Hypertension in Adults, Diagnosis & Management

his?Guidelines?summary covers identifying and treating primary hypertension (high blood pressure) in people aged 18 years and over, including people with type 2 diabetes. It aims to reduce the risk of cardiovascular problems such as myocardial infarctions and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively. NICE has also produced a guideline on?hypertension in pregnancy .

This summary only covers recommendations for primary care. Refer to the full guideline for the complete set of recommendations.?

Latest Guidance Updates (March 2022)

• New recommendation on blood pressure targets for people with cardiovascular disease in the section, Monitoring treatment and blood pressure targets
• A new recommendation on antihypertensive drug treatment for people with cardiovascular disease is in the section, Choosing Antihypertensive Drug Treatment (For People With or Without Type 2 Diabetes).

Measuring Blood Pressure

• Ensure that healthcare professionals taking blood pressure measurements have adequate initial training and periodic review of their performance.
• Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery.
• Healthcare providers must ensure that devices for measuring blood pressure are properly validated,?maintained, and regularly recalibrated according to manufacturers’ instructions.
• When measuring blood pressure in the clinic or in home, standardize the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. Use an appropriate cuff size for the person’s arm.

In people with symptoms of postural hypotension (falls or postural dizziness):

• measure blood pressure with the person either supine or seated
• measure blood pressure again with the person standing for at least 1 minute before measurement.

If the systolic blood pressure falls by 20 mmHg or more when the person is standing:

• review medication
• measure subsequent blood pressures with the person standing
• consider referral to specialist care if symptoms of postural hypotension persist.

Diagnosing Hypertension

• When considering a diagnosis of hypertension, measure blood pressure in both arms:
• If the difference in readings between arms is more than 15?mmHg, repeat the measurements.
• If the difference in readings between arms remains more than 15?mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading.
• If blood pressure measured in the clinic is 140/90?mmHg or higher:
• Take a second measurement during the consultation.
• If the second measurement is substantially different from the first, take a third measurement.
• Record the lower of the last 2 measurements as the clinic blood pressure.
• If clinic blood pressure is between 140/90?mmHg and 180/120?mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. See?section?1.5?of the full guideline for people with a clinic blood pressure of 180/120?mmHg or higher.
• If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension.
• While waiting for confirmation of a diagnosis of hypertension, carry out:
• investigations for?target organ damage?(see?the last recommendation in the section, Assessing Cardiovascular Risk and Target Organ Damage),?followed by
• A formal assessment of cardiovascular risk using a cardiovascular risk assessment tool (see the section on full formal risk assessment in?NICE’s guideline on?cardiovascular disease ).
• When using ABPM to confirm a diagnosis of hypertension, ensure that at least 2?measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14?measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension.
• When using HBPM to confirm a diagnosis of hypertension, ensure that:
• for each blood pressure recording, 2 consecutive measurements are taken, at least 1?minute apart and with the person seated?and
• blood pressure is recorded twice daily, ideally in the morning and evening?and
• blood pressure recording continues for at least 4?days, ideally for 7?days.

Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension.

Confirm diagnosis of hypertension in people with a:

• clinic blood pressure of 140/90 mmHg or higher?and
• ABPM daytime average or HBPM average of 135/85 mmHg or higher.
• If hypertension is not diagnosed but there is evidence of target organ damage, consider carrying out investigations for alternative causes of the target organ damage (for information on investigations, see NICE’s guidelines on?chronic kidney disease in adults ?and?chronic heart failure ).

If hypertension is not diagnosed, measure the person’s clinic blood pressure at least every 5?years subsequently, and consider measuring it more frequently if the person’s clinic blood pressure is close to 140/90?mmHg.

Annual Blood Pressure Measurement for People With Type 2 Diabetes

• Measure blood pressure at least annually in an adult with type?2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice.

Specialist Investigations for Possible Secondary Causes of Hypertension

• Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension.

Assessing Cardiovascular Risk and Target Organ Damage

For guidance on the early identification and management of chronic kidney disease, see?NICE’s guidelines on?chronic kidney disease in adults .

• Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension, both for raised blood pressure and other modifiable risk factors.
• Estimate cardiovascular risk in line with the recommendations on identifying and assessing cardiovascular disease risk in?NICE’s guidelines on?cardiovascular disease . Use clinic blood pressure measurements to calculate cardiovascular risk.

For all people with hypertension offer to:

• test for the presence of protein in the urine by sending a urine sample for estimation of the albumin: creatinine ratio and test for haematuria using a reagent strip
• take a blood sample to measure glycated hemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol, and HDL cholesterol
• examine the fundi for the presence of hypertensive retinopathy
• arrange for a 12-lead electrocardiograph to be performed.

Treating and Monitoring Hypertension

Lifestyle Interventions

For guidance on the prevention of obesity and cardiovascular disease, see NICE’s guidelines on?obesity prevention ?and?cardiovascular disease prevention .

• Offer lifestyle advice to people with suspected or diagnosed hypertension, and continue to offer it periodically.
• Ask about people’s diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes.
• Ask about people’s alcohol consumption and encourage a reduced intake if they drink excessively because this can reduce blood pressure and has broader health benefits. See the recommendations for practice in NICE’s guideline on?alcohol-use disorders .
• Discourage excessive consumption of coffee and other caffeine-rich products.
• Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure.?Note that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease, and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin II receptor blockers. Encourage salt reduction in these groups.
• Do not offer calcium, magnesium, or potassium supplements as a method for reducing blood pressure.
• Offer advice and help?smokers to stop smoking. See?NICE’s guidelines on?tobacco .
• Inform people about local initiatives by, for example, healthcare teams or patient organizations that provide support and promote healthy lifestyle change, especially those that include group work for motivating lifestyle change.

Starting Antihypertensive Drug Treatment

NICE has produced a?patient decision aid on treatment options for hypertension?to help people and their healthcare professionals discuss the different types of treatment and make a decision that is right for each person.

For advice on shared decision-making for medicines, see the information on patient decision aids in?NICE's guideline on medicines optimization .

To support adherence and ensure that people with hypertension make the most effective use of their medicines, see?NICE's guidelines on medicines adherence .

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent?stage?2 hypertension. Use clinical judgment for people of any age with frailty or multimorbidity

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent?stage?1 hypertension?who have 1 or more of the following:

• target organ damage
• established cardiovascular disease
• renal disease
• diabetes
• an estimated 10-year risk of cardiovascular disease of 10% or more.
• Use clinical judgment for people with frailty or multimorbidity (see also NICE’s guideline on?multimorbidity).

Discuss with the person their individual cardiovascular disease risk and their preferences for treatment, including no treatment, and explain the risks and benefits before starting antihypertensive drug treatment. Continue to offer lifestyle advice and support them to make lifestyle changes (see the section on Lifestyle Interventions), whether or not they choose to start antihypertensive drug treatment.

Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under?60 with stage?1 hypertension and an estimated 10-year risk below 10%. Bear in mind that a 10-year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease.

Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over?80 with a clinic blood pressure of over 150/90?mmHg. Use clinical judgment for people with frailty or multimorbidity (see also NICE’s guideline on?multimorbidity).

For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefits and risks.

Monitoring Treatment and Blood Pressure Targets

For specific recommendations on blood pressure control in people with other conditions or who are pregnant

• Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension.
• Measure standing as well as seated blood pressure?(see the sixth recommendation in the section, Measuring Blood Pressure) in people with hypertension and:
• with type 2 diabetes?or
• with symptoms of postural hypotension?or
• aged 80 and over.

In people with a significant postural drop or symptoms of postural hypotension, treat with a blood pressure target based on standing blood pressure.

Advise people with hypertension who choose to self-monitor their blood pressure to use HBPM

Consider ABPM or HBPM, in addition to clinic blood pressure measurements, for people with hypertension identified as having a?white-coat effect?or?masked hypertension?(in which clinic and non-clinic blood pressure results are conflicting). Be aware that the corresponding measurements for ABPM and HBPM are 5?mmHg lower than for clinic measurements (see the eighth recommendation in the section, Diagnosing Hypertension,?for diagnostic thresholds).

For people who choose to use HBPM, provide:

• training and advice on using home blood pressure monitors
• information about what to do if they are not achieving their target blood pressure.

Be aware that the corresponding measurements for HBPM are 5?mmHg lower than for clinic measurements

For adults with hypertension aged under 80, reduce clinic blood pressure to below 140/90 mmHg and ensure that it is maintained below that level.

For adults with hypertension aged 80 and over, reduce clinic blood pressure to?below 150/90 mmHg and ensure that it is maintained below that level.?Use clinical judgment for people with frailty or multimorbidity (see also NICE’s guideline on multimorbidity).

When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person’s usual waking hours (see the sixth and seventh recommendations in the section, Diagnosing Hypertension). Reduce blood pressure and ensure that it is maintained:

• below 135/85?mmHg for adults aged under 80
• below 145/85?mmHg for adults aged 80 and over.

Use clinical judgment for people with frailty or multimorbidity

Use the same blood pressure targets for people with and without cardiovascular disease.

Provide an annual review of care for adults with hypertension to monitor blood pressure, provide people with support, and discuss their lifestyle, symptoms, and medication.

Treatment Review When Type 2 Diabetes Is Diagnosed

• For an adult with type?2 diabetes on antihypertensive drug treatment when diabetes is diagnosed, review blood pressure control and medications used. Make changes only if there is poor control or if the current drug treatment is not appropriate because of microvascular complications or metabolic problems.

Choosing Antihypertensive Drug Treatment (For People With or Without Type?2 Diabetes)

The recommendations in this section apply to people with hypertension with or without type?2 diabetes. They replace the recommendations on blood pressure management in?NICE’s guideline on?type?2 diabetes in adults .?For guidance on choosing antihypertensive drug treatment in people with type 1 diabetes, see also the section on control of cardiovascular risk in NICE’s guideline on type 1 diabetes.?

Note that ACE inhibitors and angiotensin II receptor antagonists should not be used in?pregnant or breastfeeding women or women planning pregnancy unless absolutely necessary, in which case the potential risks and benefits should be discussed.

• For guidance on the choice of hypertensive agent in people with chronic kidney disease, see?NICE’s guidelines on?chronic kidney disease in adults . If possible, offer treatment with drugs taken only once a day.
• Prescribe non-proprietary drugs if these are appropriate and minimize cost.
• Offer people with isolated systolic hypertension (systolic blood pressure 160?mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure.
• Offer antihypertensive drug treatment to women of childbearing potential with diagnosed hypertension in line with the recommendations in this guideline. For women considering pregnancy or who are pregnant or breastfeeding, manage hypertension in line with the recommendations on the management of pregnancy with chronic hypertension and breastfeeding in?NICE’s guidelines on?hypertension in pregnancy .
• When choosing antihypertensive drug treatment for adults of black African or?African–Caribbean family origin, consider an angiotensin?II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor.

To diagnose high blood pressure, your health care provider examines you and asks questions about your medical history and any symptoms. Your provider listens to your heart using a device called a stethoscope.

Your blood pressure is checked using a cuff, usually placed around your arm. It's important that the cuff fits. If it's too big or too small, blood pressure readings can vary. The cuff is inflated using a small hand pump or a machine.

The first time your blood pressure is checked, it should be measured in both arms to see if there's a difference. After that, the arm with the higher reading should be used.

Blood pressure is measured in millimeters of mercury (mm Hg). A blood pressure reading has two numbers.

• The top number is called systolic pressure.?The first, or upper, number measures the pressure in the arteries when the heart beats.
• The bottom number is called diastolic pressure.?The second, or lower, number measures the pressure in the arteries between heartbeats.

High blood pressure (hypertension) is diagnosed if the blood pressure reading is equal to or greater than 130/80?mm Hg. A diagnosis of high blood pressure is usually based on the average of two or more readings taken on separate occasions.

Blood pressure is grouped according to how high it is. This is called staging. Staging helps guide treatment.

• Stage 1 hypertension.?The top number is between 130 and 139?mm Hg?and the bottom number is between 80 and 89?mm Hg.
• Stage 2 hypertension.?The top number is 140?mm Hg?or higher or the bottom number is 90?mm Hg?or higher.

Sometimes the bottom blood pressure reading is normal (less than 80?mm Hg) but the top number is high. This is called isolated systolic hypertension. It's a common type of high blood pressure in people older than 65

Tests

If you are diagnosed with high blood pressure, your provider may recommend tests to check for a cause.

• Ambulatory monitoring.?A longer blood pressure monitoring test may be done to check blood pressure at regular times over six or 24 hours. This is called ambulatory blood pressure monitoring. However, the devices used for the test aren't available in all medical centers. Check with your insurer to see if ambulatory blood pressure monitoring is a covered service.
• Lab tests.?Blood and urine tests are done to check for conditions that can cause or worsen high blood pressure. For example, tests are done to check your cholesterol and blood sugar levels. You may also have lab tests to check your kidney, liver, and thyroid function.
• Electrocardiogram (ECG or EKG).?This quick and painless test measures the heart's electrical activity. It can tell how fast or how slow the heart is beating. During an?ECG, sensors called electrodes are attached to the chest and sometimes to the arms or legs. Wires connect the sensors to a machine, which prints or displays results.
• Echocardiogram.?This noninvasive exam uses sound waves to create detailed images of the beating heart. It shows how blood moves through the heart and heart valves.

