Primary prevention
Your Organizational Guidance
ebpracticenet urges you to prioritize the following organizational guidance:
Cardiovasculaire risicobepaling in de eerste lijnPublished by: Domus MedicaLast published: 2020Évaluation du risque cardiovasculaire en première lignePublished by: Domus MedicaLast published: 2010The lifetime risk for development of hypertension is high. Efforts should be made to minimize risk factors. The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline recommends lifestyle modifications for patients with elevated blood pressure (BP), which is defined as 120 to 129/<80 mmHg, and for people with white coat hypertension.[2] Recommended lifestyle modifications include dietary changes, smoking cessation, increased physical activity, and reduced alcohol intake.[55][56]
Population-based approaches to prevent hypertension have been proposed: the American Public Health Association (APHA) has advocated for reduced sodium in the food supply, particularly in processed foods.[57] Although sodium reduction has a modest effect on BP lowering, the population effect on the huge number of at-risk people would potentially have significant consequences for cardiovascular morbidity and mortality.[58] Use of salt substitutes has demonstrated BP-mediated protective effects for major cardiovascular events and mortality.[59][60]
The US Preventive Services Task Force (USPSTF) recommends that adults at increased risk of cardiovascular disease are offered behavioral counseling interventions to promote a healthy diet and physical activity; those not at high risk may also be considered for behavioral counseling interventions.[61][62]
The table that follows summarizes recommendations for the primary prevention of hypertension taken from the American College of Cardiology/American Heart Association 2017 Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults.[2]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Adult with elevated blood pressure (BP), or with white coat hypertension
Elevated blood pressure; defined as a BP of 120-129/<80 mmHg: white coat hypertension; defined as BP ≥130/80 mmHg but <160/100 mmHg within an office setting but BP <130/80 mmHg on daytime ambulatory BP monitoring or home BP monitoring.
All
Intervention
Heart healthy dietary pattern; structured exercise program
Lifestyle modification is recommended for people with elevated blood pressure and white coat hypertension.
Heart healthy dietary pattern:
A heart healthy diet, such as the Dietary Approaches to Stop Hypertension (DASH) diet is recommended.
Advise people to consume a diet rich in:
Fruits
Vegetables
Whole grains
Low-fat dietary products
Advise people to minimize consumption of saturated and total fat.
Other diets which have been shown to lower BP include:
diets that are low in calories from carbohydrates;
high-protein diets; and
the Mediterranean dietary pattern (which incorporates the basics of healthy eating but emphasizes consumption of legumes and monounsaturated fat, avoidance of red meats, and moderate intake of wine).
Counseling by a nutritionist may be beneficial.
Structured exercise program:
Exercise programs which include elements of the following have been demonstrated to have the greatest effects on reducing BP:
Dynamic aerobic exercise
Dynamic resistance training
Static isometric exercise
Goal
BP reduction and prevention of progression to hypertension
Heart healthy dietary pattern:
Expect an approximate average BP decrease of 3 mmHg in those with normotension (with greater decreases expected with increasing BP levels).
Structured exercise program:
Specific exercise goals are as follows:
Aerobic exercise: aim for 90-150 minutes/week, 65%-75% heart rate reserve.
Dynamic resistance: aim for 90-150 minutes/week.
Isometric resistance: aim for 4 × 2 minutes (hand grip), 1 minutes rest between exercises, 30%-40% maximum voluntary contraction, 3 sessions/week for 8-10 weeks.
Expect an approximate average decrease of 2-4 mmHg in those with normotension, depending on the type of exercise used (with greater decreases expected with increasing BP levels).
Note: ambulatory BP monitoring or home BP monitoring is recommended on an annual basis in order to detect masked hypertension or progression to overt hypertension.
With overweight (BMI=25-29.9 kg/m²) or obesity (BMI ≥30 kg/m²)
Intervention
Behavioral intervention to support weight loss; consider pharmacologic or surgical intervention
Weight loss is a core recommendation and is recommended through a combination of:
Reduced calorie intake
Increased physical activity
For some people, it may be challenging to achieve and maintain weight loss goals through behavior change alone.
Pharmacotherapy or minimally invasive and bariatric surgical procedures may be considered for some individuals (with the latter typically reserved for people whose obesity is severe and intractable).
See Obesity in adults.
Goal
Weight loss and prevention of progression to hypertension
The best goal is ideal body weight, but aim for at least a 1 kg reduction in body weight for most adults who are overweight.
Expect a BP reduction of approximately 1 mmHg for every 1 kg reduction in body weight; the BP lowering effect in those with elevated BP is consistent with the BP lowering effect in those with established hypertension.
With excessive sodium consumption (≥1500 mg/day)
Intervention
Behavioral intervention to support sodium reduction
Consider recommending the following strategies:
Preferentially choosing fresh foods
Use of food labels to choose foods that are lower in sodium
Choice of foods with a ‘no added sodium’ label
Judicious use of condiments and sodium-infused foods, with substitution of spices and low sodium flavorings
Careful ordering when eating out
Control of food portion size
Minimizing use of salt at the table or while cooking
For some people, it may be challenging to maintain the lifestyle changes necessary to reduce sodium intake; however, even a small reduction in sodium consumption is likely to be safe and beneficial, especially for people whose BP is salt sensitive.
Dietary counseling by a nutritionist with expertise in behavior modification can be helpful.
Goal
Sodium reduction and prevention of progression to hypertension
The optimal goal is <1500 mg/day, but aim for at least a 1000 mg/day reduction in most adults.
Expect a BP reduction of approximately 3 mmHg in those with normotension (with greater decreases expected with increasing BP levels, and when combined with weight loss).
With suboptimal dietary potassium intake (<3500 mg/day)
Intervention
Behavioral intervention to support increased dietary potassium
Encourage the consumption of a diet rich in potassium (unless contraindicated by the presence of chronic kidney disease [CKD] or use of drugs which reduce potassium excretion).
Advise people that sources of dietary potassium include:
Fruits and vegetables
Low-fat dairy products
Selected fish and meats
Nuts
Soy products
Advise people that four to five servings of fruits and four to five servings of vegetables will usually provide 1500-3000 mg of potassium.
Because potassium-rich diets are typically heart-healthy, they are preferred over use of pills for potassium supplementation. Note that the DASH diet (see above) is high in potassium content.
Goal
Dietary potassium increase and prevention of progression to hypertension
Aim for 3500-5000 mg/day, preferably by consumption of a diet rich in potassium.
Expect a BP reduction of approximately 2 mmHg in those with normotension (with greater decreases expected with increasing BP levels, and in those consuming a high sodium diet).
With alcohol consumption
Intervention
Advise a moderate alcohol intake
It is reasonable to recommend that patients who drink alcohol maintain consumption within moderate levels.
It may be appropriate to advise people that there is a strong, predictable direct relationship between alcohol consumption and BP, especially above an intake of 3 standard drinks per day (approximately 36 ounces of regular beer, 15 ounces of wine, or 4.5 ounces of distilled spirits).
Goal
Alcohol intake in keeping with ‘safe drinking’ targets
For people who consume alcohol, advise that consumption is ≤2 standard drinks daily (men) or ≤1 standard drink daily (women).
In the United States, one standard drink contains roughly 14 g of pure alcohol, which is typically found in:
12 ounces of regular beer (usually about 5% alcohol)
5 ounces of wine (usually about 12% alcohol)
1.5 ounces of distilled spirits (usually about 40% alcohol)
Expect a BP reduction of approximately 3 mmHg in those with normotension (with greater decreases expected with increasing BP levels and with greater levels of initial drinking).
Secondary prevention
Aggressive lifestyle modifications (dietary changes, smoking cessation, increased physical activity, reduced alcohol intake) should be initiated in patients with pre-hypertension (blood pressure [BP] 120-139/80-89 mmHg) to delay or prevent the onset of overt hypertension. The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline defines elevated BP as 120 to 129/<80 mmHg and recommends lifestyle modification for these patients, which should be reassessed 3-6 months after initiation.[2] Other cardiovascular risk parameters should be aggressively managed. For example, statins should be used in accordance with guidelines in people with diabetes. Accordingly, patients with pre-hypertension or elevated BP should be evaluated for occult cardiovascular risk by screening for diabetes or dyslipidemia with fasting blood sugar and lipid levels. Global cardiovascular risk should be assessed. [ ASCVD Risk Estimator Plus Opens in new window ]
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