A Cochrane collaboration librarian conducted an independent MEDLINE search from 2006 to August 2007 to update the 2007 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence.
RECOMMENDATIONS: For lifestyle modifications to prevent and treat
hypertension, restrict
dietary sodium intake to less than 100 mmol/day (and 65 mmol/day to 100 mmol/day in hypertensive patients); perform 30 min to 60 min of 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 (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is 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 consider stress management in selected individuals with
hypertension. For the pharmacological management of
hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with
diabetes mellitus or
chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. For 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 (in nonblack patients), long-acting
calcium channel blockers (CCBs),
angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered for initial treatment of
hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. Other agents appropriate for first-line
therapy for
isolated systolic hypertension include long-acting
dihydropyridine CCBs or ARBs. 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/
diuretic combination is preferred; in patients with proteinuric 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 but 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: