Hypertension Patient Education

High Normal or Elevated BP

• Warn patients with high normal or elevated BP that they are at high risk for developing hypertension
• Inform them that lifestyle modification may reduce this risk
• Advise those with DM and kidney disease that they are candidates for drug therapy if lifestyle modification fails to decrease their BP to goal
• Periodic follow-up (eg every 3-6 months) is recommended to detect and treat hypertension as early as possible

All Patients

• Patients need to be highly motivated to establish and maintain a healthy lifestyle and to take prescribed antihypertensive medications
• If diagnosis of hypertension is not made, measure the patient’s clinic BP at least annually thereafter
  • More frequent BP measurement for patients whose clinic BP is close to 130/80 mmHg
• Encourage measuring BP at home
  • In Asians, strict 24-hour BP control starting with HBPM is important
• Patients should be made aware that lowering BP can decrease death from stroke, coronary events, heart failure, along with decreasing the progression of renal failure
  • All causes of mortality can be reduced with effective antihypertensive management
• Work with the patient to establish the goal of therapy
• The patient’s cultural beliefs may influence their attitude and the physician needs to be sensitive when handling these issues

BP Measurement and Monitoring

• Before taking BP measurements, advise patients to:
  • Avoid exercise, caffeine intake and smoking 30 minutes prior to measurement
  • Remove any clothing that can hinder cuff placement
  • Make sure the logbook is within reach
  • Make sure all devices to be used are working properly (tubes, cuff, batteries, stethoscope)
  • Avoid crossing legs, talking and any sudden movements during the measurement
• Advise patients about different BP measuring devices:
  • Make sure devices to be used are professionally validated annually
  • Devices that measure BP from the brachial artery are preferred than those that read from distal sites (fingers, wrists)
  • Electronic/digital BP devices are preferred to be used
  • Patients and caregivers should be well trained in using an aneroid BP device; advise patients to have their mercurial/aneroid apparatus checked every 1-2 years and every 6 months for electronic devices 
• Inform patients about appropriate cuff sizes (refer to table below)

RECOMMENDED CUFF SIZES
Arm Circumference	Description	Cuff Size
22-26 cm	Small Adult	12x22 cm
27-34 cm	Adult	16x30 cm
35-44 cm	Large Adult	16x36 cm
45-52 cm	Adult Thigh	16x42 cm

• Instruct patients on how to do self-measurement/monitoring of BP. Advise them to:
  • Measure at the same time in the morning and evening
  • Find a quiet room with a comfortable chair
  • Rest for at least 5 minutes before taking BP measurement
  • Sit down with back supported, feet on the floor, arm supported horizontally, and BP cuff at the level of the heart
  • When using a sphygmomanometer, slowly inflate the cuff while palpating the brachial artery. When the pulse disappears (SBP), slowly deflate the cuff, taking note when the pulse reappears (DBP)
  • Now with the use of a stethoscope, reinflate the cuff 20 mmHg above the previous SBP, then deflate the cuff by 1-2 mmHg/second. Inform the patient that when a tapping sound is heard, this is the SBP, and when it disappears, this is the DBP
  • Follow instructions on how to use electronic devices properly. Stay still while the apparatus takes the BP reading
  • Wait for 1-2 minutes, then take another BP measurement
  • Write the results in the logbook immediately after each reading

• Considered the cornerstone of hypertension prevention and treatment
• BP-lowering effects can be equivalent to drug monotherapy; major drawback is diminishing patient compliance over time
• Effects include:
  • Prevention or delay of hypertension among nonhypertensive individuals
  • Prevention of or delay in the use of drug therapy among those in stage 1 or grade 1 hypertension
  • Contribute to BP reduction among hypertensive patients already on drug therapy, allowing for the reduction of the doses and number of antihypertensive agents
• May also contribute to the control of other medical conditions and CV risk factors
• Annual follow-up is recommended to detect and treat hypertension as early as possible

Weight Reduction and Maintenance

• Helpful in treating hypertension, DM and lipid disorders, especially among overweight or obese patients
  • Weight loss of ≥5% in overweight or obese patients is significant 
• Maintenance of a healthy body weight (BMI of about 23 kg/m²) and waist circumference (<90 cm in men; <80 cm in women)
  • SBP is reduced by 1 mmHg with a weight loss of 1 kg from baseline
• Should use a multidisciplinary approach that includes regular exercise and appropriate diet
  • Increase intake of polyunsaturated fatty acids and decrease total and saturated fat
• Weight loss and exercise are recommended in patients also because of the relationship between obesity and obstructive sleep apnea
  • Continuous positive airway pressure (CPAP) therapy may also be used to reduce obstructive sleep apnea

Salt Restriction

• Asians have a higher salt sensitivity, even with higher intake of salt and mild obesity
• There is evidence that a causal relationship between BP and salt intake exists
  • Excessive salt intake may contribute to resistant hypertension
  • Mechanisms include increasing peripheral vascular resistance and extracellular volume
• A daily intake of 5-6 g of salt is recommended for the general population; optimal goal is <1.5 g/day 
  • Studies have shown that a salt reduction to about 5 g/day results in a modest (1-2 mmHg) SBP-lowering effect among normotensive individuals while this effect is more pronounced (4-5 mmHg) among hypertensive individuals
• Effects of salt reduction is seen more among older people, among black population, and in patients with metabolic syndrome, DM or CKD

Other Dietary Changes

• Advise patients to follow the Dietary Approaches to Stop Hypertension (DASH) diet and to consume whole grains and proteins from plant sources, soluble fiber, low-fat daily products
• Replace traditional diet with fresh vegetables and fruits
  • Consumption of fruits among overweight patients should be done with caution due to possible high carbohydrate content of some fruits which may promote weight gain
• Potassium supplementation (3.5-5 g/day) is recommended except in patients with CKD or patients using drugs that decrease excretion of potassium

Regular Exercise

• Regular aerobic and resistance exercises can contribute in both in the prevention and management of hypertension, and in lowering risk of CV morbidity and mortality
• Patients may be advised to engage in at least 30 minutes of moderate-intensity dynamic aerobic exercise (eg walking, cycling, jogging, swimming) for 5-7 days weekly

Moderate Alcohol Consumption

• Discourage excessive alcohol consumption since great amounts can raise BP
• Limit alcohol consumption:
  • Among hypertensive men: To <20-30 g of ethanol/day (<140 g/week or <14 units/week)
  • Among hypertensive women: To <10-20 g of ethanol/day (<80 g/week or <8 units/week)

Smoking Cessation

• Since smoking is a major CV risk factor, patients must be advised to stop this habit
• Also a most effective lifestyle measure for preventing CVDs, including myocardial infarction, stroke and peripheral vascular diseases