood pressure (BP) Measure BP on at least two separate occasions with a calibrated mercury sphygmomanometer, or automated device that is regularly calibrated against a mercury sphygmomanometer. At the patient’s first BP assessment, measure BP on both arms.34, 40 Thereafter, use the arm with the higher reading. In patients who may have orthostatic hypotension (eg elderly, those with diabetes), measure BP in sitting position and repeat after the patient has been standing for at least two minutes 47

If possible, use ambulatory BP monitoring or self-measurement for patients with:
  • unusual variation between BP readings in the clinic
  • suspected white coat hypertension
  • hypertension that is resistant to drug treatment
  • suspected hypotensive episodes (eg in elderly or diabetic patients)
Risk calculation should be performed using clinical BP measurements (as the algorithms are based on these)
Lifestyle modification Lifestyle risk factors should be managed at all risk levels 34, 40, 48

All people, regardless of their absolute cardiovascular disease (CVD) risk assessment, should be given dietary advice. Those at low to moderate absolute CVD risk should be given dietary and other lifestyle advice (refer to Chapter 7. Prevention of chronic disease)

Advise to aim for healthy targets:
  • Encourage any physical activity and aim for at least 30 minutes of moderate-intensity physical activity on most, if not all, days
  • Recommend smoking cessation
  • Suggest a target waist measurement <94 cm for men and <80 cm for women, and a body mass index (BMI) <25 kg/m2
  • Recommend dietary salt restriction ≤4 g/day (65 mmol/day sodium)
  • Encourage limiting alcohol intake to ≤2 standard drinks per day for males and ≤1 standard drink per day for females
Medications BP treatment should aim to lower BP towards (while balancing risks and benefits): 34, 49
  • ≤140/90 mmHg for adults without CVD (including those with chronic kidney disease [CKD])
  • ≤130/80 mmHg for adults with diabetes or with microalbuminuria or macroalbuminuria (urine albumin-to-creatinine ratio urine albumin-to-creatinine ratio [UACR] >2.5 mg/mmol for males, >3.5 mg/mmol for females)
  • In patients at high absolute risk there is some evidence that a lower treatment goal (systolic blood pressure [SBP] <120 mmHg) in individuals who tolerate more intensive treatment provides additional benefit. Adverse effects need to be monitored
BMI, body mass index; BP, blood pressure; CKD, chronic kidney disease; CVD, cardiovascular disease; SBP, systolic blood pressure; UACR, urine albumin-to-creatinine ratio
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