Management of elevated blood pressure and hypertension

Treatment of high blood pressure (BP) is likely the most easily modifiable risk factor in preventing CV and renal sequelae in CKM disease so BP should be measured at every practical opportunity
An individualised approach is recommended taking into account competing risks and preferences and explored through shared decision making

Recommended thresholds for treatment of BP depend whether other CKM disease features are present:
- BP ≥ 140/90 mmHg → prompt confirmation and treat with lifestyle advice + pharmacotherapy in all if appropriate
- BP 130 – 139/80 - 89 mmHg → prompt confirmation and treat with lifestyle advice + pharmacotherapy if 5 year CV risk ≥ 10% OR ANY of the following:
  - CVD including ischaemic heart disease, cerebrovascular disease, peripheral arterial disease, atrial fibrillation and heart failure
  - Diabetes with any microvascular or macrovascular complication
  - Familial hypercholesterolaemia
  - Chronic kidney disease (eGFR <60mL/min and/or UACR >3 mg/mmol)
  - NB: Gout, MASLD and OSA all independently increase CV risk and events, but are not currently included in the PREDICT CV risk calculator. Therefore, CV risk is likely underestimated in these conditions and treatment of BP 130-139/80-89 mmHg should still be considered in these conditions if no other indications, particularly if 5 year CV risk 4-5%.
- BP 130 - 138/80 - 89 mmHg and 5 year CV risk 5 - < 10% → lifestyle advice + treat underlying condition + consider pharmacotherapy IF ANY of the following:
  - Gout or auto-immune inflammatory disease
  - MASLD
  - OSA
  - Severe mental illness particularly with antipsychotic use
  - Previous gestational diabetes and/or preeclampsia
  - Direct family history of CVD < 40 years of age
  - Cardiac calcium score ≥ 100
- BP 130 - 138/80 - 89 mmHg and 5 year CV risk < 5% → lifestyle advice alone
Target systolic BP is 120 – 129 mmHg in most individuals
- A systolic BP < 120 mmHg is not concerning if well tolerated and likely preferable if young or heart failure
- Relaxed BP targets to the lowest reasonably and safely achievable BP are appropriate if any of the following:
  - Frailty and/or limited life expectancy
  - Age ≥ 85 years
  - Symptomatic postural hypotension
    - Measure lying/standing or sitting/standing BP if high risk of postural hypotension and treat to standing BP if > 10 mmHg postural drop.
  - Intolerant of antihypertensives
- Unlike other features of CKM, treating BP has no ‘metabolic memory or legacy effect’. Therefore, BP targets and treatment should only be relaxed when clinically appropriate
- Diastolic BP targets are now no longer first-line BP targets due to evidence for the greater benefit of controlling systolic BP. Although it is desirable to have a diastolic BP < 80 mmHg, a systolic BP 120 – 129 mmHg is the primary target.
Treatment consists of both non-pharmacological and pharmacological management and should ideally be based on several ‘out of office’ or home BP monitoring at rest as BP levels in clinic are typically ≥ 5 mmHg higher. Home monitoring is best done in a structured approach e.g. morning and evening BP measurements at rest for 1 week.
- If out of office BP monitoring not available then measure BP after 5 mins seated comfortably in a quiet environment with a validated device with an appropriate cuff size with the cuff at the level of the heart. Ideally BP should be measured 3 times 1-2 mins apart with the average of the last 2 readings used.
Non-pharmacological management is always important and is discussed in detail in lifestyle management. Key points include:
- Smoking and alcohol cessation
  - Increasing evidence that vaping cessation is also beneficial
- A low-salt diet with fruit and leafy vegetables to ensure adequate potassium intake
- Increased physical activity and movement
- Aiming for > 5% total body weight loss if overweight
First line pharmacotherapy for lowering BP are ACE inhibitors (ACEi) or angiotensin receptor blockers (ARB), calcium channel blockers (CCB) and thiazide diuretics (TD). Typically, these medications are more effective and better tolerated in low doses in combination, but may be used alone. Cardioselective beta blockers (β-blocker) may be used if ischaemic heart disease, heart failure or atrial fibrillation. Guidance on likely best agents in each to use based on efficacy and tolerance is below.
Best choice of ACEi, ARB, CCB or TD is dependent on whether renal disease predominates and presence of other comorbidities:
