• Urinalysis
• Blood chemistry (potassium, sodium, creatinine/estimated glomerular filtration rate [eGFR])
• Fasting blood glucose
• Fasting total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides
• Standard 12 lead electrocardiogram (ECG)
• Microalbuminuria** (albumin/creatinine ratio [ACR])
• Framingham risk assessment (10-year CHD risk) (Appendix B of the original guideline document) or the United Kingdom Prospective Diabetes Study (UKPDS) risk assessment if Type II Diabetes (DM). See Diabetes Care at www.bcguidelines.ca.

** Detection of microalbuminuria as an indicator of kidney damage may be helpful when choosing a management strategy for hypertension. Currently, there is some evidence showing that angiotensin converting enzyme inhibitors (ACEI) do improve cardiovascular outcomes for patients with microalbuminuria.

Part II: Management

A flow sheet is included in this guideline (Appendix D of the original guideline document) to help facilitate care for your hypertensive patients.

The Framingham Risk Assessment Chart (Appendix B of the original guideline) is designed to estimate 10-year CHD risk in adults who do not have heart disease or diabetes. For the purpose of this guideline, CHD risk is used as a proxy for cardiovascular disease risk. The risk of stroke is approximately 25% of CHD risk. The risk factors included in the Framingham calculation are: gender, age, total cholesterol, HDL cholesterol, systolic blood pressure, treatment for hypertension and cigarette smoking.

The Framingham Risk Assessment Chart is a useful tool for estimating CHD risk in hypertensive patients, and may help inform your treatment decisions.

Blood Pressure Readings and the Management of Hypertension

The management of essential hypertension requires patient lifestyle management and/or therapeutic intervention to work towards the following blood pressure readings:

Table: Desirable Blood Pressure Readings^{*+ ±}

* The benefits of initiating antihypertensive therapy when mild to moderate hypertension is first diagnosed after the age of 80 years are still uncertain. Treatment can be continued with caution in previously treated patients after the age of 80 years.

+ The risk of a systolic blood pressure in the range of 140 to 160 and/or a diastolic blood pressure in the range of 90 to 100, in the absence of target organ damage or other risk factors, is small and may not outweigh the potential harms of pharmacologic treatment in all patients.

± Exercise caution in patients who have a diastolic BP close to 60, and regardless of BP, reassess the need for treatment if hypotensive symptoms exist.

At each visit:

• Measure blood pressure
• Reinforce benefits of a healthy lifestyle
• Confirm that medications are taken appropriately
• Review the patient's knowledge of their condition and their treatment
• Establish the minimum dose of medication required to achieve the desired BP

At least annually:

• Consider risk factors
• Re-check co-morbidities
• Examine for evidence of target organ damage
• Check creatinine/eGFR

Lifestyle Management

As a diagnosis is being established, provide adequate explanation and support to patients so that they clearly understand the nature and significance of this condition, and that they have the primary responsibility for the management of their blood pressure. Provide patients with information on available community support, such as those offered by the Heart and Stroke Foundation, including self-management courses (see Hypertension Patient Guide [listed in "Patient Resources" field of this summary]).

Offer and review the following lifestyle recommendations at each visit:

• Smoking cessation: Complete cessation of smoking and avoidance of exposure to second hand smoke is recommended. For assistance to quit, refer patients to QuitNow Services at 1 877 455-2233 (toll-free in BC; available 24/7/365) and at www.quitnow.ca to obtain self-help materials.
• Physical activity: All people should be prescribed 30-60 minutes of moderate intensity dynamic activity 4-7 days per week (dynamic activity includes: walking 3 km [2 miles] in 30 minutes once per day or walking 1.5 km [1 mile] in 15 minutes two times per day, jogging, cycling or swimming). Recommend getting a pedometer for immediate positive feedback.
• Weight reduction: Maintenance of a healthy body weight (body mass index [BMI] 18.5-24.9 kg/m², waist circumference <102 cm [40"] for men and <88 cm [35"] for women) is recommended for everyone. All overweight hypertensive individuals should be advised to lose weight. Weight loss strategies should be long-term and employ a multidisciplinary approach that includes dietary education, increased physical activity and behavioural intervention.
• Dietary recommendations: Hypertensive individuals and normotensive individuals at increased risk of developing hypertension should consume a diet that emphasizes fruits, vegetables, low-fat dairy products, fibre, whole grains, and protein sources that are reduced in saturated fats and cholesterol (Dietary Approaches to Stop Hypertension [DASH] diet) (see Appendix E in the original guideline document). In addition, reduced consumption of trans-fats and increased consumption of fish high in omega 3 fatty acids reduces cardiovascular risk.
• Reduce salt intake: In addition to a well-balanced diet, a reduced dietary sodium intake of ≤1,500 milligrams per day (approximately 1 tsp of table salt) is recommended for individuals with hypertension. Advise patients about the "hidden" salt content of processed foods, such as lunchmeat, canned soups and pasta.
• Alcohol consumption: Alcohol consumption should be limited to two drinks or less per day and consumption should not exceed 14 standard drinks per week for men and 9 standard drinks per week for women. A standard drink is defined as:
  • 1 can (341 mL) of 5% beer
  • 1 glass (150 mL) of 12% wine
  • 1.5 oz (45 mL) of 40% spirits
• Potassium, calcium and magnesium intake: Supplementation of potassium, calcium and magnesium is not recommended for the prevention or treatment of hypertension.

