VI. Health behaviour management

Prevention and Treatment

Revised recommendations for 2020

  • Reduce alcohol consumption (or abstain) to reduce BP and prevent hypertension.
  • To prevent hypertension, there is no safe limit for alcohol consumption.

In a systematic review and meta-analysis of original cohort studies an increase in incidence of hypertension with any amount of alcohol consumption in men, and an increase in incidence of hypertension with more than 2 drinks per day in women was reported. Additionally, a separate analysis of the risk thresholds from large-scale data sources showed a positive linear association between alcohol consumption and mortality attributed to hypertension (hazard ratio per 100 g/wk greater consumption, 1.24; 95% CI, 1.15-1.33).

In adults with hypertension who consume more than 2 drinks per day, a reduction in alcohol consumption is associated with a decreased BP. In a systematic review and meta-analysis of clinical trials the effect of a change in alcohol consumption on BP in subjects with hypertension was investigated. This analysis showed that there was a significant reduction in BP associated with a reduction in alcohol consumption in hypertensive subjects who consumed 3 or more drinks per day in a dose-dependent manner. The largest reduction in BP (SBP: 5.50 mm Hg [95% CI, 6.70 to 4.30] and DBP: 3.97 mm Hg [95% CI, 4.70 to 3.25]) was reported in subjects with a baseline consumption of 6 or more drinks per day.

Recommendations
A.Physical exercise

  1. For nonhypertensive individuals (to reduce the possibility of becoming hypertensive) or for hypertensive patients (to reduce their BP), prescribe the accumulation of 30-60 minutes of moderate-intensity dynamic exercise (eg, walking, jogging, cycling, or swimming) 4-7 days per week in addition to the routine activities of daily living (Grade D). Higher intensities of exercise are not more effective (Grade D). For nonhypertensive or hypertensive individuals with SBP/DBP of 140-159/90-99 mm Hg , the use of resistance or weight training exercise (such as free-weight lifting, fixed-weight lifting, or handgrip ex-ercise) does not adversely influence BP (Grade D).

B. Weight reduction

  1. Height, weight, and waist circumference should be measured and body mass index calculated for all adults (Grade D).
  2. Maintenance of a healthy body weight (body mass in-dex 18.5-24.9, and waist circumference < 102 cm for men and < 88 cm for women) is recommended for nonhypertensive individuals to prevent hypertension (Grade C) and for hypertensive patients to reduce BP (Grade B). All overweight hypertensive individuals should be advised to lose weight (Grade B).
  3. Weight loss strategies should use a multidisciplinary approach that includes dietary education, increased physical activity, and behavioural intervention (Grade B).

C. Alcohol consumption

  1. In healthy adults, abstaining from alcohol or reducing alcohol intake to 2 drinks per day or less is recommended to prevent hypertension (Grade B; revised recommendation).
  2. In adults with hypertension who drink more than 2 drinks per day, a reduction in alcohol intake is associated with decreased BP and is recommended. In adults with hypertension who drink 6 or
    more drinks per day, a reduction in alcohol intake to 2 or fewer drinks per day is associated with decreased BP and is recom-mended (Grade A; revised recommendation).

D. Diet

  1. It is recommended that hypertensive patients and normotensive individuals at increased risk of devel-oping hypertension consume a diet that emphasizes fruits, vegetables, low-fat dairy products, whole grain foods rich in dietary fibre, and protein from plant sources that is reduced in saturated fat and cholesterol (Dietary Approaches to Stop Hypertension [DASH] diet63-66; Supplemental Table S5; Grade B).

Sodium intake

  1. To prevent hypertension and reduce BP in hypertensive adults, consider reducing sodium intake toward 2000 mg (5 g of salt or 87 mmol of sodium) per day (Grade A).

Calcium and magnesium intake

  1. Supplementation of calcium and magnesium is not recommended for the prevention or treatment of hy-pertension (Grade B).

Potassium intake

  1. In patients not at risk of hyperkalemia (see Table 4), in-crease dietary potassium intake to reduce BP (Grade A).

Stress management

  1. In hypertensive patients in whom stress might be contributing to high BP, stress management should be considered as an intervention (Grade D).
  2. Individualized cognitive-behavioural interventions are more likely to be effective when relaxation techniques are used (Grade B).

Management: Uncomplicated Pharmacotherapy

Key Messages

  • Hypertension Canada continues to promote a risk-based approach to treatment thresholds and targets (Tables 5 and 6).
  • Hypertension Canada continues to encourage the use of clinical judgement and shared decision-making when identifying BP targets to ensure feasibility in the patient’s broader clinical, social, and economic context.
  • Patients with existing cardiovascular disease or with elevated cardiovascular risk should be considered for intensive SBP targets (ie, SBP 120 mm Hg).
  • Angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), and longer-acting thia-zide-like diuretics continue to be recommended as effective first-line treatment in all adults with uncomplicated hypertension.
  • b-Blockers can be used safely as first-line therapy in younger patients only with uncomplicated hypertension.