A Cochrane Collaboration librarian conducted an independent MEDLINE search from 2008 to August 2009 to update the 2009 recommendations. To identify additional studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence.
RECOMMENDATIONS: For lifestyle modifications to prevent and treat
hypertension, restrict
dietary sodium to 1500 mg (65 mmol) per day in adults 50 years of age or younger, to 1300 mg (57 mmol) per day in adults 51 to 70 years of age, and to 1200 mg (52 mmol) per day in adults older than 70 years of age; perform 30 min to 60 min of moderate aerobic exercise four to seven days per week; maintain a healthy
body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week for men or nine standard drinks per week for women; follow a diet that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and
protein from plant sources, and that is low in saturated fat and
cholesterol; and consider stress management in selected individuals with
hypertension. For the pharmacological management of
hypertension, treatment thresholds and targets should be predicated on the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in patients with
diabetes mellitus or
chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures.
Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, considerations for initial
therapy should include
thiazide diuretics,
angiotensin- converting enzyme (
ACE) inhibitors (in patients who are not black), long-acting
calcium channel blockers (CCBs),
angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as initial treatment of
hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of
ACE inhibitors and ARBs should not be used, unless compelling indications are present to suggest consideration of dual
therapy. Agents appropriate for first-line
therapy for
isolated systolic hypertension include
thiazide diuretics, long-acting
dihydropyridine CCBs or ARBs. In patients with
coronary artery disease,
ACE inhibitors, ARBs or betablockers are recommended as first-line
therapy; in patients with
cerebrovascular disease, an
ACE inhibitor/
diuretic combination is preferred; in patients with proteinuric nondiabetic
chronic kidney disease,
ACE inhibitors or ARBs (if intolerant to
ACE inhibitors) are recommended; and in patients with
diabetes mellitus,
ACE inhibitors or ARBs (or, in patients without
albuminuria,
thiazides or
dihydropyridine CCBs) are appropriate first-line
therapies. In selected high-risk patients in whom combination
therapy is being considered, an
ACE inhibitor plus a long-acting
dihydropyridine CCB is preferable to an
ACE inhibitor plus a
thiazide diuretic. All hypertensive patients with
dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian
lipid treatment guidelines. Selected patients with
hypertension who do not achieve thresholds for
statin therapy, but who are otherwise at high risk for cardiovascular events, should nonetheless receive
statin therapy. Once blood pressure is controlled, low-dose
acetylsalicylic acid therapy should be considered.
VALIDATION: