Section 4 - Management of diagnosed conditions

1. What is hypertension? ^1–3

• A SBP  ≥ 140 mmHg and/or a DBP ≥ 90 mmHg
• A persons BP varies according to age, gender and the presence of risk factors
• There are two types of hypertension:
  • primary hypertension: attributed to lifestyle behaviours, age and genetics
  • secondary hypertension: attributed to potentially reversible causes e.g.
    medicines, pregnancy, sleep apnoea, kidney disease, endocrine disorders
• Elevated BP alters the function and structure of the circulatory system, damaging organs particularly the brain, heart, kidneys and the eyes
• People rarely know they have hypertension until their BP is checked

2. Diagnosis of hypertension ^1–3

• Hypertension is based on multiple BP measurements taken on separate occasions, one or more weeks apart, or sooner if BP is ≥ 180/110 mmHg with evidence of CVD
• See Special considerations (child) or Clinical measurements (adult) to take a BP
• Hypertension can be confirmed with ambulatory or home monitoring and is supported by a thorough medical history, physical examination and laboratory investigations to identify comorbidities and CVD risk factors
• Patients with hypertension are often asymptomatic, however specific symptoms can suggest secondary hypertension including:
  • muscle weakness or cramps
  • arrhythmias or palpitations
  • pulmonary oedema
  • sweating or frequent headaches
  • snoring or daytime sleepiness
• BP should be checked:
  • annually for Aboriginal and Torres Strait Islander people > 18 years
  • 2nd yearly for non-Aboriginal and Torres Strait Islander people > 18 years
  • for all children > 10 years of age with a BMI > 85th centile for age and gender

3. Management of hypertension ^1–3

• The goals of managing hypertension are to reduce cardiovascular risk profile and prevent end organ disease by:
  • supporting patient to address Lifestyle modifications
  • maintaining medicine regimens
  • identifying and addressing comorbidities in the context of a patient’s Australian cardiovascular disease risk calculator:
    • Dyslipidaemia
    • Chronic kidney disease
    • Overweight and obesity (adult)
    • Diabetes
    • Coronary heart disease,
    • Stroke and transient ischaemic attack
    • Atrial fibrillation
  • Meeting target levels as per Table 1. and aiming for BP control within 3 months

1. Support patient self-management ^1–3
   • Provide hypertension resources outlining what hypertension is and how it affects blood vessels, cardiovascular risk and other chronic conditions. See Resource 2.
   • Reinforce the importance of adhering to BP medicine regimen
   • Encourage the patient to identify barriers to adequate lifestyle modification and
     medical adherence and to set goals to overcome those barriers. See Engaging our patients
2. Social-emotional support
   • See Social-emotional wellbeing
3. Diet and nutrition ^1,2
   • High sodium (salt) intake increases blood pressure
   • Reducing salt intake to < 4 g/day reduces SBP by 4–5 mmHg in hypertensive people and 2 mmHg in normotensive people
   • Avoid cooking with salt and takeaway processed foods high in salt
   • Increasing dietary potassium in hypertensive people with normal renal function can reduce SBP by 4–8 mmHg
   • See Diet and nutrition
4. Weight control ^1–3
   • Weight loss reduces BP, improves glycaemic control and Chronic kidney disease markers and reduces CVD risk and all-cause mortality
   • A 1% reduction in body weight lowers systolic BP by an average of 1 mmHg
   • A weight loss of 4.5 kg can reduce BP and prevent hypertension in Overweight and obesity (adult) and Overweight and obesity (child)
5. Smoking cessation ^1–3
   • Smoking cessation reduces blood pressure, CVD risk and the chance of an acute coronary event within 2–6 years after quitting
6. Alcohol reduction ^1–3
   • Consuming ≥ 2 standard drinks/day for men and ≥ 1 standard drinks/day for women increases the risk of developing hypertension
   • See Alcohol reduction
7. Physical activity ^1–3
   • Regular Physical activity and sleep lowers BP and all-cause mortality
8. Monitoring ¹

• Explaining clinic or home monitoring empowers patients to address lifestyle behaviours and adhere to management interventions
• Check BP at each visit and monitor according to 5. Cycle of care
• Refer for echocardiogram if Heart failure or murmur identified

4. Medicines for hypertension^1,2

• As BP increases, it is more difficult to control with Lifestyle modifications alone and antihypertensive medicines become necessary
• Identify medicines that influence BP. See Table 2.
• Combination therapy is often necessary. Fewer than 50% of people treated for
  hypertension will achieve an optimal BP response with a single agent
• Combination of an ARB or ACEI, a diuretic and an NSAID (the ‘triple whammy’) can cause acute kidney injury. Avoid with kidney disease, dehydration and elderly patients

