Management of Hypertension

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Donald Singleton
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1 Clinical Practice Guidelines Management of Hypertension Definition and classification of blood pressure levels (mmhg) Category Systolic Diastolic Normal <0 <80 Pre-hypertension Grade hypertension (mild) Grade hypertension (moderate) Grade 3 hypertension (severe) 80 0 Isolated systolic hypertension 40 <90 When the systolic and diastolic BP fall into different categories, the higher category should apply. For example, a BP of 6/9 mmhg should be Grade hypertension. Objectives of clinical assessment to confirm the presence of chronic elevation of BP and determine the BP level to exclude or identify secondary causes of hypertension to determine the presence of target organ damage and quantify its extent to search for other cardiovascular risk factors and clinical conditions that may influence the prognosis and treatment Clinical blood pressure measurement Use the following procedures when recording BP: Allow the patient to sit or lie down for severalminutes before measuring the BP. The patient should refrain from smoking or ingesting caffeine during the 30 minutes preceding the measurement Use a cuff with a bladder that is -3 cm x 35 cm in size, with a larger bladder for fat arms. The bladder within the cuff should encircle at least 80% of the arm. Place the cuff at heart level, whatever the position of the patient. Use the disappearance of Phase V Korotkoff sounds to measure the diastolic BP Measure the BP in both arms at the first visit and take or more readings separated by minute. Average these values. If the first readings differ by more than 5 mmhg, additional readings should be obtained and averaged Measure the BP in both the standing and supine position for elderly subjects and diabetic patients In pregnant women, supine blood pressure should be measured in the left lateral position.

2 Recommendations for follow-up based on initial blood pressure Initial blood pressure Normal Pre-hypertension Grade Grade Grade 3 Follow up recommended Re-check in years* Re-check in year# Confirm within months Evaluate within one month Evaluate and treat immediately or within one week depending on clinical situation and complications * If systolic and diastolic categories are different, follow recommendations for shorter time follow-up (e.g., 60/86 mmhg should be evaluated or referred to source of care within month). # Modify the scheduling of follow-up according to reliable information about past BP measurements, other cardiovascular risk factors, or target organ disease. Determine the presence of target organ damage and quantify its extent and search for factors influencing prognosis Risk Factors For Cardiovascular Diseases Target gan Damage (TOD) Associated Clinical Conditions( ACC) Levels of systolic and diastolic blood pressure (Grades -3) Men >55 years Women >65 years Smoking Total cholesterol >6. mmol/l (40 mg/dl) LDL cholesterol > 4.0 mmol/l (60 mg/dl) HDL cholesterol M <.0, F <. mmol/l (<40, <45 mg/dl) Obesity, inactivity History of cardiovascular disease in first-degree relatives < 50 years Left ventricular hypertrophy (electrocardiogram, echocardiogram) Microalbuminuria (0-30 mg / day) Ultrasound or radiological evidence of atherosclerotic plaque (aorta, carotid, coronary, iliac, and femoral arteries) Hypertensive retinopathy grade III or IV Cerebrovascular disease Ischaemic stroke, haemorrhage, TIA Heart disease MI, angina, coronary revascularization, CHF Renal disease Plasma creatinine F>.4, M>.5 mg/dl Albuminuria >300 mg/day Peripheral vascular disease

3 Risk stratification to quantify prognosis and treatment plan according to the risk BLOOD PRESSURE (mmhg) Other Risk Factors & Disease History Level I. no other risk factors II. - risk factors Grade SBP or DBP LOW RISK 3-6 months MED RISK -3 months III. 3 or more risk factors or TOD or diabetes or ACC Grade SBP or DBP Grade 3 SBP 80 or DBP 0 MED RISK -3 months MED RISK -3 months Risk strata (typical 0 year risk of stroke or myocardial infarction): Low Risk = less than 5%; Medium Risk = about 5-0% risk ; High Risk = over 0% TOD Target gan Damage ACC Associated Clinical Conditions, including clinical cardiovascular disease or renal disease Treatment goals Low and Medium risk < 40/90 mmhg. High risk <30/80 mmhg Principles of drug treatment Use appropriate drug combinations to achieve target BP levels if this cannot be achieved by one single antihypertensive agent. Use of appropriate drug combinations enables BP lowering efficacy to be maximized while minimizing side effects. In most patients, appropriate combination therapy produces BP reductions that are twice as great as those obtained with monotherapy (e.g. reductions in BP increasing from to mmhg systolic BP and from 7 to 4 mmhg diastolic BP in patients with an initial BP of 60/00 mmhg). In patients whose pretreatment BP is moderately elevated (e.g. BP 60/00 mmhg) or especially if it is severely elevated (e.g. BP 80/0 mmhg), it may be appropriate to begin with combination therapy, because many such patients will require or even 3 drugs for adequate BP control. Use long-acting drugs providing 4-hour efficacy on a once daily basis.