Pharmacologic Treatment

1. Indications for drug therapy in uncomplicated hypertension

   The benefits of pharmacologic treatment in people with mild hypertension (an average blood pressure between 140/90 and 160/100), and a 10-year CHD risk of less than 20% are unclear (Table 2 of the original guideline document). Use clinical judgement when recommending therapy for this patient group.

   Pharmacologic treatment in addition to lifestyle modification is recommended for patients with an average blood pressure ≥160/100, even in the absence of other major cardiovascular risk factors.

2. Treatment of uncomplicated hypertension

   Consider monotherapy with a low-dose thiazide diuretic as first-line treatment.

   If blood pressure is not adequately controlled, use combination therapy by adding one or more of the following agents:

   • Angiotensin converting enzyme inhibitor (ACEI)
   • Angiotensin II receptor blocker (ARB) if ACEI intolerant
   • Long-acting dihydropyridine calcium channel blocker (DHP-CCB)

   Note:

   • Beta-blockers may no longer be a first-line treatment option (with some exceptions)
   • Long-acting DHP-CCBs are a preferred second-line treatment option for patients at risk for, or with a history of, stroke
   • Alpha-blockers are not a first-line treatment option

   Consideration should also be given to the addition of low-dose aspirin (ASA) therapy in hypertensive patients with a Framingham risk score of ≥ 20% who are between 50 and 70 years-of-age. Avoid using ASA in patients with a history of hemorrhagic stroke. Blood pressure must be well controlled.

3. First-line treatment for hypertension complicated by co-morbid conditions

   It is important to control co-morbid conditions optimally when managing hypertension. Pharmacologic treatment must be chosen with even more care in these individuals. The following table lists recommended medications for consideration when individualizing antihypertensive drug therapy. See Appendix F in the original guideline document for a list of commonly prescribed antihypertensive medications in each class.

Table: First-line Treatment of Hypertension Complicated by Co-Morbid Conditions

Table adapted from McLean et al., 2007.

* Proteinuria is defined as urinary protein >500 mg/24hr or albumin-creatinine ratio (ACR) >30.

** Albuminuria is defined as persistent ACR >2.0 mg/mmol in men and >2.8 mg/mmol in women.

Electronic copies: Available in Portable Document Format (PDF) from the British Columbia Medical Association Web site.

Print copies: Available from Guidelines and Protocols Advisory Committee, PO Box 9642 STN PROV GOVT, Victoria BC V8W 9P1

• Hypertension – detection, diagnosis and management. Summary of guideline. Toronto (ON): British Columbia Medical Association; 2008 Feb 15. 2 p. Electronic copies: Available in Portable Document Format (PDF) from the British Columbia Medical Association Web site.

Print copies: Available from Guidelines and Protocols Advisory Committee, PO Box 9642 STN PROV GOVT, Victoria BC V8W 9P1

The following is also available:

• PDA Formats are available from the British Columbia Medical Association Web site.

Also, the appendices of the original guideline document contain a blood pressure monitoring worksheet, a hypertension care flow sheet, and a Framingham instruction sheet and risk assessment chart.

• Hypertension – detection, diagnosis and management. A guide for patients. Toronto (ON): British Columbia Medical Association; 2008 Feb 15. 4 p. Electronic copies: Available in Portable Document Format (PDF) from the British Columbia Medical Association Web site.

Print copies: Available from Guidelines and Protocols Advisory Committee, PO Box 9642 STN PROV GOVT, Victoria BC V8W 9P1

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