For lifestyle and pharmacological interventions, evidence was reviewed from randomized controlled trials and systematic reviews of trials. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. For treatment of patients with
kidney disease, the progression of kidney dysfunction was also accepted as a clinically relevant primary outcome.
EVIDENCE: Dietary lifestyle modifications for prevention of
hypertension, in addition to a well-balanced diet, include a
dietary sodium intake of less than 100 mmol/day. In hypertensive patients, the
dietary sodium intake should be limited to 65 mmol/day to 100 mmol/day. Other lifestyle modifications for both normotensive and hypertensive patients include: performing 30 min to 60 min of aerobic exercise four to seven days per week; maintaining a healthy
body weight (body mass index of 18.5 kg/m2 to 24.9 kg/m2) and waist circumference (less than 102 cm in men and less than 88 cm in women); limiting alcohol consumption to no more than 14 units per week in men or nine units per week in women; following a diet reduced in saturated fat and
cholesterol, and one that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and
protein from plant sources; and considering stress management in selected individuals with
hypertension. For the pharmacological management of
hypertension, treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and any comorbid conditions: blood pressure should be lowered to lower than 140/90 mmHg in all patients and lower than 130/80 mmHg in those with
diabetes mellitus or
chronic kidney disease. Most patients require more than one agent to achieve these blood pressure targets. In adults without compelling indications for other agents, initial
therapy should include
thiazide diuretics; other agents appropriate for first-line
therapy for diastolic and/or
systolic hypertension include
angiotensin-converting enzyme (
ACE) inhibitors (except in black patients), long-acting
calcium channel blockers (CCBs),
angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). First-line
therapy for
isolated systolic hypertension includes long-acting
dihydropyridine CCBs or ARBs. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent
myocardial infarction, or
heart failure, beta-blockers and
ACE inhibitors are recommended as first-line
therapy; in patients with
cerebrovascular disease, an
ACE inhibitor plus
diuretic combination is preferred; in patients with nondiabetic
chronic kidney disease,
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. All hypertensive patients with
dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of
dyslipidemia and prevention of
cardiovascular disease). Selected high-risk patients with
hypertension who do not achieve thresholds for
statin therapy according to the position paper should nonetheless receive
statin therapy. Once blood pressure is controlled,
acetylsalicylic acid therapy should be considered.
VALIDATION: