Conditions

Treatment options for

Hypertension

Treatment options:

Lifestyle interventions to reduce blood pressure

Walking

4/2mmHg reduction with 150 minutes of moderate intensity walking a week.

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  • from a 2021 Cochrane review including 73 small RCTs 1
  • MODERATE quality evidence

Aerobic exercise

5/3mmHg reduction with 30-60 minutes aerobic exercise 3 x a week.

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  • from a  1997 systematic review including 27 small RCTs, most at risk of bias2
  • VERY LOW quality evidence

Weight loss

4/3mmHg reduction with weight loss of about 4 kilos.

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  • from a 2021 Cochrane review which included 3 RCTs3
  • LOW quality evidence

Alcohol intake reduction

3/2mmHg reduction with lowering alcohol intake by two-thirds (from a baseline of 3-6 units per day).

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  • from a 2001 systematic review including 15 RCTs4
  • MODERATE quality evidence

Salt intake reduction

5/3mmHg reduction with lowering salt intake by 4.4g/day

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  • from a 2013 Cochrane review including 34 trials5
  • HIGH quality evidence
  • For perspective, current UK guidance recommends no more than 6g salt (about a teaspoon) per day for an adult

 

Much of this evidence is described as LOW quality. Why?

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Many of the RCTs included in the reviews in this section are small and quite old (pre-2000), when the conduct and reporting standards for research were less rigorous, so there is a risk of bias in many of these results.

This means that the estimates of benefit are uncertain.

However, there is much observational evidence showing associations between healthy lifestyle factors and lower blood pressure which supports the findings from the RCTs.

 

References

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1)Lee LL, Mulvaney CA, Wong YK et al. Walking for hypertension. Cochrane Database of Systematic Reviews 2021, Issue 2. Art. No.: CD008823. DOI: 10.1002/14651858.CD008823.pub2

2)Halbert J, Silagy C, Finucane P et al. The effectiveness of exercise training in lowering blood pressure: a meta-analysis of randomised controlled trials of 4 weeks or longer. J Hum Hypertens 1997; 11, 641–649

3)Semlitsch T, Krenn C, Jeitler K et al. Long‐term effects of weight‐reducing diets in people with hypertension. Cochrane Database of Systematic Reviews 2021, Issue 2. Art. No.: CD008274

4)Xin X, He J, Frontini MG et al. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2001; 38(5): 1112-1117

5)He FJ, Li J, MacGregor GA. Effect of longer‐term modest salt reduction on blood pressure. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD004937. DOI: 10.1002/14651858.CD004937.pub2

Drug treatment of stage 1 hypertension

Stage 1 hypertension means: clinic BP 140-159/90-99mmHg.

NICE recommends considering drug treatment for adults with Stage 1 hypertension and a baseline QRISK score of 10% or more.

The amount of cardiovascular risk reduction for an individual depends on their baseline risk.

Here, “combined cardiovascular events” means:  fatal and non-fatal angina, MI, TIA and stroke.

We have presented information on Stage 1 hypertension separately, as the evidence base is more uncertain than that for Stage 2+3.

Here, we show a lower risk reduction (RRR 12%) from drug treatment for Stage 1 hypertension, in line with the most recent NICE review. However, newer research suggests that the  benefits may in fact be similar to those for treating Stage 2+3 (a RRR of 28%). This is uncertain, see the ‘Uncertainties and controversies’ button below.

No treatment
With treatment
ARR -- Absolute Risk Reduction
NNT -- Number Needed to Treat
RRR -- Relative Risk Reduction
No treatment
5 people have a cardiovascular event over 10 years
With treatment
4.4 people have a cardiovascular event over 10 years
ARR 0.6% Absolute Risk Reduction
NNT 167 Number Needed to Treat
RRR 12% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 5% take treatment for hypertension, 0.6 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
10 people have a cardiovascular event over 10 years
With treatment
8.8 people have a cardiovascular event over 10 years
ARR 1.2% Absolute Risk Reduction
NNT 83 Number Needed to Treat
RRR 12% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 10% take treatment for hypertension, 1.2 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
15 people have a cardiovascular event over 10 years
With treatment
13.2 people have a cardiovascular event over 10 years
ARR 1.8% Absolute Risk Reduction
NNT 56 Number Needed to Treat
RRR 12% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 15% take treatment for hypertension, 1.8 will avoid a cardiovascular event compared with if they hadn't taken treatment.

No treatment
20 people have a cardiovascular event over 10 years
With treatment
17.6 people have a cardiovascular event over 10 years
ARR 2.4% Absolute Risk Reduction
NNT 42 Number Needed to Treat
RRR 12% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 20% take treatment for hypertension, 2.4 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
25 people have a cardiovascular event over 10 years
With treatment
22 people have a cardiovascular event over 10 years
ARR 3% Absolute Risk Reduction
NNT 33 Number Needed to Treat
RRR 12% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 25% take treatment for hypertension, 3 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
30 people have a cardiovascular event over 10 years
With treatment
26.4 people have a cardiovascular event over 10 years
ARR 3.6% Absolute Risk Reduction
NNT 28 Number Needed to Treat
RRR 12% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 30% take treatment for hypertension, 3.6 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
35 people have a cardiovascular event over 10 years
With treatment
30.8 people have a cardiovascular event over 10 years
ARR 4.2% Absolute Risk Reduction
NNT 24 Number Needed to Treat
RRR 12% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 35% take treatment for hypertension, 4.2 will avoid a cardiovascular event compared with if they hadn't taken treatment.

No treatment
40 people have a cardiovascular event over 10 years
With treatment
35.2 people have a cardiovascular event over 10 years
ARR 4.8% Absolute Risk Reduction
NNT 21 Number Needed to Treat
RRR 12% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 40% take treatment for hypertension, 4.8 will avoid a cardiovascular event compared with if they hadn't taken treatment

Information on treatment harms comes from older RCTs and a more recent observational study.

Both have their limitations but are presented here as a guide.

RCTs: Likelihood of withdrawal from treatment due to side effects from BP-lowering treatment over a 5 year period:

Placebo Drug treatment Absolute Risk Increase Number Needed to Harm
3% 14.4% 11.4% 9

The treatments being used were propranolol, bendroflumethiazide and methyldopa.

From: Cochrane review of drug treatment for mild hypertension1

Evidence quality rated as MODERATE because:

  • only 1 trial (from 1985 involving 17,000 patients) reported this outcome2.

Observational study: rates of specific side effects from BP-lowering treatment over a 6-year period (all drug classes combined) in people at low cardiovascular risk.

Evidence quality rates as LOW because of the nature of the study, but its findings are well worth considering as the design is so relevant to general practice.

Outcome Not prescribed treatment Prescribed treatment Absolute Risk Increase* Number Needed to Harm  over 10 years**
Hypotension 0.8% 1.4% 0.6% 41
Syncope 2.5% 3.2% 0.7% 35
Acute kidney injury 0.8% 1.0% 0.2% 91
Electrolyte abnormality 0.3% 0.5% 0.2% 111
Falls    No increased risk found

*Absolute risk increases are after a median follow up of 5.8 years. ** Figures calculated by the researchers.

  • a 2018 UK GP database study3
  • compared patients with mild hypertension and low overall cardiovascular risk not prescribed treatment with a similar cohort who were prescribed treatment

These figures represent events recorded as clinical codes in GP or hospital records.

Click below for more details on the trial.

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This study showed small absolute rates of harms (because this was a young and relatively healthy population), but a significant relative increase compared to no treatment.

How reliable are these findings?

As with all observational research, biases and limitations might affect the results:

  • Clinical codes need to be present to detect outcomes. Side effects just recorded in free text or which did not present to a doctor would not have been included, so the study may underestimate true side effect rates.
  • Around 1/3 of the patients in the “no treatment” group ended up taking anti-hypertensives over the course of the study. This would lead to underestimating the difference in side effect rates between the two groups.
  • Patients in the “treatment” group are more likely to attend their GP surgery and report side effects, which would overestimate the difference in side effect rates between the groups.

 

Data detail

  • data from UK GP records from 1998 to 1025

  • included two groups, about 19,000 patients each

  • one group had been prescribed BP-lowering treatment within the first year of diagnosis, the other had not

  • followed up for an average of 5.8 years (up to 15 years)

Study participant characteristics:

  • Stage 1 hypertension (defined by 3 x BP readings in range), mean BP 145/86mmHg

  • mean QRISK score 8%

  • without established CVD, AF, diabetes, CKD

  • mean age 55, roughly 1/2 women, mix of demographic characteristics

 

References

1)Diao D, Wright JM, Cundiff DK, Gueyffier F. Pharmacotherapy for mild hypertension. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD006742. DOI: 10.1002/14651858.CD006742.pub2

2)

3)Sheppard JP, Stevens S, Stevens R et al. Benefits and Harms of Antihypertensive Treatment in Low-Risk Patients With Mild Hypertension. JAMA Intern Med 2018; 178(12): 1626-1634

Drug treatment of stage 2-3 hypertension

Stage 2-3 hypertension means: clinic BP 160/100 or higher.

NICE recommends offering drug treatment to adults with these levels of hypertension regardless of their baseline QRISK.

The extent to which drug treatment reduces an individual’s cardiovascular risk still depends on their baseline risk.

Here, “combined cardiovascular events” means: fatal and non-fatal MI and stroke (but not including angina or TIA), plus hospitalisation or death from heart failure.

No treatment
With treatment
ARR -- Absolute Risk Reduction
NNT -- Number Needed to Treat
RRR -- Relative Risk Reduction
No treatment
5 people have a cardiovascular event over 10 years
With treatment
3.6 people have a cardiovascular event over 10 years
ARR 1.4% Absolute Risk Reduction
NNT 71 Number Needed to Treat
RRR 28% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 5% take treatment for hypertension, 1.4 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
10 people have a cardiovascular event over 10 years
With treatment
7.2 people have a cardiovascular event over 10 years
ARR 2.8% Absolute Risk Reduction
NNT 36 Number Needed to Treat
RRR 28% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 10% take treatment for hypertension, 2.8 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
15 people have a cardiovascular event over 10 years
With treatment
10.8 people have a cardiovascular event over 10 years
ARR 4.2 Absolute Risk Reduction
NNT 24 Number Needed to Treat
RRR 28% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 15% take treatment for hypertension, 4.2 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
20 people have a cardiovascular event over 10 years
With treatment
14.4 people have a cardiovascular event over 10 years
ARR 5.6% Absolute Risk Reduction
NNT 18 Number Needed to Treat
RRR 28% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 20% take treatment for hypertension, 5.6 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
25 people have a cardiovascular event over 10 years
With treatment
18 people have a cardiovascular event over 10 years
ARR 7% Absolute Risk Reduction
NNT 14 Number Needed to Treat
RRR 28% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 25% take treatment for hypertension, 7 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
30 people have a cardiovascular event over 10 years
With treatment
21.6 people have a cardiovascular event over 10 years
ARR 8.4% Absolute Risk Reduction
NNT 12 Number Needed to Treat
RRR 28% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 30% take treatment for hypertension, 8.4 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
35 people have a cardiovascular event over 10 years
With treatment
25.2 people have a cardiovascular event over 10 years
ARR 9.8% Absolute Risk Reduction
NNT 10 Number Needed to Treat
RRR 28% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 35% take treatment for hypertension, 9.8 will avoid a cardiovascular event compared with if they hadn't taken treatment

No treatment
40 people have a cardiovascular event over 10 years
With treatment
38.8 people have a cardiovascular event over 10 years
ARR 11.2% Absolute Risk Reduction
NNT 9 Number Needed to Treat
RRR 28% Relative Risk Reduction

If 100 people with a baseline 10-year risk of cardiovascular disease of 40% take treatment for hypertension, 11.2 will avoid a cardiovascular event compared with if they hadn't taken treatment

There is uncertainty about the rates of side effects from BP treatments.

RCTs vary in how they report harms, and tend to involve people who are at lower risk of harms to start with. These numbers should be viewed as a guide only.

Likelihood of withdrawal from treatment due to side effects from BP-lowering treatment over a 5 year period:

Placebo Drug treatment Absolute Risk Increase Number Needed to Harm
5.4% 15.7% 10.3% 10

From: Cochrane review (2109) of BP treatment in adults over 60 across all ranges of BP severity1

Evidence quality rated as LOW because

  • only 4 trials out of 16 reported on treatment withdrawal
  • wide variation between trials in side effect rates

Rates of specific side effects from BP-lowering treatment over a 3 year period:

Outcome Placebo or less intense treatment Treatment or more intense treatment Absolute Risk Increase Number Needed to Harm
All drug classes combined
Hypotension 3.3% 6.1% 2.7% 36
Syncope 1.1% 1.3% 0.2% 500
Acute kidney injury 1.5% 2.1% 0.6% 171
Falls    No increased risk found
ACE inhibitors and angiotensin receptor blockers (ARBs)
Hyperkalaemia 3.0% 4.8% 1.8% 54
Acute kidney injury 1.1% 1.5% 0.4% 250
Thiazide diuretics
Hypokalaemia 0.8% 8.2% 7.4% 13
Gout* 0.2% 2.0% 1.7% 58

* The estimates for gout risks with thiazide diuretics were not quite statistically significant though probably represent a true effect

From: a systematic review of trials of drug treatment vs placebo AND intense treatment v less intense treatment across all ranges of BP severity2.

Evidence quality rated as VERY LOW because:

  • concerns of reporting or publication bias for these outcomes
  • wide variation between trials in side effect rates
  • most trials involved patients with significant comorbidities

 

References

1)Musini VM, Tejani AM, Bassett K et al. Pharmacotherapy for hypertension in adults 60 years or older. Cochrane Database of Systematic Reviews 2019, Issue 6. Art. No.: CD000028

2)Albasri A, Hattle M, Koshiaris C et al. Association between antihypertensive treatment and adverse events: systematic review and meta-analysis