Blood pressure (high) for healthcare providers

Cardiovascular disease (CVD) risk assessment and management for people aged 30 to 74 years without prior CVD is based on 5-year CVD risk prediction equations from the NZ PREDICT study, the NZ Primary Prevention Equations. See heart risk assessment for clinicians for details. 

From Cardiovascular disease risk assessment in primary care(external link), BPAC, NZ, 2018

• Lifestyle interventions are recommended for every patient with a blood pressure ≥ 130/80 mmHg.
• Calculate the patient’s 5-year cardiovascular risk to inform decisions about blood pressure-lowering medicines:
  • Blood pressure-lowering medicines are not recommended in patients with a risk < 5%
  • Discussions with patients about the benefits and harms of blood pressure-lowering medicines are appropriate in those with a risk 5–15% and a blood pressure ≥ 140/90 mmHg
  • Blood pressure-lowering medicines are strongly recommended for patients with a risk ≥ 15% and blood pressure ≥ 130/80 mmHg
  • Blood pressure-lowering medicines are recommended for patients with a blood pressure ≥ 160/100 mmHg regardless of cardiovascular risk.
• If blood pressure-lowering medicines are initiated, a target ≤ 130/80 mmHg is recommended for most patients; however, this target should be approached with caution in older frail patients.
• Angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers and thiazide diuretics are all first-line blood pressure-lowering medicines. 

Hypertension – the silent killer(external link) BPAC, NZ, 2020
What's new in cardiovascular disease assessment and management for primary care clinicians(external link) BPAC, NZ, 2018
Cardiovascular disease risk assessment in primary care – managing lipids(external link) BPAC, NZ, 2018
Cardiovascular disease risk assessment in primary care – the role of aspirin(external link) BPAC, NZ, 2018
Cardiovascular disease risk assessment and management for primary care(external link) Ministry of Health, NZ, 2018

Goodfellow MedCase – hypertension in older adults – finding the right target

The NZ Cardiovascular Disease Risk Assessment and Management for Primary Care 2018 (NZ CVD Guidelines) advise caution in treating blood pressure in older people due to concerns about risks such as falls or orthostatic hypotension.

The general target blood pressure of < 130/80 mmHg is suggested for those with few comorbidities and life expectancy > 5 years, but must be individualised based on likely benefits and risks of therapy.

This MedCase(external link) offers a framework for managing blood pressure in the older adult. 

Goodfellow Gem – BP 140 treated to 120 – no increase in concern re falling

In an extra analysis of the SPRINT trial, where hypertensive patients were randomised to a treatment target of 140 mm Hg or 120 mm Hg, the concerns about falling were measured on the Efficacy Scale International questionnaire at  baseline, six months, one year, and annually thereafter.¹

While there was an expected increase in falling concerns there was no difference between the groups randomised to 140 vs 120 mm Hg.

In the original paper there was a statistically significant increase in syncope but not in terms of injurious falls.²  With older patients it's prudent to check their blood pressures sitting and standing but at the same time remembering that older patients have the highest CVD risk so treatment is a balance of benefit against harms.

References:

1. Impact of intensive blood pressure therapy on concern about falling – longitudinal results from the systolic blood pressure intervention trial (SPRINT)(external link) J Am Geriatr Soc, 2019
2. A randomized trial of intensive versus standard blood-pressure control(external link) NEJM, 2015

Results of the SPRINT trial have found that in high-risk CVD patients (20% risk of an event in 10 years), a target BP of 120 mm Hg showed improved outcomes (reduced CVD events and death) as compared with a target BP of 140 mm Hg. Read more: Tight BP control improves CV outcomes in high-risk patients(external link) 
The British Hypertension Society (BHS)(external link) provides a list of blood pressure monitors they have validated. 
Wiysonge CS, Bradley HA, Volmink J, et al. Beta-blockers for hypertension. Cochrane Database Syst Rev. 2017 Jan 20;1:CD002003. doi: 10.1002/14651858.CD002003.pub5. (Review) [Cochrane Plain Language summary](external link) 
Garjón J, Saiz LC, Azparren A, Elizondo JJ, Gaminde I, Ariz MJ, Erviti J. First-line combination therapy versus first-line monotherapy for primary hypertension. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD010316. DOI: 10.1002/14651858.CD010316.pub2. Conclusion: inconclusive, larger studies needed. [Cochrane Library](external link) 
Cochrane hypertension library(external link)

Online modules BMJ Learning

Managing hypertension in primary care(external link) An overview of the latest guidance on managing patients with hypertension and a guide to differentiating between primary and secondary hypertension. (1 hour) Feb 2023
Investigating hypertension in younger patients(external link) Hypertension is often thought of as a disease of older age, but it occurs across all adult ages, including in younger patients. Read the article on this subject then take the multiple-choice assessment. (30 minutes) Mar 2022

Goodfellow Unit Webinar: Resistant hypertension

Managing difficult blood pressures with Hari Talreja

(Goodfellow Unit, NZ, 2020)

PHARMAC Seminars

1. The treatment of hypertension in primary care – Prof. Bruce Arroll (34 minutes)

(PHARMAC, NZ, 2019)

2. Difficult to manage cases of hypertension in primary care – Prof. Gerry Devlin (20 minutes)

(PHARMAC, NZ, 2019)

For more videos of the same series, visit PHARMAC Seminars CVD update(external link). 

Blood pressure (high)

"A major change in the 2024 ESC Guidelines(external link) is the recommendation to pursue a target systolic BP of 120–129 mmHg among adults receiving BP-lowering medications.

There are caveats to this recommendation, including:

1. The requirement that treatment to this BP target is well tolerated by the patient.
2. The fact that more lenient BP targets are ok with symptomatic orthostatic hypotension, those aged 85 years or over, or those with moderate-to-severe frailty or limited life expectancy.
3. A strong emphasis on out-of-office BP measurement to confirm that the systolic BP target of 120–129 mmHg is achieved. 

Where a target systolic BP of 120–129 mmHg is not pursued, either due to intolerance or the existence of conditions that favour a more lenient BP target, target a BP that is as low as reasonably achievable".

Extract from Goodfellow Unit, NZ, 2024