Updated 11 November 2014

Treating hypertension

Treatment will consist of lifestyle changes for all patients, plus medication (most often starting with more than one drug, and progressing to three) for most patients.

Your doctor will start your treatment according to your risk and your individual compelling indications.

The treatment objectives are:

•    To reach blood pressure targets (lower than 140/90 mmHg for people with no major risk factors, co-existing disorders or target organ damage, but 130/80 mmHg for people with major risk factors, diabetes other co-existing disorders, or target organ damage) within three months.
•    To limit or prevent additional target organ damage – particularly to the heart, brain, kidneys, blood vessels and eyes.
•    To achieve blood pressure control with no or minimal side effects.
•    To decrease the overall cardiovascular risk, not only the blood pressure.
•    To find a formulation that provides 24-hour efficacy.
•    In order to achieve these objectives, your doctor will compile a full treatment plan, consisting of the following:
•    To identify and treat all risk factors, target organ damage and associated conditions
•    To escalate treatment if your blood pressure is not controlled to target within three months
•    To refer you to a specialist or dietician when needed
•    To monitor and re-assess you on a regular basis for blood pressure control, adherence to your medication and drug side effects

Important considerations, which will determine your individualised treatment plan, are:

•    Socio-economic factors, price and availability.
•    The cardiovascular risk factors of the patient.
•    The presence of target-organ damage, heart disease or diabetes.
•    The presence of other co-existing disorders. This may limit or favour the use of certain drugs.
•    The possibility of interactions with drugs used by the patient for other conditions.

Treatment will consist of lifestyle changes for all patients, plus medication (most often starting with more than one drug and progressing to three) for most patients.

In many cases where people have been diagnosed with high blood pressure and they are receiving treatment, the patient’s high blood pressure is not controlled nearly well enough. Less than 30% of treated patients in South Africa are treated to target blood pressure. Another problem area is that other important risk factors like cholesterol are not being treated, diluting the benefits blood pressure treatment.

Treatment - lifestyle changes

Although some risk factors for hypertension cannot be controlled, most risk factors for essential hypertension are related to poor health habits and factors which can be controlled by lifestyle modification.
Lifestyle changes should be adopted by ALL people with hypertension. In some cases lifestyle changes may lead to adequate control of hypertension without additional medication. But lifestyle modification is also important for those with other risk factors who do not yet suffer from hypertension. This can delay or prevent development of high blood pressure and heart disease.

In the three tables below, you can view the risk factors and the recommended lifestyle modification or actions at a glance.

Risk factors you can control


Recommended action or lifestyle modification

Overweight or obesity

A Body Mass Index (BMI) > 25 is considered as overweight. Abdominal obesity is also important and men should have a waist circumference < 94 cm and women < 80 cm.

Lose weight. This is the most effective non-drug method of lowering blood pressure. Losing as little as 4,5 kg can lead to a meaningful drop in blood pressure. In fact, some studies find that for every kilogram of weight lost, blood pressure drops 2,5mm Hg systolic and 1,5 mm Hg diastolic. Weight loss can also enhance the blood pressure lowering effect of anti-hypertensive drugs.

Inactive lifestyle

If you exercise less than two hours per week, your lifestyle can be described as inactive.
Even people with normal blood pressure who do not exercise and are "out of shape" have a 20 to 50% higher risk of developing hypertension than more active people.

Exercise. Aim to exercise about 2 hours per week. Twenty minutes of brisk walking 4 times a week, is a good start. Thirty to 45 minutes of mild to moderate aerobic exercise such as brisk walking or cycling four times a week can nudge your blood pressure down a few points, particularly if you're also losing weight. Vigorous exercise, such as riding a stationary bike for 40 minutes at high intensity, can lower blood pressure by more than 10 mmHg.A high activity level lowers your blood pressure, strengthens your heart and lungs and tones your muscles. As a bonus it is also a powerful stress-reducing tool. Exercise should be regular and dynamic, and should be determined by both your ability and by what your doctor advises. RED FLAG: Exercise should be avoided in severe hypertension (blood pressure > 180/110 mmHg) until it is better controlled. In high risk patients assessment by a cardiologist or specialist physician may be advised, as exercise may unmask underlying heart disease.

Unhealthy food choices

You are at increased risk if you: Drink more than two drinks per day
* Eat less than five fruits and vegetables per day
* Consume more than 3 g (half a teaspoon) of salt per day, including salt in preserved foods
* Your diet contains a lot of pastries, pies, or deep fried foods
* You love loads of oil and fatty food.

