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Clinical guidelines

Guidelines for preventive activities in general practice 8th 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 age 18 years (A) at least every 2 years. BP should be interpreted in the context of an absolute cardiovascular risk assessment after age 45 years (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
Who is at risk?What should be done?How often?
Low absolute risk
  • <10% CVD risk
Provide lifestyle advice and education (I,B).
Offer pharmacotherapy if BP persistently over 160/100 mmHg
BP every 2 years (III,C)424,428-430
Moderate risk
  • 10–15% absolute cardiovascular risk
Provide intensive lifestyle advice (II,B).
Consider pharmacotherapy if risk factors have not reduced after 3–6 months of lifestyle intervention.
Offer pharmacotherapy simultaneously with lifestyle intervention if BP persistently over 160/100 mmHg or if family history of premature CVD or South Asian, Middle Eastern, Maori, Aboriginal or Pacific Islander descent (III,C).
BP every 6–12 months (III,C)310,424,426-428,431
High risk
  • >15% absolute cardiovascular risk
  • Clinically determined high risk:
    • diabetes and age >60 years
    • diabetes with microalbuminuria (>20 µg/min or UACR >2.5 mg/mmol for males, >3.5 mg/mmol for females)
    • moderate or severe CKD (persistent proteinuria or eGFR <45 mL/min/1.73 m2)
    • previous diagnosis of FH
    • SBP ≥180 mmHg or DBP ≥110 mmHg
    • serum total cholesterol >7.5 mmol/L
    • Aboriginal and Torres Strait Islander peoples aged over 74 years
Provide intensive lifestyle advice (II,B)424,429
Commence pharmacotherapy (simultaneously with lipid therapy unless contraindicated)432,433
Treatment goal is BP
≤140/90 mmHg in adults without CVD including those with CKD (I,B–III,D)* (≤130/80 in people with diabetes or micro or macroalbuminuria (UACR >2.5 mg/mmol in males and >3.5 mg/mmol in females))
BP every 6-12 weeks (III,C)
High risk
  • Existing CVD (previous event, symptomatic CVD), stroke or transient ischaemic attacks (TIAs) or CKD
Lifestyle risk factor counselling
Pharmacotherapy to lower risk (I,A)
Every 6 months (III,C)429

* D recommendation for clinically determined high risk.

Table 8.2.2 Hypertension: preventive interventions
InterventionTechnique
Measure 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. Thereafter, use the arm with the higher reading. In patients who may have orthostatic hypotension (e.g. the elderly, those with diabetes), measure BP in sitting position and repeat after the patient has been standing for at least 2 minutes.424,429
If possible, use ambulatory BP monitoring or self-measurement for patients with any of the following:
  • unusual variation between BP readings in the clinic
  • suspected white coat hypertension
  • hypertension that is resistant to drug treatment
  • suspected hypotensive episodes (e.g. in elderly or diabetic patients)
Risk calculation should be performed using clinical BP measurements (as the algorithms are based on these). Ambulatory BP readings are considered to be better predictors of outcomes than clinic BP measurements, and therefore should be used to monitor BP lowering therapy.
Lifestyle modification Lifestyle risk factors should be managed at all risk levels.424,429
All people, regardless of their absolute risk level, should be given dietary advice. Those at low to moderate absolute risk of CVD should be given dietary and other lifestyle advice. (See Section 7: Prevention of chronic disease)
Advise to aim for healthy targets:
  • at least 30 minutes of moderate-intensity physical activity on most, if not all, days
  • smoking cessation
  • waist measurement <94 cm for men and <80 cm for women, BMI <25 kg/m2
  • dietary salt restriction ≤;4 g/day (65 mmol/day sodium)
  • limit 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): 424
  • ≤140/90 for adults without CVD (including those with CKD)
  • ≤130/80 for adults with diabetes or with micro- or macro-albuminuria (UACR >2.5 mg/mmol for males, >3.5 mg/mmol for females).
Treatment may commence with an ACE inhibitor, angiotensin II antagonist, calcium channel blocker or a low-dose thiazide or thiazide-like diuretic. A second or third agent from a different class may be added to treat towards targets.

References

  1. Welborn TA, Dhaliwal SS, Bennett SA. Waist–hip ratio is the dominant risk factor predicting cardiovascular death in Australia. Med J Aust 2003;179(11/12):580–5
  2. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. Heart Foundation, 2012
  3. National Vascular Disease Prevention Alliance. Guidelines for the assessment of absolute cardiovascular disease risk. 2009. Heart Foundation, 2009
  4. van Dis I, Kromhout D, Geleijnse JM, Boer JM, Verschuren WM. Body mass index and waist circumference predict both 10-year nonfatal and fatal cardiovascular disease risk: study conducted in 20,000 Dutch men and women aged 20–65 years. Eur J Cardiovasc Prev Rehabil 2009;16(6):729–34
  5. Levy PJ, Jackson SA, McCoy TP, Ferrario CM. Clinical characteristics of patients with premature lower extremity atherosclerosis associated with familial early cardiovascular disease and/or cancer. Int Angiol 2006;25(3):304–9
  6. US Preventive Services Task Force. Screening for high blood pressure: US Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2007;147(11):783–6
  7. National Heart Foundation of Australia (National Blood Pressure and Vascular Disease Advisory Committee).Guide to management of hypertension 2008. Updated December 2010. Heart Foundation, 2010
  8. Vasan RS, Larson MG, Leip EP, Kannel WB, Levy D. Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study: a cohort study. Lancet 2001;358(9294):1682–6
  9. Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peopless. Canberra: AIHW, 2001
  10. Go A, Chertow G, Fan D, McCulloch C, Hsu C-y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351(13):1296–305
  11. Culleton B, Larson M, Wilson P, Evans J, Parfrey P, Levy D. Cardiovascular disease and mortality in a community-based cohort with mild renal insufficiency. Kidney Int 1999;56(6):2214–9
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