High Blood Pressure Support Group

Blood pressure is a continuously distributed variable, and the risk of associated cardiovascular disease likewise rises continuously. The point at which blood pressure is defined as hypertension is therefore somewhat arbitrary. Presently finding sustained blood pressure of 140/90 mmHg or above, measured on both arms is generally regarded as diagnostic. Because blood pressure readings in many individuals are highly variable — especially in the office setting — the diagnosis of hypertension should be made only after noting a mean elevation on two or more readings on two or more office visits, unless the elevations are severe or associated with compelling indications such as diabetes mellitus, chronic kidney disease, heart failure, post-myocardial infarction, stroke, and high coronary disease risk.

Doctors recommend weight loss and regular exercise as the first steps in treating mild to moderate hypertension. These steps are highly effective in reducing blood pressure, but easier to suggest than to achieve, and most patients with moderate or severe hypertension end up requiring indefinite drug therapy to bring their blood pressure down to a safe level. Discontinuing smoking does not directly reduce blood pressure, but is very important for people with hypertension because it reduces the risk of many dangerous outcomes of hypertension, such as stroke and heart attack.

Mild hypertension is usually treated by diet, exercise and improved physical fitness. A diet rich in fruits and vegetables and fat-free dairy foods and low in fat and sodium lowers blood pressure in people with hypertension. Dietary sodium (salt) causes hypertension in some people and reducing salt intake decreases blood pressure in a third of people. Regular mild exercise improves blood flow, and helps to lower blood pressure.

Reduction of environmental stressors such as high sound levels and over-illumination can be an additional method of ameliorating hypertension.

There are many classes of medications for treating hypertension, together called antihypertensives, which — by varying means — act by lowering blood pressure. Evidence suggests that reduction of the blood pressure by 5-6 mmHg can decrease the risk of stroke by 40%, of coronary heart disease by 15-20%, and reduces the likelihood of dementia, heart failure, and mortality from vascular disease.

Which type of medication to use initially for hypertension has been the subject of several large studies. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends starting with a thiazide diuretic if single therapy is being initiated and another medication is not indicated.[1] This is based on a slightly better outcome for chlortalidone in the ALLHAT study versus other anti-hypertensives and because thiazide diuretics are relatively cheap.[3] A subsequent smaller study (ANBP2) published after the JNC7 did not show this small difference in outcome and actually showed a slightly better outcome for ACE-inhibitors in older male patients.[4]

Despite thiazides being cheap, effective, and recommended as the best first-line drug for hypertension by many experts, they are not prescribed as often as some newer drugs. Arguably, this is because they are off-patent and thus rarely promoted by the drug industry.

Physicians may start with non-thiazide antihypertensive medications if there is a compelling reason to do so. An example is the use of ACE-inhibitors in diabetic patients who have evidence of kidney disease, as they have been shown to both reduce blood pressure and slow the progression of diabetic nephropathy. In patients with coronary artery disease or a history of a heart attack, beta blockers and ACE-inhibitors both lower blood pressure and protect heart muscle over a lifetime, leading to reduced mortality.

Commonly used drugs include:

* Beta blockers such as metoprolol (Lopressor®), atenolol, labetalol, carvedilol (Coreg®)
* ACE inhibitors such as lisinopril (Zestril®), quinapril, fosinopril (Monopril®), captopril, enalapril, ramipril (Altace®)
* Angiotensin receptor blockers (ARBs): eg, losartan (Cozaar®), valsartan (Diovan®), irbesartan (Avapro®)
* Calcium channel blockers such as amlodipine (Norvasc®), verapamil
* Diuretics: eg, chlortalidone, hydrochlorothiazide (also called HCTZ)
* Combination products (which usually contain HCTZ and one other drug)
* Alpha blockers such as terazosin, prazosin

The aim of treatment should be blood pressure control (<140/90 mmHg for most patients, and lower in certain contexts such as diabetes or kidney disease). Each added drug may reduce the systolic blood pressure by 5-10 mmHg, so often multiple drugs are necessary to achieve blood pressure control.