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Hypertension

Updated 08 August 2018

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.

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

The treatment objectives are:

  • To reach blood pressure (BP) targets lower than 140/90mmHg. Some guidelines recommend stricter targets (<130/80mmHg) for people with several major risk factors, diabetes or other co-existing disorders, or target organ damage. Targets should be met within three months.
  • To limit or prevent additional target organ damage, particularly to the heart, brain, kidneys, blood vessels and eyes. 
  • To achieve BP control with no or minimal side effects. 
  • To decrease the overall cardiovascular risk and not only the BP. 
  • To find a formulation of drugs that provide control, both in the day and at night.

In order to achieve these objectives, your doctor will compile a full treatment plan to:

  • Identify and treat all your risk factors, target organ damage and associated conditions.
  • Escalate treatment if your BP isn’t controlled to target within three months.
  • Refer you to a specialist and/or dietician when needed. 
  • Monitor and reassess you on a regular basis for BP control, adherence to your medication, and drug side effects.

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

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

Treatment consists of lifestyle changes for all individuals with hypertension, plus medication. 

Most people with hypertension require two or more antihypertensive drugs, and most guidelines recommend two drugs in a single-pill combination if BP is >160/100mmHg. Single-pill combinations improve adherence to medication and achieve prompter BP control. 

If your BP is between 140-160/80-100mmHg, initial lifestyle management is recommended, unless you have two or more major cardiovascular risk factors, diabetes, organ damage or complications of hypertension. In the latter case, a single drug is prescribed. Follow-up is recommended within six weeks and escalation of treatment may be required if your targets are not met.  

In many cases, BP targets are not met, with the most common cause being a lack of adherence to medication and/or lifestyle changes. Data suggest that up to 30% of hypertension patients are either non-adherent or poorly adherent after six months. Less than 30% of treated patients in South Africa are reaching target BP. 

Another problem is that other important risk factors, like cholesterol or diabetes, are not being treated appropriately, diluting the benefits BP treatment. For example, there’s a widespread, erroneous belief that statin treatment for cholesterol is harmful. But the contrary is true. In randomised, controlled clinical trials, statins save lives, prevent strokes and heart attacks, and amplify the benefits of BP treatment.

Treatment: lifestyle changes
Although some risk factors for hypertension cannot be controlled (e.g. age and family history), most risk factors for essential hypertension are related to poor health habits and factors that can be controlled by means of 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 don’t yet suffer from hypertension. This can delay or prevent the development of high blood pressure (BP) 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

Criteria

Recommended action or lifestyle modification

Overweight or obesity

A Body Mass Index (BMI) >25 is considered as overweight.

Abdominal obesity is also important. Men should have a waist circumference of <102cm. Women should aim for <94cm.

Some guidelines suggest stricter goals for waist circumference.

Lose weight. This is one of the most effective non-drug methods of lowering BP.

Losing as little as 4,5kg can lead to a meaningful drop in BP. In fact, some studies have found that, for every kilogram of weight lost, BP drops by 1mmHg in systolic BP.

Weight loss may also enhance the BP-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 BP, who don’t exercise and are “out of shape”, have a 20-50% higher risk of developing hypertension than more active people.

Exercise. Twenty minutes of brisk walking, four 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 BP 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 BP by more than 10mmHg.

A high activity level lowers your BP, strengthens your heart and lungs, and tones your muscles. As a bonus, it’s 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 (>180/110mmHg) until it’s better controlled. In high-risk individuals, assessment by a cardiologist or specialist physician may be advised, as exercise may unmask underlying heart disease.

Unhealthy food choices

You’re at increased risk if you:

* Drink more than two drinks per day.
* Eat less than five fruits and vegetables per day.
* Consume more than 5g (half a teaspoon) of salt per day, including salt in preserved foods.
* Your diet contains a lot of pastries, pies and/or deep-fried foods.
* You eat a lot of saturated fat in the form of red meat.

Opt for healthy eating and drinking habits. One study found that people with hypertension lowered their BP by 11.5mmHg systolic and 5.5mmHg diastolic through diet alone. The diet may have worked because it promoted weight loss and was low in salt and high in potassium, both of which are associated with lower BP.

* Opt for unsaturated-fat, high-fibre foods: This includes whole grains and legumes. Choose low-fat dairy products and lean meat like ostrich, and avoid trans-fats (e.g. crisps and cookies).

