The IFHA and ISH hypertension guidelines relevance to the proposed Pan-African roadmap

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1 The IFHA and ISH hypertension guidelines relevance to the proposed Pan-African roadmap Basden ONWUBERE Chair ISH Africa RAG

2 Hypertension is a Public Health Epidemic: In contrast to global trends, the prevalence of hypertension in most countries in Africa is increasing: In 1990, < 20% of the adult African population had hypertension In 2010, more than 30% had hypertension The prevalence rates of hypertension are amongst the world s highest in some African countries One half of BP-related disease occurs in people with increased but still normal BP (i.e. Prehypertension )

3 INTERNATIONAL FORUM FOR HYPERTENSION CONTROL AND PREVENTION IN AFRICA

4 INTERNATIONAL FORUM FOR HYPERTENSION CONTROL AND PREVENTION IN AFRICA In July 2002 the Heads of African States and Governments at a meeting in Libreville considered HBP as a major public health problem in Africa. May , an International Conference on HBP and CVD in Africa was convened in Brussels under the auspices of EU, AU, WHO, WHL, WHF, PASCAR & OTHERS Attended by prominent Scientists, researchers, stakeholders and potential sponsors.

5 INTERNATIONAL FORUM FOR HYPERTENSION CONTROL AND PREVENTION IN AFRICA Aim of Conference (as a follow-up to the Libreville meeting) was to set up specific and priority strategies to help in containing or averting the emerging CVD epidemic in Africa. Major outcome was formation of IFHA

6 AIMS & OBJECTIVES OF IFHA Raise the awareness of the African Governments, opinion leaders and mass media on the hazards of emerging NCDs, mainly HPN and other CVD risk factors related to changes in lifestyle and socio-economic constraints; Develop specific - and when possible- evidence-based recommendations for prevention, detection and cost effective management of Hypertension and other CVD risk factors in the African context; Contribute to capacity building in African countries with regards to NCDs control and prevention;

7 AIMS & OBJECTIVES OF IFHA Identify programme partners and establish a global network through linkage of national, continental and international organizations devoted to HBP control and prevention Promote and enhance research initiatives in the field of Hypertension and other CVD risk factors Encourage and help African countries to establish National Organizations for Hypertension and CVD control and prevention.

8 IFHA: RECORDED ACHIEVEMENTS Successfully organized 6 biennial Pan- African Meetings on HPN in diff parts of Africa Publication of Recommendations for Hypertension and CVD risks management and control in SSA (2003). Initiation and participation in Research projects Has collaborated with ISH, ESH, WHL and WHO in organizing 7 Hypertension Teaching Seminars in Africa.

9 Recommendations for prevention, diagnosis and management of hypertension and cardiovascular risk factors in sub-saharan Africa Daniel Lemogoum, Yackoob Kassim Seedat, Abdul Fattah Biola Mabadeje, Shanti Mendis, Pascal Bovet, Basden Onwubere, Kathleen Ngu Blackett, Claude Lenfant, Jean Rene M buyamba Kabangu, Pierre Block, Mohamed Belhocine and Jean Paul Degaute, on behalf of the International Forum for Hypertension control and prevention in Africa (IFHA) Journal of Hypertension 2003, 21(11):1 8 9

10 HIGHLIGHTS OF 2003 RECOMMENDATIONS Followed the main lines stated in 2003 WHO/ISH Statement on HBP 2002 WHO CVD Risk Management Package in Low- and Medium-Resource settings. JNC 7 Guidelines 2003 ESH/ESC Guidelines Consensus statement of the HPN in African- Americans Working Group of ISHIB Available evidence from SSA at the time.

11 SPECIFIC AREAS ADDRESSED Blood pressure measurement and clinical evaluation Risk factor identification and stratification Management of HBP and CVD risk factors Special Situations Patient education Prevention of hypertension

12 Blood pressure measurement and clinical evaluation Blood pressure detection and confirmation Recommended devices Self-measurement/ambulatory monitoring Thorough clinical evaluation

13 Risk factor identification and stratification

14 WHO CVD-RISK MANAGEMENT PACKAGE FOR LOW-MEDIUM RESOURCE SETTINGS STRATIFY RISK LOW MEDIUM HIGH/VERY HIGH LIFESTYLE MODIFICATION AS APPROPRIATE Monitor BP and Other RF for 6-12 months Monitor BP and Other RF for 3-6 months SBP > 150 Or DBP > 95 SBP < 150 Or DBP < 95 SBP < 140 Or DBP < 90 SBP > 140 Or DBP > 90 Continue to monitor BEGIN DRUG TREATMENT WHO, Geneva 2002

15 Choice of drug: compelling and possible indications Compelling indications Diabetes mellitus (types 1 and 2) with proteinuria Elderly with ISH Angina Post-MI or CAD Left ventricular hypertrophy Congestive heart failure Chronic renal disease Stroke Prostatism Pregnancy Drugs ACEI (ARB) Thiazides Long acting CCB B-blocker or CCB (HR limiting) B-blocker, ACEI (ARB) Thiazide diuretic α ACEI (ARB), CCB ACEI (ARB), β-blocker,αβ-blocker, spironolactone, thiazide diuretic and/or loop diuretic for vol overload ACEI (ARB) with thiazide diuretic, loop diuretic and/or metolazone instead of thiazide diuretic s/creatinine 116 g/l, GFR, 30 ml/min),ndhp CCB Thiazide diuretic, ACEI, CCB α-blocker (Not used as monotherapy for hypertension Methyldopa, labetalol, CCB

16 Special situations Hypertension emergencies and urgencies Refractory hypertension Hypertension in children and adolescents

17 Patient education Explanation of the meaning and implications of HBP Encourage record keeping and need for regular Clinic attendance Emphasize life-style modification Drug information should be made available to patients. Need for strict compliance conveyed.

18 Prevention of hypertension Great need for prevention emphasized Primordial Primary Screening for HBP

19 FOLLOW-UP In Abuja (October, 2013)6 th IFHAorganized Pan-African Hypertension Meeting: Urgent need to review the Guidelines in view of emerging evidence and increasing burden of HBP and CVD in Africa. Review Committee formed under Chair of Prof. YK Seedat and given mandate for a Guideline for HBP and CVD Risk Mgt in Africa.

20 CONCLUSION AND RECOMMENDATIONS 2003 IFHA Recommendations - a bold step at solving an enormous problem and Key-players deserve commendation The increasing burden of CVDs in Africa from available evidence-based data calls for immediate action and realization of a common objective. Need to take holistic approach involving all Stakeholders in line with current global practice.

21 INTERNATIONAL SOCIETY OF HYPERTENSION Established in 1966, the International Society of Hypertension (ISH) is committed to promoting and encouraging the advancement of scientific research and knowledge and its application to the prevention and management of heart disease and stroke in hypertension and related cardiovascular diseases around the world.

22 INTERNATIONAL SOCIETY OF HYPERTENSION ISH has worked with interest groups to improve global control and prevention of HBP. Hypertension educational and awareness programmes are also organized in all the regions of the world.

23 INTERNATIONAL SOCIETY OF HYPERTENSION New ISH Hypertension Guidelines were published in December 2013 together with the American Society of Hypertension (ASH). The guidelines have been written to provide a straightforward approach to managing hypertension in the community, for practitioners in low and middle-income countries as well as developed countries.

24

25 INTERNATIONAL SOCIETY OF HYPERTENSION 1. General Introduction 2. Epidemiology 3. Special Issues With Black Patients (African Ancestry) 4. How is Hypertension Defined? 5. How is Hypertension Classified? 6. Causes of Hypertension 7. Making the Diagnosis of Hypertension 8. Evaluating the Patient 9. Physical Examination 10. Tests 11. Goals of Treating Hypertension 12. Nonpharmacologic Treatment of Hypertension 13. Drug treatment for Hypertension 14. Brief Comments on Drug Classes 15. Treatment-Resistant Hypertension

26 DEFINITION OF HYPERTENSION Most major guidelines recommend that hypertension be diagnosed when a person s SBP is 140mmHg or higher, or their DBP is 90mmHg or higher, or both,on repeated examination. No convincing evidence on benefit of adopting lower levels as cut-off.

27 DEFINITION OF HYPERTENSION These definitions are based on the results of major clinical trials that have shown the benefits of treating people to these levels of BP. Even though, BP of 115/75 is ideal, it found no convincing evidence to justify treating HBP down to such a low level.

28 CLASSIFICATION OF HYPERTENSION People with SBPs between 120 and 139mmHg, or DBP between 80 and 89mmHg, the term prehypertension can be used. Patients with this condition should not be treated with BP medications. They should be encouraged to make lifestyle changes to delay or even prevent progression to HBP. Stage 1 hypertension: patients with SBP mmHg, or DBP 90 99mmHg. Stage 2 hypertension: SBP 160mmHg or higher, or DBP 100mmHg or higher.

29 SPECIAL ISSUES WITH BLACK PATIENTS (AFRICAN ANCESTRY) Hypertension is a particularly common finding in black people. Hypertension occurs at a younger age and is often more severe in terms of BP levels in black than in whites. A higher proportion of black people are sensitive to the BP raising effects of salt in the diet than whites and this together with obesity, esp in females may partly explain the earlier and more severe HBP in this group than others.

30 SPECIAL ISSUES WITH BLACK PATIENTS (AFRICAN ANCESTRY) Black subjects with HBP are particularly vulnerable to strokes and hypertensive kidney disease. They are 3 to 5 times as likely as whites to have renal complications and end-stage kidney disease. There is a tendency for black subjects to have differing BP responses to the available antihypertensive drug classes: usually respond well to treatment with CCBs and diuretics but have smaller BP reductions with ACEIs, ARBs, and β- blockers However, appropriate combination therapies provide powerful antihypertensive responses that are similar in black and white individuals. Most hypertensive subjects will require more than one antihypertensive drug to maintain BP control.

31 ASH/ISH ALGORITHM

32 PASCAR HYPERTENSION ROADMAP PASCAR has identified the fight against hypertension as N 1 priority action to achieve WHO/WHF 25 x 25 goal A Hypertension Task Force of continental experts: plan a 15% control rate of BP in the next 10 years, Three successful meetings held. Final document expected after 4 th meeting 2016

33 Relevance of IFHA and ASH/ISH Guidelines to the proposed Pan-African roadmap The IFHA guideline is prepared for a largely African population It was conceived out of the great need to adapt existing international guidelines to take care of peculiarities of the continent. Available evidence based local data were also used. Pitfalls are that it was produced over a decade ago and does not address entire African population that PASCAR is focussing

34 Relevance of IFHA and ASH/ISH Guidelines to the proposed Pan-African roadmap The ASH/ISH clinical practice guideline contains more recent evidence-based data and contains valuable message for blacks of African ancestory similar in significant ways to large areas of African region. Even though the Guideline recognizes the socio-economic influence on HBP control there is no strong emphasis.

35 CONCLUSIONS Guidelines are important in clinical practice to aid healthcare providers In poor resource settings, cognisance should be taken not only on the socio-economic peculiarities of the population in focus but also on evidence-based data from available local studies. Different population groups and Societies are encouraged to develop evidence-based guidelines based on local peculiarities. This is what PASCAR is doing at the moment.

36 Relevance of IFHA and ASH/ISH Guidelines to the proposed Pan-African roadmap The PASCAR Hypertension Roadmap has lessons to draw from both IFHA and ASH/ISH Guidelines and it is believed they have been taken into consideration.

37 THANKS IMMENSELY

38 EIGHTH ISH HYPERTENSION TEACHING SEMINAR IN AFRICA Organized by the ISH Africa RAG in collaboration with the ESH and IFHA International Hypertension experts as Faculty Open to medical professionals up to 50 years and living in Africa Date: April 18 19, 2016 Maputo, Mozambique Details soon at ISH website:

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