How to lower blood pressure

How to lower blood pressure

Definition of high blood pressure and who to treat

Hypertension, or high blood pressure, is defined as persistently elevated arterial blood pressure.

It is almost always silent. There are no symptoms.

But what is normal? There is no such thing as normal blood pressure. There is a normal range = 100/70 – 135/85. Above 135/85 warrants medical assessment. These are the levels at which treatment is considered.

• Healthy range: Clinic/home BP <135/85
• Stage 1 Hypertension: Clinic BP ≥140/90 mmHg – repeat 2 weeks later – treat some
• Stage 2 Hypertension: Clinic BP ≥160/100 mmHg – treat soon
• Severe Hypertension: Clinic BP ≥180/120 mmHg
  • Needs medical attention
  • Treat now
  • Investigate for secondary cause.

How to lower blood pressure – 5 principles

There are 5 main principles of treatment to reduce blood pressure.

1. Lifestyle modification

First-line for all patients:

• • Reduce salt intak
  • Adopt a balanced diet: Rich in fruits, vegetables, whole grains, and low in saturated fats
  • Regular physical activity: At least 180 minutes of moderate exercise per week
  • Limit alcohol consumption: No more than 14 units per week
  • Smoking cessation
  • Weight reduction: Aim for a BMI of under 30 kg/m².

2. Treat secondary cause

E.g. referral to endocrine surgeon; or deliver the baby (pre-eclampsia).

3. Pharmacological therapy

• • Stage 1 Hypertension: Consider treatment if there is a 10-year cardiovascular risk of ≥10% (using the QRISK3 score), diabetes, or evidence of end-organ damage
  • Stage 2 Hypertension: Pharmacological treatment is recommended for all patients
    • First-line medication
      • ACE inhibitors (e.g. ramipril) or ARBs (e.g. losartan): Preferred in patients under 55 years or those with diabetes
      • Calcium channel blockers (e.g. amlodipine): Preferred in patients over 55 years or those of Afro-Caribbean descent (often require three drugs or more to control their BP)
      • Thiazide-like diuretics (e.g. indapamide): Consider if calcium channel blockers are not suitable.
    • Beta-blockers (e.g. Bisoprolol): Not first-line but may be used in specific cases (e.g. patients with heart failure, angina, or tachyarrhythmias). Labetolol is often used in pregnancy. Anxiolytic effects are helpful
    • Other vasodilators: e.g. Hydralazine. Minoxidil can be used by specialists for severe BP
    • Centrally acting drugs: e.g. Methyldopa (also used in pregnancy)
    • Combination therapy: Often required for effective control, involving drugs from different classes.

4. Role of loop diuretics and/or fluid restriction

This is especially useful in patients with CHF, CKD or nephrotic syndrome. In patients with advanced CKD (CKD4/5), uncontrolled hypertension can be one of the indications to start dialysis.

5. Follow-up and monitoring

Regular follow-up to monitor BP control (and U&Es) and potential side effects.

Target blood pressure

130/80 is a good average target for most patients, and 120/70 if you have diabetes.

If BP cannot be controlled on 3 drugs

Patients should be referred to see a hospital consultant. These can be in various departments including cardiology, endocrinology or nephrology (depending on local practice).

Summary

We have described how to lower blood pressure. We hope it has been helpful.