Fatty fish, like salmon and tuna, contains omega-3 oils that may protect your heart. Olive and canola oils are also good for you.

Avoid sugar, especially in the form of carbonated drinks.

Beware of food products that are labelled “fat-free”, as these may contain high levels of sugar.

* Less salt: Everyone should reduce salt intake, but this has more benefits in black people. Those with kidney problems and those who are older than 65 seem to benefit when they lower their daily salt intake to no more than 5g per day – about half a teaspoon of salt.

More than 82% of SA people consume too much salt – about 9g of salt daily. Individual response of BP 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 salt content. Unfortunately, this isn’t easy at all (even for a professional). There is an urgent for simple colour coding to define low, medium or high-salt foodstuffs. Even a salad in a restaurant may contain half your allowed salt intake through addition of salad dressings. Minimise salt added to food at the table.

The most important step is to avoid processed foods, which are full of salt. Salt is also bad news for your kidneys, one of the target organs that can be damaged by hypertension and vascular disease. As a simple rule, unprocessed food has a very low salt content.

Eat plenty of fresh fruits 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 BP in salt-sensitive people.

* Limit your alcohol intake: Alcohol raises your BP, even if you don't have hypertension, and reduces your heart's pumping ability. It can also interfere with the effectiveness of BP medications. If you’re female, limit your alcohol intake to less than one drink per day; if you’re male, limit your intake to two drinks per day. One drink is 360ml beer, 150ml wine, or 30ml distilled liquor.

* Coffee: Although still much debated, coffee produces a temporary increase in heart rate and BP, also in people who don’t suffer from hypertension. It would be wise for hypertensive people to drink less coffee.

Search for the DASH eating plan – it’s a user-friendly guide.

Smoking


Active and passive smoking is a major culprit, causing damage to the heart and blood vessels, and raising BP 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. It’s 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 BP. These include the contraceptive pill and over-the-counter drugs like some diet pills, anti-inflammatories, antidepressants, cortisone, decongestants and liquorice.

* Using the contraceptive pill can raise BP in 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

Drugs like Ecstasy, “tik” and cocaine can affect BP.

* Stop taking recreational drugs.

* Inform your health professional about your drug habits.



Associated conditions that increase risk

Criteria

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 BP on organs in your body are called “target organ disease”.

* Existing heart disease (enlarged heart, heart failure, previous heart attack, 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 the same lifestyle modifications discussed above.

* You need to control your BP with the utmost discipline to a level below 140/90mmHg, and possibly below 130/80mmHg, if any of the criteria on the left apply to you.

* Associated conditions such as diabetes and elevated cholesterol levels must be treated aggressively by your health professional.



Associated conditions that increase risk

Criteria

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 BP on organs in your body are called “target organ disease”.

* Existing heart disease (enlarged heart, heart failure, previous heart attack, 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 the same lifestyle modifications discussed above.

* You need to control your BP with the utmost discipline to a level below 140/90mmHg, and possibly below 130/80mmHg, if any of the criteria on the left apply to you.

* Associated conditions such as diabetes and elevated cholesterol levels 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 salt intake, and maintaining adequate potassium intake (3.5g per day) is enough to lower BP and keep it down. However, by six 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. Medication Although lifestyle changes help, they may not be enough – especially if your BP is markedly elevated and/or you’re at high risk. If you can’t bring your BP 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 your hypertension. A wide range of drugs are used in the treatment of hypertension, but first-line drug treatment includes a diuretic, calcium channel blockers (CCBs) or an ACE inhibitor/angiotensin receptor. Depending on your level of BP and your specific profile, your doctor may prescribe one of the first-line drugs.

But if you have more severe hypertension, two of the first-line drugs are usually prescribed, preferably in a single-pill combination to improve adherence. Most people require two drugs to control their BP. If your BP remains >140/90mmHg, despite the use of three pills in an optimal dose, this is termed resistant hypertension. You may require additional evaluation by a specialist, and a fourth pill may be needed.

The control of BP 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 BP. Your drug prescription will be tailored specifically for you. It’s important to note that you should take your prescribed antihypertensive medication diligently and that you should NEVER stop your medication 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 or she can prescribe another class of antihypertensive that may work better for you. Finding the right antihypertensive medication for you might mean switching between drugs.

