User:GT67/managementofhypertension

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Lifestyle modifications
The first line of treatment for hypertension is identical to the recommended preventative lifestyle changes and includes: dietary changes physical exercise, and weight loss. These have all been shown to significantly reduce blood pressure in people with hypertension. If hypertension is high enough to justify immediate use of medications, lifestyle changes are still recommended in conjunction with medication. Different programs aimed to reduce psychological stress such as biofeedback, relaxation or meditation are advertised to reduce hypertension. However, in general claims of efficacy are not supported by scientific studies, which have been in general of low quality.

Dietary change such as a low sodium diet is beneficial. A long term (more than 4 weeks) low sodium diet in Caucasians is effective in reducing blood pressure, both in people with hypertension and in people with normal blood pressure. Also, the DASH diet, a diet rich in nuts, whole grains, fish, poultry, fruits and vegetables promoted in the USA by the National Heart, Lung, and Blood Institute lowers blood pressure. A major feature of the plan is limiting intake of sodium, although the diet is also rich in potassium, magnesium, calcium, as well as protein.

Medications
Several classes of medications, collectively referred to as antihypertensive drugs, are currently available for treating hypertension. Prescription should take into account the person's cardiovascular risk (including risk of myocardial infarction and stroke) as well as blood pressure readings, in order to gain a more accurate picture of the person's cardiovascular profile. Evidence in those with mild hypertension (SBP less than 160 mmHg and /or DBP less than 100 mmHg) and no other health problems does not support a reduction in the risk of death or rate of health complications from medication treatment.

If drug treatment is initiated the Joint National Committee on High Blood Pressure (JNC-7) recommends that the physician not only monitor for response to treatment but should also assess for any adverse reactions resulting from the medication. Reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34%, of ischaemic heart disease by 21%, and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease. The aim of treatment should be to reduce blood pressure to <140/90 mmHg for most individuals, and lower for those with diabetes or kidney disease (some medical professionals recommend keeping levels below 120/80 mmHg). If the blood pressure goal is not met, a change in treatment should be made as therapeutic inertia is a clear impediment to blood pressure control.

Guidelines on the choice of agents and how best to step up treatment for various subgroups have changed over time and differ between countries. The best first line agent is disputed. The Cochrane collaboration, World Health Organization and the United States guidelines supports low dose thiazide-based diuretic as first line treatment. The UK guidelines emphasise calcium channel blockers (CCB) in preference for people over the age of 55 years or if of African or Caribbean family origin, with angiotensin converting enzyme inhibitors (ACE-I) used first line for younger people. In Japan starting with any one of six classes of medications including: CCB, ACEI/ARB, thiazide diuretics, beta-blockers, and alpha-blockers is deemed reasonable while in Canada all of these but alpha-blockers are recommended as options.

Drug combinations
The majority of people require more than one drug to control their hypertension. JNC7 and ESH-ESC guidelines advocate starting treatment with two drugs when blood pressure is >20 mmHg above systolic or >10 mmHg above diastolic targets. Preferred combinations are renin–angiotensin system inhibitors and calcium channel blockers, or renin–angiotensin system inhibitors and diuretics. Acceptable combinations include calcium channel blockers and diuretics, beta-blockers and diuretics, dihydropyridine calcium channel blockers and beta-blockers, or dihydropyridine calcium channel blockers with either verapamil or diltiazem. Unacceptable combinations are non-dihydropyridine calcium blockers (such as verapamil or diltiazem) and beta-blockers, dual renin–angiotensin system blockade (e.g. angiotensin converting enzyme inhibitor + angiotensin receptor blocker), renin–angiotensin system blockers and beta-blockers, beta-blockers and centrally acting agents. Combinations of an ACE-inhibitor or angiotensin II–receptor antagonist, a diuretic and an NSAID (including selective COX-2 inhibitors and non-prescribed drugs such as ibuprofen) should be avoided whenever possible due to a high documented risk of acute renal failure. The combination is known colloquially as a "triple whammy" in the Australian health industry. Tablets containing fixed combinations of two classes of drugs are available and while convenient for the people, may be best reserved for those who have been established on the individual components.