4 Choice of antihypertensive drugs Thiazide type diuretics are the preferred initial therapy in patients with uncomplicated hypertension if there are no compelling indications for a particular class of antihypertensive agents. Consider any compelling indications and contraindications for an antihypertensive agent when prescribing its use. Contraindications Class Conditions favouring the use Compelling Possible Diuretics (thiazides) Congestive heart failure; Gout Pregnancy elderly hypertensives; isolated systolic hypertension; hypertensives of African origin Diuretics (loop) Renal insufficiency; congestive heart failure Diuretics (anti-aldosterone) Congestive heart failure; post-myocardial infarction Renal failure; hyperkalaemia β-blockers Angina pectoris; Asthma; Peripheral vascular disease; post-myocardial infarction; congestive heart failure (up-titration); pregnancy; tachyarrhythmias chronic obstructive pulmonary disease; A-V block (grade or 3) glucose intolerance; athletes and physically active patients Calcium antagonists (dihydropyridines) Calcium antagonists (verapamil, diltiazem) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor antagonists (AT -blockers) α-blockers Elderly patients; isolated systolic hypertension; angina pectoris; peripheral vascular disease; carotid atherosclerosis; pregnancy Angina pectoris; carotid atherosclerosis; supraventricular tachycardia Congestive heart failure; LV dysfunction; post-myocardial infarction; non-diabetic nephropathy; type diabetic nephropathy; proteinuria Type diabetic nephropathy; diabetic microalbuminuria; proteinuria; left ventricular hypertrophy; ACE-inhibitor cough Prostatic hyperplasia (BPH); hyperlipidaemia A-V block (grade or 3); congestive heart failure Pregnancy; hyperkalaemia; bilateral renal artery stenosis Pregnancy; hyperkalaemia; bilateral renal artery stenosis thostatic hypotension Tachyarrhythmias congestive heart failure Congestive heart failure Use appropriate drug combinations to achieve target BP levels if this cannot be achieved by one single antihypertensive agent Effective drug combinations to treat hypertension are: Diuretic and angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker Diuretic and calcium channel blocker (non dihydropridines) Calcium channel blocker (dihydropyridines only) and beta-blocker Calcium channel blocker and ACE inhibitor or angiotensin II receptor blocker

5 Class Drug Usual dose range In mg/day Thiazide diuretics Loop diuretics Potassium-sparing diuretics Aldosterone receptor blockers Beta-blockers Combined alpha- and Beta-blockers ACE inhibitors Angiotensin II antagonists Calcium Channel Blockers nondihydropyridines chlorothiazide hydrochlorothiazide indapamide metolazone bumetanide frusemide amiloride triamterene spironolactone 5 50 atenolol bisoprolol metoprolol metoprolol extended propranolol carvedilol labetalol captopril enalapril fosinopril lisinopril perindopril ramipril trandolapril candesartan irbesartan losartan valsartan diltiazem extended diltiazem immediate verapamil immediate Usual daily frequency Calcium Channel Blockers dihydropyridines amlodipine felodipinen ifedipine long-acting Alpha- blockers doxazosin prazosin terazosin Central alpha- agonists and other centrally acting drugs clonidine methyldopa reserpine , Direct vasodilators hydralazine minoxidil Process Indicators and Recommended Frequency Performance Parameter Risk level* -Low and medium risk -High risk Weight Fasting blood glucose Fasting lipid profile Serum electrolyte, urea and Creatinine Urinalysis Patient education* -Low and medium risk -High risk **Recommended review frequency after stabilization of blood pressure 6 monthly 3 monthly Annually or more frequently according to individual risk factor profile At diagnosis and regular intervals according to risk level 6 monthly 3 monthly

6 Initiation of antihypertensive therapy and follow-up Confirm SBP >40mmHg or DBP >90mmHg on occasions Assess Risk factors Target organ damage (TOD) Associated clinical conditions (ACC) Initiate modification Stratify Absolute risk High risk Begin Drug Treatment immediately Medium Risk Monitor BP weekly & other risk factors for -3 months Low Risk Monitor BP monthly & other risk factors for 3-6 months SBP 40 DBP 90 Begin Drug Treatment SBP<40 DBP<90 Continue To Monitor SBP 40 DBP 90 Begin Drug Treatment SBP<40 DBP<90 Continue To Moniter Indications for specialist referral Urgent treatment needed Accelerated hypertension (severe hypertension with grade III IV retinopathy) Particularly severe hypertension (>0/0mmHg) Impending complications (eg transient ischaemic attack, left ventricular failure) Possible underlying cause Any clue in history or examination of a secondary cause, for example, hypokalaemia with increased or high normal plasma sodium (Conn s syndrome) Elevated serum creatinine Proteinuria or haematuria Sudden-onset or worsening of hypertension Resistance to multi-drug regimen, that is, >3 drugs Therapeutic problems Multiple drug intolerance Multiple drug contraindications Persistent nonadherence or noncompliance Special situations Unusual blood pressure variability Possible white-coat hypertension Hypertension in pregnancy

2003 World Health Organization (WHO) / International Society of Hypertension (ISH) Statement on Management of Hypertension.

2003 World Health Organization (WHO) / International Society of Hypertension (ISH) Statement on Management of Hypertension Writing Group: Background Hypertension worldwide causes 7.1 million premature