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

  • Diuretics. Also known as water tablets, diuretics are part of the first line of drug treatment. Diuretics act on your kidneys to help your body eliminate salt and water. This decreases the pressure within the blood vessels and reduces the workload on the heart. Hydrochlorthiazide and indapamide are used most commonly in South Africa. Although diuretics are associated with side effects like erectile dysfunction, gout and weakness, they’re inexpensive and very effective in lowering BP and preventing complications. In most instances, low doses are used (12.5mg hydrochlorothiazide or 1.25mg indapamide daily) to avoid side effects. If your BP isn’t controlled on these doses, a second drug is added.
  • Beta and alpha adrenergic blockers. These drugs (e.g. Atenolol, Carvedilol, Cardura) work by blocking the effects of adrenaline and noradrenaline in your body. Beta blockers lower BP by reducing your heart rate and decreasing the force of contraction of the heart, while alpha blockers dilate the blood vessels. Beta blockers are not first-line therapy, but they’re very valuable in the treatment of certain cardiac problems. They have reduced stroke protection compared to other antihypertensive drugs, especially in older people. The place of alpha blockers in hypertension isn’t established, and they should generally be prescribed by specialists only. Diuretics and beta blockers shouldn’t generally be used in combination, because of a risk of diabetes with long-term treatment.
  • ACE inhibitors and angiotensin receptor blockers (ARBs). An angiotensin converting enzyme (ACE) inhibitor 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 (e.g. Capoten, Tritace, Renitec) develop a dry, hacking cough. This annoying side effect typically occurs in the 10 to 24 weeks after starting the drug. A very small percentage of patients may develop swelling of the 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 they block the actions, not the formation, of angiotensin II. Therefore, they’re also a blood-vessel relaxer. These drugs block angiotensin II directly and generally don’t cause side effects such as coughing or angioedema. Both ACE inhibitors and ARBs are particularly effective in people with diabetes and renal disease, and combine well with low-dose diuretics and calcium channel blockers.
  • Calcium channel blockers (CCBs). 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 CCBs such as AdalatXL and amlodipine (e.g. Norvasc, Amloc) effectively reduce BP The short-acting drugs aren't recommended for hypertension because control is erratic and some reports have linked them to adverse health effects. CCBs are very valuable drugs and reduce BP in all types of individuals with hypertension. They also reduce stroke more effectively than other drugs. The most common side effect is swelling of the feet and ankles. This is a problem for women in particular. 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 BP 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 if you have impaired liver or kidney function. Moxonidine is similar to methyldopa, but without the same degree of side effects. It’s useful in people with metabolic syndrome and resistant hypertension.

Aldosterone antagonists
Spironolactone and eplerenone block the hormone aldosterone, and are extremely useful in the treatment of resistant hypertension, heart disease and some endocrine disorders.

These drugs should generally not be used in people with impaired kidney function, as they raise potassium levels. Potassium levels need to be monitored in all individuals. Spironolactone may cause unwanted breast enlargement in men and loss of libido. Eplerenone doesn’t cause these side effects, and may be a very useful alternative, but is very expensive and not usually reimbursed by medical aids.

Monotherapy vs. combination therapy
Individuals with hypertension are usually started on one drug.

The expected reduction of BP on monotherapy is 7-13mmHg systolic and 4-8mmHg diastolic. In more and more patients, such a reduction will not be sufficient to restore BP to normal. In fact, studies have 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 isn’t satisfactory, the dosage may be increased or another hypertensive drug may be added. Combining drugs from different classes has proved to lower BP more effectively than using one drug at a 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
Preferred drug combinations are the following:

  • Diuretic and ACE inhibitor or ARB
  • Diuretic and CCB (preferred in elderly and black people)
  • CCB and ACE inhibitor/ARB • ACE inhibitor/ARB, calcium antagonist and diuretic

Principles of drug treatment

  • Drug treatment is usually started with one or two drugs, depending on the initial BP (see above). It’s started at the lowest dose to limit side effects.
  • If you experience no side effects on a single drug, but your BP response is inadequate, the dose can be increased.
  • However, it’s preferable to 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 won’t combine drugs that have similar side effects.
  • Doctors try to use long-acting drugs that are effective for 24 hours. This gives more consistent BP control and makes it easier to manage. 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-hypertensive drugs, and also a decrease in overall cardiovascular risk and target organ damage.

Reviewed by Prof Brian Rayner, nephrologist and Director of the Hypertension Clinic, Groote Schuur Hospital. MBChB, FCP, MMed, PhD. May 2018.

 

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Ask the Expert

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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