In the elderly
Treating moderate to severe hypertension decreases death rates and cardiovascular morbidity and mortality in people aged 60 and older. There are limited studies of people over 80 years old but a recent review concluded that antihypertensive treatment reduced cardiovascular deaths and disease, but did not significantly reduce total death rates. The recommended BP goal is advised as <140/90 mm Hg with thiazide diuretics being the first line medication in America, and in the revised UK guidelines calcium-channel blockers are advocated as first line with targets of clinic readings <150/90, or <145/85 on ambulatory or home blood pressure monitoring.

Resistant hypertension
Resistant hypertension is defined as hypertension that remains above goal blood pressure in spite of concurrent use of three antihypertensive agents belonging to different antihypertensive drug classes. Guidelines for treating resistant hypertension have been published in the UK and US.

Medications
The British Hypertension Society AB/CD algorithm has been widely adopted for deciding drug therapy for an individual.38 The algorithm was substantially ratified by the ASCOT trial and AB/ CD has now been accepted by JBS2 as the best method of defining combination drug therapy. The AB/CD algorithm was designed to improve blood pressure control based on age-related renin levels and appropriate combinations. In June 2006 the National Institute for Clinical Health and Excellence (NICE) and the BHS jointly released a revised guideline that updated the clinical evidence base to include recent meta-analyses and RCTs and included a cost effectiveness analysis comparing the various blood pressure lowering drug classes.270 The results showed that: The recommendations based on this evidence are summarized below. It incorporates all classes of antihypertensive drugs. Although not specifically validated by a clinical trial, the recommended drug combinations and sequencing are similar to those used in many clinical trials of blood pressure lowering drugs.
 * beta blockers were the least clinically and cost effective drug at preventing major cardiovascular events
 * calcium channel blockers and thiazide-type diuretics were the most clinically and cost effective choice for the majority of cases
 * for people under the age of 55, drugs affecting the renin-angiotensin system are likely to be most effective.

First-line treatment
First-line therapy for people <55 years of age is an angiotensin converting enzyme inhibitor (ACE-I) or an angiotensin II receptor blocker (ARB) if the patient is intolerant to the ACE-I. People who are ≥55 years of age or black people of African or Caribbean origin of any age, calcium channel blockers or thiazide-type diuretics are the first-line therapy.

Second-line treatment
If first-line therapy fails, second-line therapy consists of adding a CCB or a thiazide-type diuretic for patient who initially started an ACE-I or ARB as first-line treatment. For patients who were started on a calcium channel blocker or a thiazide-type diuretic should also be given an ACE-I or and ARB.

Third-line treatment
When blood pressure goal is not reached after introducing a second-line treatment option, patient should be on three medications: an ACE-I or ARB (not both), a CCB, and a thiazide-type diuretic.

Fourth-line treatment
Patients who fail third-line treatment can further add diuretic therapy, an alpha blocker, or a beta blocker and should consider seeking the advice of a specialist. However, beta blockers are not a preferred initial therapy for hypertension but are an alternative to ACE inhibitors in patients <55 years in whom ACE inhibitors or ARBs are not tolerated, or contraindicated (includes women of childbearing potential). Black patients are only those of African or Caribbean descent. In the absence of evidence, all other patients should be treated according to the algorithm as non-black.

Most Readily Prescribed
The following table depicts the most readily prescribed medications to treat high blood pressure in Scotland. Amlodipine was the most dispensed medication used to treat angina and high blood pressure, and the 9th most dispensed medication overall, during the fiscal year of 2011/2012 in Scotland.

Socioeconomic impact
The estimated cost burden of high blood pressure in the U.K. has been estimated to be over £7 billion.

Government policies
The following current national waiting time standards have been developed for patients who have developed cardiac conditions requiring intervention: no patient will wait more than 16 weeks for cardiac intervention following General Practice (GP) referral through a rapid access chest pain clinic (RACPC) and no patient will wait more than 16 weeks for treatment after they have been seen as an outpatient by a heart specialist who has recommended treatment. Currently, the NHS Scotland lacks systems that capture the total patient journey and have relied on an interim solution, which is to monitor the progress of wait times using component parts of the journey. Additionally, practices are required to complete a CVD risk assessment in people who have been diagnosed with hypertension without confirmed CVD, after April 1, 2009.