Taking your blood pressure at home

Your healthcare provider may ask you to regularly check your blood pressure at home. Home monitoring is a good way to keep track of your blood pressure. It helps your care providers know if your medicine is working or if your condition is getting worse.

Home blood pressure monitors are available at local stores and pharmacies.

For the most reliable blood pressure measurement, the American Heart Association recommends using a monitor with a cuff that goes around your upper arm, when available.

Devices that measure your blood pressure at your wrist or finger aren't recommended by the American Heart Association because they can provide less reliable results.

Treatment

Changing your lifestyle can help control and manage high blood pressure. Your healthcare provider may recommend that you make lifestyle changes including:

• Eating a heart-healthy diet with less salt
• Getting regular physical activity
• Maintaining a healthy weight or losing weight
• Limiting alcohol
• Not smoking
• Getting 7 to 9 hours of sleep daily

Sometimes lifestyle changes aren't enough to treat high blood pressure. If they don't help, your provider may recommend medicine to lower your blood pressure.

Medications

The type of medicine used to treat hypertension depends on your overall health and how high your blood pressure is. Two or more blood pressure drugs often work better than one. It can take some time to find the medicine or combination of medicines that work best for you.

When taking blood pressure medicine, it's important to know your goal blood pressure level. You should aim for a blood pressure treatment goal of less than 130/80?mm Hg?if:

• You're a healthy adult age 65 or older
• You're a healthy adult younger than age 65 with a 10% or higher risk of developing cardiovascular disease in the next 10 years
• You have chronic kidney disease, diabetes or coronary artery disease

The ideal blood pressure goal can vary with age and health conditions, particularly if you're older than age 65.

Medicines used to treat high blood pressure include:

• Water pills (diuretics).?These drugs help remove sodium and water from the body. They are often the first medicines used to treat high blood pressure.
• There are different classes of diuretics, including thiazide, loop and potassium-sparing. Which one your provider recommends depends on your blood pressure measurements and other health conditions, such as kidney disease or heart failure. Diuretics commonly used to treat blood pressure include chlorthalidone, hydrochlorothiazide (Microzide), and others.
• A common side effect of diuretics is increased urination. Urinating a lot can reduce potassium levels. A good balance of potassium is necessary to help the heart beat correctly. If you have low potassium (hypokalemia), your provider may recommend a potassium-sparing diuretic that contains triamterene.
• Angiotensin-converting enzyme (ACE) inhibitors.?These drugs help relax blood vessels. They block the formation of a natural chemical that narrows blood vessels. Examples include lisinopril (Prinivil, Zestril), benazepril (Lotensin), captopril, and others.
• Angiotensin II receptor blockers (ARBs).?These drugs also relax blood vessels. They block the action, not the formation, of a natural chemical that narrows blood vessels.?ARBs?include candesartan (Atacand), losartan (Cozaar) and others.
• Calcium channel blockers.?These drugs help relax the muscles of the blood vessels. Some slow your heart rate. They include amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others), and others. Calcium channel blockers may work better for older people and Black people than ACE?inhibitors alone.
• Don't eat or drink grapefruit products when taking calcium channel blockers. Grapefruit increases blood levels of certain calcium channel blockers, which can be dangerous. Talk to your provider or pharmacist if you're concerned about interactions.

Other medicines sometimes used to treat high blood pressure

If you're having trouble reaching your blood pressure goal with combinations of the above medicines, your provider may prescribe:

• Alpha-blockers.?These medicines reduce nerve signals to blood vessels. They help lower the effects of natural chemicals that narrow blood vessels. Alpha blockers include doxazosin (Cardura), prazosin (Minipress) and others.
• Alpha-beta blockers.?Alpha-beta blockers block nerve signals to blood vessels and slow the heartbeat. They reduce the amount of blood that must be pumped through the vessels. Alpha-beta blockers include carvedilol (Coreg) and labetalol (Trandate).
• Beta-blockers.?These medicines reduce the workload on the heart and widen the blood vessels. This helps the heart beat slower and with less force. Beta-blockers include atenolol (Tenormin), metoprolol (Lopressor, Toprol-XL, Kapspargo sprinkle), and others.
• Beta-blockers aren't usually recommended as the only medicine prescribed. They may work best when combined with other blood pressure drugs.
• Aldosterone antagonists.?These drugs may be used to treat resistant hypertension. They block the effect of a natural chemical that can lead to salt and fluid buildup in the body. Examples are spironolactone (Aldactone) and eplerenone (Inspra).
• Renin inhibitors.?Aliskiren (Tekturna) slows the production of renin, an enzyme produced by the kidneys that starts a chain of chemical steps that increases blood pressure.
• Due to the risk of serious complications, including stroke, you shouldn't take aliskiren with?ACE?inhibitors or?ARBs.
• Vasodilators.?These medicines stop the muscles in the artery walls from tightening. This prevents the arteries from narrowing. Examples include hydralazine and minoxidil.
• Central-acting agents.?These medicines prevent the brain from telling the nervous system to increase the heart rate and narrow the blood vessels. Examples include clonidine (Catapres, Kapvay), guanfacine (Intuniv) and methyldopa.

Always take blood pressure medicines as prescribed. Never skip a dose or abruptly stop taking blood pressure medicines. Suddenly stopping certain ones, such as beta-blockers, can cause a sharp increase in blood pressure called rebound hypertension.

If you skip doses because of cost, side effects or forgetfulness, talk to your care provider about solutions. Don't change your treatment without your provider's guidance.

Treating resistant hypertension

You may have resistant hypertension if:

• You take at least three different blood pressure drugs, including a diuretic. But your blood pressure remains stubbornly high.
• You're taking four different medicines to control high blood pressure. Your care provider should check for a possible secondary cause of high blood pressure.

Having resistant hypertension doesn't mean your blood pressure will never get lower. If you and your provider can determine the cause, a more effective treatment plan can be created.

Treating resistant hypertension may involve many steps, including:

• Changing blood pressure medicines to find the best combination and dosage.
• Reviewing all your medicines, including those bought without a prescription.
• Checking blood pressure at home to see if medical appointments cause high blood pressure. This is called white-coat hypertension.
• Eating healthy, managing weight, and making other recommended lifestyle changes.

High blood pressure during pregnancy

If you have high blood pressure and are pregnant, discuss with your care providers how to control blood pressure during your pregnancy.

Potential future treatments

Researchers have been studying the use of heat to destroy specific nerves in the kidney that may play a role in resistant hypertension. The method is called renal denervation. Early studies showed some benefits. But more-robust studies found that it doesn't significantly lower blood pressure in people with resistant hypertension. More research is underway to determine what role, if any, this therapy may have in treating hypertension.

Lifestyle and home remedies

A commitment to a healthy lifestyle can help prevent and manage high blood pressure. Try these heart-healthy strategies:

• Eat healthy foods.?Eat a healthy diet. Try the Dietary Approaches to Stop Hypertension (DASH) diet. Choose fruits, vegetables, whole grains, poultry, fish, and low-fat dairy foods. Get plenty of potassium from natural sources, which can help lower blood pressure. Eat less saturated fat and trans fat.
• Use less salt.?Processed meats, canned foods, commercial soups, frozen dinners, and certain bread can be hidden sources of salt. Check food labels for sodium content. Limit foods and beverages that are high in sodium. A sodium intake of 1,500 mg a day or less is considered ideal for most adults. But ask your provider what's best for you.
• Limit alcohol.?Even if you're healthy, alcohol can raise your blood pressure. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women, and up to two drinks a day for men. One drink equals 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.
• Don't smoke.?Tobacco injures blood vessel walls and speeds up the process of hardening the arteries. If you smoke, ask your care provider for strategies to help you quit.
• Maintain a healthy weight.?If you're overweight or have obesity, losing weight can help control blood pressure and lower the risk of complications. Ask your healthcare provider what weight is best for you. In general, blood pressure drops by about 1?mm Hg?with every 2.2 pounds (1 kilogram) of weight lost. In people with high blood pressure, the drop in blood pressure may be even more significant per kilogram of weight lost.
• Get more exercise.?Regular exercise keeps the body healthy. It can lower blood pressure, ease stress, manage weight and reduce the risk of chronic health conditions. Aim to get at least 150 minutes a week of moderate aerobic activity or 75 minutes a week of vigorous aerobic activity, or a combination of the two.
• If you have high blood pressure, consistent moderate- to high-intensity workouts can lower your top blood pressure reading by about 11?mm Hg?and the bottom number by about 5?mm Hg
• Practice good sleep habits.?Poor sleep may increase the risk of heart disease and other chronic conditions. Adults should aim to get 7 to 9 hours of sleep daily. Kids often need more. Go to bed and wake up at the same time every day, including on weekends. If you have trouble sleeping, talk to your provider about strategies that might help.
• Manage stress.?Find ways to help reduce emotional stress. Getting more exercise, practicing mindfulness, and connecting with others in support groups are some ways to reduce stress.
• Try slow, deep breathing.?Practice taking deep, slow breaths to help relax. Some research shows that slow, paced breathing (5 to 7 deep breaths per minute) combined with mindfulness techniques can reduce blood pressure. There are devices available to promote slow, deep breathing. According to the American Heart Association, device-guided breathing may be a reasonable nondrug option for lowering blood pressure. It may be an good option if you have anxiety with high blood pressure or can't tolerate standard treatments.