1. Steps to initiate, monitor and adjust antihypertensives ^1–3

• Step 1
  • Undertake Australian cardiovascular disease risk calculator for:
    • all people aged 45–79 years
    • people with diabetes aged 35–79 years
    • Aboriginal and Torres Strait Islander people aged 30–79 years
  OR
  • Identify patients requiring immediate antihypertensive therapy:
    • moderate or severe Chronic kidney disease:
      • people with sustained eGFR < 45 mL/min/1.73m², or
      • men with persistent ACR > 25 mg/mmol, or
      • women with persistent ACR > 35 mg/mmol, or
    • a confirmed diagnosis of familial Dyslipidaemia
    • Initiate antihypertensives as per Flowchart
• Step 2 – Choose and initiate medicines at lowest dose to reach target BP utilising Flowchart 2. and Table 3.
• Step 3 – Stabilise, maintain and monitor medicine doses according to patient response. See Flowchart 3.

Flowchart 1. Initiating antihypertensives according to absolute CVD risk ^1,2



♥ Continue lifestyle modification, monitor BP, manage associated conditions and reassess cardiovascular risk regularly. Adapted with permission from the Guideline for the diagnosis and management of hypertension in adults. © 2016 National Heart Foundation of Australia

Flowchart 2. Medicine initiation strategy to reach target BP ^1,2



* Maximum effect of medicine likely within 4–6 weeks

Table 3. Medicines for hypertension 1–3,5,6
First-line medicines
Angiotensin converting enzyme inhibitors (ACEi) Commence at the lowest dose in elderly patients and those taking diuretics Potential benefits in diabetes, stroke/TIA, CKD, HF, AF and post MI Contraindicated or potentially harmful in bilateral renal artery stenosis and pregnancy
Lisinopril 5–40 mg PO daily OR Perindopril erbumine 4–8 mg PO daily OR Perindopril arginine 5–10 mg PO daily OR Ramipril 2.5–10 mg PO daily or in 2 equally divided doses
Angiotensin II receptor antagonists (ARBs) As above with ACEi Use with caution in those who have experienced angioedema with ACE inhibitors
Irbesartan 150–300 mg PO daily OR Telmisartan 40–80 mg PO daily
Calcium channel blockers (dihydropyridine) Amlodipine and felodipine: lowest doses are recommended, particularly in the elderly Nifedipine: long-acting formulations are preferable Contraindicated or potentially harmful in heart failure
Amlodipine 5–10 mg PO daily OR Felodipine MR 5–20 mg PO daily OR Lercanidipine 10–20 mg PO daily OR Nifedipine MR 30–120 mg PO daily
Thiazide diuretics It is usually unnecessary to exceed the doses shown Long term use not recommended in young patients due to risk of diabetes Potential benefits in stroke/TIA and heart failure
Hydrochlorothiazide 12.5–25 mg PO daily OR *Indapamide 1.25–2.5 mg PO daily OR Indapamide MR 1.5 mg PO daily
Second-line medicines
Calcium channel blockers (nondihydropyridine) Potential benefits in atrial fibrillation Contraindicated or potentially harmful in heart failure, bradycardia and 20 or 30 AV block
Diltiazem MR180–360 mg PO daily OR Verapamil MR 120–480 mg PO daily (in divided doses if > 240mg)
Beta-blockers Useful for elevated BP, post-MI, heart failure and stable angina Less effective than first-line medicines for uncomplicated hypertension to reduce stroke risk Contraindicated in bradycardia (45–50 bpm), 20 or 30 AV block, sick sinus syndrome (without pacemaker), severe hypotension and uncontrolled heart failure or asthma Assess benefits and risks of use in diabetes, well-controlled asthma or COPD
Atenolol 25–100 mg PO daily OR Metoprolol tartrate 25–100 mg PO bd
Other medicines Clonidine: rebound hypertension may occur with sudden cessation Hydralazine: used in combination with a beta-blocker or verapamil and a diuretic, to prevent reflex tachycardia. Maintenance doses above 100 mg daily are associated with increased risk of lupus-like syndrome and should not be given without determining patient’s acetylator status Contraindicated or potentially harmful in depression (clonidine, methyldopa, moxonidine)
Clonidine 50 microgs PO bd (to a max. 300 microgs bd) OR Hydralazine 25 mg PO bd (to a max. 100 mg bd) OR Methyldopa 125 mg PO bd (to a max. 500 mg tds) OR Moxonidine 200 microgs PO daily (to a max. 300 microgs bd or 200 microgs bd if eGFR 30–60 mL/min) OR Prazosin 0.5 mg PO bd (to a max. 10 mg bd)
*See LAM and PBS for medicine indications and restrictions

Flowchart 3. Antihypertensive stabilisation, maintenance and monitoring ^1,2



♥ As per Australian cardiovascular disease risk calculator

5. Cycle of care

6. References

• All Chronic Conditions Manual references are available on the Office of Rural and Remote Health website

7. Resources

1. Queensland Clinical Guidelines. Hypertension and pregnancy
2. The National Heart Foundation of Australia