- Chronic kidney disease is present (eGFR <60 mLmin and/or UACR > 3 mg/mmol):
  - Strongly consider ACEi or ARB if no hypotension and check BP in 1 month
  - Titrate ACEi or ARB to maximal tolerated dose
  - Check BP monthly until to target – if BP remains above target add CCB or TD
  - If BP still above target then add other (e.g. TD if CCB previously added)
- No renal or CV disease:
  - Strongly consider low dose ACEi or ARB and CCB in combination
  - Check BP in 1 month → if above target increase dose of combination agents
  - Check BP monthly until to target - if BP remains above target then add TD
- Gout:
  - Consider ACEi or ARB as first-line options. (Note that losartan and dihydropyridine CCBs may serve as helpful adjuncts due to their small uricosuric effect, but they should not replace urate-lowering therapy and the focus should be on the most effective anti-hypertensive)
  - Beware TD typically increase uric acid levels
- Ischaemic heart disease, heart failure or atrial fibrillation:
  - β-blockers may be added at any stage. May need to decrease CCB and/or TD if hypotension
  - In heart failure Entresto (Sacubitril/Valsartan) is preferred renin-angiotensin system inhibitor (rather than ACEi or ARB) but need to meet special authority criteria for funding. Use spironolactone or eplerenone and empagliflozin rather than TD or CCB if risk of hypotension.
    - Maximise doses of Entresto, β-blocker and spironolactone before addition of other agents.
      - Remember to monitor potassium when using Entresto or spironolactone as per ACEi/ARB below
Causes of secondary hypertension should be considered if young and/or persistent hypertension despite adherence to ≥ 3 antihypertensive agents
Likely preferred agents in each of blood pressure lowering medications available in Aotearoa NZ:
- ACEi and ARB:
  - Ramipril typically preferred ACEi but perindopril useful alternative. Quinapril also useful alternative if combination with TD desirable but often requires twice daily dosing.
    - Usual dose range of ramipril is 2.5 mg – 10 mg daily but may start 1.25 mg daily if elderly and/or risk of hypotension
    - Usual dose range of perindopril is 2 mg - 8 mg daily
    - Usual dose range of quinapril is 2.5 mg – 20 mg once or twice daily. Combination with hydrochlorothiazide available at 10 mg and 20 mg doses of quinapril.
  - Candesartan typically preferred ARB but losartan useful alternative if combination with TD desirable.
    - Usual dose range of candesartan is 8 mg – 32 mg daily but may start at 4 mg daily if elderly and/or risk of hypotension
    - Usual dose range of losartan is 50 mg – 100 mg daily but may start at 12.5 mg - 25 mg daily if elderly and/or risk of hypotension. Combination with hydrochlorothiazide available at 50 mg losartan dose.
  - Check creatinine + electrolytes 2-4 weeks after starting or dose change to ensure no hyperkalaemia or deterioration of renal function
    - K+ < 5.5 mmol/L and up to 30% decrease in creatinine requires no dose change
    - Hyperkalaemia is often spurious due to haemolysis during the delay from collection until analysis in the lab - consider repeating to ensure real.
- CCB:
  - Amlodipine and felodipine preferred with usual dose range for both 2.5 mg – 5 mg daily
  - 10 mg daily doses associated with greater risk of adverse effects for often little benefit
  - Useful if elevated diastolic BP as vasodilators
- TD:
  - Chlorthalidone is typically preferred TD but bendroflumethazide useful alternative.
  - Usual dose of chlorthalidone: is 12.5 mg – 25 mg daily and usual dose of bendroflumethazide is 2.5 mg - 5 mg daily. Higher doses typically lead to little additional BP lowering but greatly increase adverse effects.
  - Hydrochlorothiazide is a weak BP lowering agent but may be useful if combination tablets preferable
  - Check eGFR + electrolytes 1-2 weeks after starting to ensure no adverse effects
- β-blockers – Metoprolol controlled release (CR) or bisoprolol preferred for ischaemic heart disease and rate control
  - Carvedilol likely preferable if congestive heart failure
The guidance in this section is predominantly based on the 2024 European Society of Cardiology Guidelines for the management of elevated blood pressure and hypertension, which can be accessed at www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Elevated-Blood-Pressure-and-Hypertension

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