A note from Dr. ALAA MOHAMMED

Daytime or Night-time Administration of Antihypertensive Medications??

In most individuals, blood pressure tends to be lower while asleep and peaks right after?awakening. However, in some individuals, this diurnal variation does not exist or is attenuated.

These individuals, labeled as “non-dippers,” have greater end-organ damage including greater left ventricular hypertrophy, silent cerebrovascular disease, and chronic renal damage as compared with “dippers.” 3?Hence, nighttime blood pressure control is an important consideration when deciding the timing of the administration of antihypertensives.

Another area of importance that is often neglected in the treatment of hypertension is the impact of chronotherapy on diurnal heart rate variation.

Heart rate variability is an important predictor of cardiovascular outcomes, and poor heart rate variability has been suggested to be an independent predictor of all-cause mortality.4?Thus, after consideration of time to peak effect, nighttime administration of negative chronotropic medications like beta-blockers and calcium channel blockers may offer a clear advantage.

In fact, nighttime administration of all antihypertensive agents has shown to be associated with decreased nocturnal hypertension, reduction in the non-dipping pattern of ambulatory blood pressure, and overall improved cardiovascular outcomes. Hermida?et al.5?in the multicenter prospective Hygia trial showed a significant 45% reduction in cardiovascular outcomes with ingestion of ≥1 blood pressure-lowering medication at bedtime as compared with ingestion of all medications upon waking. This was an open-label trial of around 19,000 patients in a primary care setting in Spain, with a follow-up period of 6.3 years. The large population sample size and long follow-up period are major strengths of this trial which clearly showed the beneficial effects of bedtime intake of antihypertensive medications.

This study population, however, lacked racial diversity. Therefore, more studies need to be conducted in diverse populations before the routine bedtime intake of antihypertensive drugs can be recommended widely. Further, this study did not address the effect of bedtime vs. morning intake of antihypertensive drugs in diapers and non-dippers on cardiovascular outcomes separately. It has been widely shown that non-dippers benefit from the nighttime administration of antihypertensive medications, but the same effect has yet to be shown in the dipper population. Still, the beneficial effects of this study are hard to ignore. The bedtime administration of all antihypertensive medications not only can improve cardiovascular outcomes but also can substantially improve patient compliance and adherence to the medication regimen.

Bedtime administration of antihypertensive medications has been found to be particularly useful in patients with comorbid conditions such as chronic kidney disease, diabetes, and obstructive sleep apnea.6?Essentially for improving antihypertensive medication adherence and cardiovascular outcomes, a comprehensive holistic approach is needed. This includes steps such as chronotherapy for antihypertensive medications along with a team-based collaborative approach to improving patient education and compliance. Here, we need to mention the results of a Barbershop study by Victor?et al.7?In a cluster-randomized trial, the authors found that health promotion by barbers combined with pharmacists-driven antihypertensive medications management resulted in a large reduction in blood pressure in African-American patients.

Their simple approach emphasized the value of health promotion, education, regular follow-up, and blood pressure measurement in a setting comfortable and convenient to the patient population. This study also showed a considerable reduction in both systolic and diastolic blood pressures, with cohort retention of 95%, few adverse effects, and improvement in patient satisfaction.

Lastly, the impact of lifestyle changes on cardiovascular outcomes in hypertension management is often not given due importance. Simple things like following a low salt, plant protein-based diet, decreased animal fat intake, optimal sleep hygiene, adequate physical activity, avoiding a sedentary lifestyle, smoking cessation, and using relaxation techniques such as yoga/meditation can help not only in improving blood pressure control but improvement in patient’s sense of well-being. Importantly, patients feel more connected with physicians who are not just concerned about their test results/medications but the overall health and well-being of patients.