Opt for healthy eating and drinking habits
A recent study found people with hypertension lowered their blood pressure by 11.5 mm Hg systolic and 5.5 mm Hg diastolic through diet alone. 40% of these people were able to stop their medication completely. The diet may have worked because it promoted weight loss and was high in the minerals calcium, potassium and magnesium, which are associated with lower blood pressure.
* Opt for low fat, high fibre food including whole grains and legumes. Choose low-fat dairy products and lean meat like ostrich. Fatty fish, like salmon and tuna, contains omega-3 oils that protect your heart.
* Less Salt: Everyone should reduce salt intake, but this has more benefits in black people. Those with kidney problems and those older than 65 seem to benefit when they lower their daily sodium intake to no more than 2,4 g per day – (about half a teaspoon) of salt. (More than 82% of SA people consume too much salt - about 9 g of salt daily.) Individual response of blood pressure to salt intake differs widely and is difficult to measure. Most of the salt you eat daily is already added during the preparation of processed foods. Read food labels carefully for sodium amounts. Even a salad in a restaurant may contain half your allowed salt intake through addition of salad dressings. Don’t add salt to food at the table. The most important thing is to avoid processed foods, which is full of sodium, in many forms. Salt is also bad news for your kidneys, one of the target organs that can be damaged by hypertension and vascular disease.
* Eat plenty of fresh fruit and vegetables to supply potassium and other crucial nutrients. 100% of South Africans are “potassium deficient”. Potassium seems to replace and eliminate excess sodium from the body, which reduces blood pressure in salt-sensitive people.
* Limit your alcohol intake: Alcohol raises your blood pressure even if you don't have hypertension and reduces your heart's pumping ability. It can also interfere with the effectiveness of blood pressure medications. If you are female, limit your alcohol intake to less than one drink per day; if you are male, limit your intake to two drinks per day. One drink is 360 ml beer, 150 ml wine or 30 ml distilled liquor.
* Coffee: Although still much debated, coffee produces a temporary increase in heart rate and blood pressure, also in people who do not suffer from hypertension. It would be wise for hypertensive people to avoid the repeated elevations in blood pressure by drinking less coffee.
See the DASH eating plan for a user-friendly guide.


Active and passive smoking is a major culprit, causing damage to the heart and blood vessels, and raising blood pressure by constricting and therefore narrowing the vessels. A disaster triangle of disease is formed when people with hypertension and high cholesterol opt to smoke.

Stop smoking
Smoking is the most preventable cause of premature death in the Western world and is the most important lifestyle change that will reduce your risk of complications due to both hypertension and heart and blood vessel disease. If you're a smoker, especially one with hypertension, you must stop. And if you're not a smoker, don't start. If people smoke in your home or work environment, this may also harm your health.

The contraceptive Pill and over-the-counter medication

Certain drugs can affect blood pressure.
These include the contraceptive Pill and over-the-counter drugs like some diet pills, anti-inflammatories, antidepressants, cortisone and decongestants, and liquorice.

*Using the contraceptive pill can raise the blood pressure of some women, especially if they smoke, and increase their risk for stroke and a heart attack. This is of even greater importance after the age of 35. The solution: stop smoking or change your method of contraception to a progesterone-only pill.
* Discuss your over-the-counter medication with your health professional

Recreational drugs

Many drugs like Ecstasy, “tik” or cocaine.

* Stop taking recreational drugs
* Inform your health professional about your dug habits.

Risk factors beyond your control


Recommended action or lifestyle modification

Ethnicity, genes, age

You are at a higher risk for hypertension, if you are:
* Black,
* Over 50,
* Have a family history of hypertension or early heart disease in family members < 55 years.

Unfortunately you can not choose your parents. Genetic influences play an important role, and of course no one can stop the ageing process. But you can take action:
1. Have your blood pressure taken every 6 months.
2. Avoid all controllable risk factors, and implement lifestyle changes mentioned above as early as possible, whether you are hypertensive or not

3. If diagnosed with hypertension, take your medication diligently
4. All co-existing conditions such as diabetes should be treated appropriately and properly.

Associated conditions that increase risk


Recommended action and Lifestyle modification

Certain diseases or damage to some of your organs can also increase your risk for hypertension and cardiovascular disease. The adverse effects of high blood pressure on organs in your body are called “target organ disease.”

·         Existing heart disease (Enlarged heart, heart failure, previous heart attack and angina.

·         Previous bypass operation or balloon dilatation.

·         Diabetes

·         Elevated total or LDL cholesterol levels, or low HDL cholesterol levels

·         Previous stroke, including so-called mini-strokes

·         Kidney damage

·         Damage to the retina of the eye

·         Damage to the blood vessels.

·         Implement lifestyle modifications as for controllable risk factors.

·         You need to control your blood pressure with the utmost discipline to a level below 130/80 mmHg if any of criteria on the left apply to you. Associated conditions such as diabetes, elevated cholesterol levels and others must be treated aggressively by your health professional

The good news about all these lifestyle factors is that you can do a great deal to improve your health.

For many people, losing weight, exercising regularly, limiting alcohol and sodium and maintaining adequate potassium (3.5 g per day) is enough to lower blood pressure and keep it down. However by 6 months many people revert to their previous unhealthy lifestyle, and in most instances antihypertensive drugs need to be used in conjunction with lifestyle changes. This is particularly relevant to people with a high cardiac risk.


Although lifestyle changes help, they may not be enough, especially if your blood pressure is markedly elevated and/or you are at high risk. If you can't bring your blood pressure under control by making these changes you may also need to take medication.
Lifestyle changes may still reduce the number and doses of medications needed to control hypertension.

The first step in the management of hypertension used to be the use of one drug (usually a diuretic) and the next adding a second drug. But according to the latest data most patients need to be treated with two or even three different antihypertensive drugs from the outset. Increasingly these can be used in a fixed combination or single tablet.

If blood pressure remains >140/90 mm Hg (or >160/90 mmHg in older people) despite the use of three pills (resistant hypertension), a fourth pill may be needed.

The control of blood pressure depends on many factors: heart rate, the force of the pumping action, the volume of blood and the diameter of the blood vessels. Different antihypertensive drugs work on different aspects to lower blood pressure. Your drug prescription will be tailored specifically for you.

It is important to note that if you should take your prescribed antihypertensive medication diligently and should never stop your medication or change the dosage due to undesirable side-effects, or because you feel better. If your doctor has prescribed drugs to control your hypertension, it needs to be controlled on a daily basis.

Your hypertension cannot be cured, but it can be controlled, the same way as diabetes can be controlled. If you suffer from unwanted side-effects, discuss this with your doctor. He can prescribe another class of antihypertensive which may work better for you. Finding the right antihypertensive medication for you might mean switching between drugs and finding the best combinations for you.

The most important classes of drugs used in the treatment of high blood pressure include:

•    Diuretics– Also known as water tablets, diuretics (hydrochlorthiazide and indapamide used most commonly in South Africa) are often the first line of drug treatment. Diuretics act on your kidneys to help your body eliminate sodium and water. This in turn decreases the pressure within the blood vessels and reduces the workload on the heart. Although diuretics are associated with side effects like erectile dysfunction, gout and weakness, they are cheap and very effective in lowering blood pressure and preventing complications. As soon as the daily dosage reaches 25 mg per day, a second drug will be introduced if blood pressure is still elevated after two months. (Click here for more detailed information on Diuretics)

•    Beta and alpha adrenergic blockers– These drugs (Atenolol, Carvedilol, Cardura and others) work by blocking the effects of adrenaline and noradrenaline in your body. Beta blockers lower blood pressure by reducing your heart rate and decreasing the force of contraction of the heart, while alpha blockers dilate the blood vessels.

Beta blockers are valuable with cardiac problems, but have reduced stroke protection compared to other antihypertensive drugs, especially in older people. The place of alpha blockers in hypertension is not established, and should generally be used by specialists only. Diuretics and beta blockers should not generally be used in combination because of the risk of diabetes with long term treatment. (Click here for more detailed information on Beta blockers.)

•    ACE inhibitors and angiotensin receptor blockers (ARBs)– Angiotensin converting enzyme (ACE) inhibitors is a dilator (relaxer) of blood vessels. It works by blocking the formation of the natural body chemical angiotensin II, which constricts blood vessels.

However, up to 20% of people who take ACE inhibitors (Capoten, Tritace, Renitec and others) develop a dry, hacking cough. This annoying side effect typically occurs in the 10 to 24 weeks after starting the drug. A small percentage of patients may develop swelling of lips, face and tongue (angioedema) and the Ace inhibitor must be immediately stopped, as this reaction can be fatal. This side effect is more common in black people and those with severe allergies. Some ACE inhibitors can also cause a metallic taste in the mouth.

Angiotensin receptor blockers (ARBs) are similar to ACE inhibitors, but it blocks the actions, not the formation of angiotensin II. Therefore it is also a blood vessel relaxer. It blocks angiotensin II directly and generally do not cause side-effects such as cough or angioedema. Both Ace inhibitors and angiotensin receptor blockers are particularly effective in patients with diabetes and renal disease and combine well with low dose diuretics and calcium channel blockers.

•    Direct renin inhibitors- A new class of antihypertensive drugs which will soon ( the launch is scheduled) reach South Africa is a direct renin inhibitor (aliskiren), which blocks the production of angiotensin II by blocking the production of renin. These drugs seem to have fewer side-effects compared with other antihypertensives.

•    Calcium channel blockers– These drugs block the entry of calcium into the smooth muscle of the blood vessels, causing them to dilate or relax. Certain types can also slow the heart rate. Long-acting calcium channel blockers such as AdalatXL and Amlodipine (Norvasc, Amloc and others) effectively reduce blood pressure. The short-acting drugs aren't recommended for hypertension because control is erratic and some reports have linked them to adverse health effects. Calcium channels blockers are very valuable drugs and reduce blood in all types of patients with hypertension, and reduce stroke more effectively than other drugs. The most common side effect is swelling of the feet and ankles and is a problem especially in females. Combining the drug with an Ace inhibitor or angiotensin receptor blockers reduces this side effect.

•    Centrally-acting drugs - These drugs act on the brain’s mechanisms for controlling blood vessel size.

•    The end result is that blood vessels relax and blood pressure decreases. Of the centrally-acting drugs, mainly reserpine, moxonidine and methyldopa are used in clinical practice. Reserpine can be used in uncomplicated hypertension. Methyldopa is specifically recommended for use in pregnancy and is rarely used in other circumstances. It must never be used in patients with impaired liver or kidney function. Moxondine is similar to methyl dopa, but without the same degree of side effects. Useful in patients with metabolic syndrome and resistant hypertension.

Monotherapy versus combination therapy

Patients are usually started on one drug. The expected reduction of blood pressure on monotherapy is 7 – 13 mmHgsystolic, and 4 – 8 mmHg diastolic. In more and more patients such reduction will not be sufficient to restore blood pressure to normal. In fact, studies have also shown that up to 70% of patients seem to need a combination of antihypertensive drugs.

Each drug has an entry level dosage. If the result is not satisfactory, the dosage may be increased or another hypertensive drug added. Combining drugs from different classes has proved to lower blood pressure more effectively than using one drug in higher dosage. When combining different drugs, lower dosages of each can be used. In this way, the possibility of side effects is lower.

Examples of drug combinations: (To be effective, drugs from different classes must be combined to obtain an additive hypotensive effect. Combining drugs with similar side effects must be avoided.)

•    Diuretic and beta-blocker
•    Diuretic and ACE inhibitor
•    Diuretic and angiotensin II antagonist
•    Calcium antagonist and beta-blocker
•    Calcium antagonist and ACE inhibitor
•    Alpha-blocker and beta-blocker

In many cases the drugs are combined in one tablet.

Principles of drug treatment:

•    Drug treatment is usually started with one drug, at the lowest dose, to limit side effects.
•    If the patient has no side-effects on the drug, but the blood pressure response is inadequate, the dose can be increased.
•    However, doctors will often rather add a small dose of a different class of drug, instead of giving a higher dose of the initial drug. Thus an additive hypotensive effect is achieved with minimal side effects.
•    Your doctor will not combine drugs that have similar side-effects.
•    Doctors try to use long-acting drugs that are effective for 24 hours. This gives more consistent blood pressure control and is more user-friendly for the patient. It may also provide greater protection against cardiovascular events, like heart attack or stroke in the early morning hours.
•    Drug treatment must always be combined with the appropriate lifestyle modifications. This may lead to lower dosages of anti-hypertensives, and also a decrease in overall cardiovascular risk and target organ damage.

Reviewed and updated by Prof Brian Rayner, head of the division of nephrology and hypertension, University of Cape Town and Groote Schuur Academic Hospital, November 2010


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Hypertension expert

Dr Jacomien de Villiers qualified as a specialist physician at the University of Pretoria in 1995. She worked at various clinics at the Department of Internal Medicine, Steve Biko Hospital, these include General Internal Medicine, Hypertension, Diabetes and Cardiology. She has run a private practice since 2001, as well as a consultant post at the Endocrine Clinic of Steve Biko Hospital.

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