Guideline for the diagnosis and management of hypertension in adults Purpose statement This guideline aims to arm health professionals working across the Australian healthcare system, in particular those working within primary care and community services, with the latest for controlling blood pressure, including methods for diagnosis and monitoring, and effective treatment strategies for patients with hypertension with and without co-morbidities. 1
Guideline Developers National Blood Pressure and Vascular Disease Advisory Committee Professor Craig Anderson (MBBS, PhD, FRACP, FAFPHM, FAMHS) Professor Len Arnolda (PhD, MBBS, FRACP, FCSANZ), Chair Ms Diane Cowley (BN, GDip Midwifery(NZ), MPH, MHA&S, MNP) Dr John Dowden (FRCP (Edin), FRACGP, MRCGP, MCGP) Dr Genevieve Gabb (MBBS (Hons), FRACP, Grad Dip ClinEpi) Professor Jonathan Golledge (MB BChir, BA, MA, MChir, FRCS, FRACS, NHMRC Fellow) Professor Graeme Hankey (MBBS, MD, FRCP (Lond), FRCP (Edin), FRACP) Dr Faline Howes (BMedSci, MBBS (Hons), MPH, FRACGP) Mr Les Leckie (Community/Consumer Representative) Professor Arduino Mangoni (PhD, FRCP (Lond, Glas, Edin), FRACP) Professor Vlado Perkovic (MBBS, PhD, FRACP, FASN) Professor Markus Schlaich (MD. FAHA. NHMRC Senior Research Fellow) Professor Nicholas Zwar (MBBS, MPH, PhD, FRACGP) National Heart Foundation of Australia Dr Tanya Medley (BAppSci (Hons), PhD) Ms Jinty Wilson (MBA) Method - Larger synthesis of, independently assessed for bias - Grading of recommendations to international standards - Publishing on electronic platform 2
Timing to release of guideline Public consultation closed 28 th August Review of public consultation Editing by 2 nd October nternal approval processes by 27 th November Final editing Launch guidelines early December Significant updates - Hypertension and absolute cardiovascular disease risk - Growing for out of clinic blood pressure measurement - Oral dosages and adverse effects of antihypertensive drugs - Blood pressure variability - Obstructive sleep apnoea - Peripheral arterial disease - Treatment resistant hypertension - Patients Perspectives - New blood pressure targets 3
Hypertension and absolute cardiovascular disease risk Suspected hypertension For those eligible conduct Absolute Cardiovascular Disease Risk Assessment www.cvdcheck.org.au High risk >15% Moderate risk 10-15% Low risk <10% Lifestyle Advice a. mmediate drug treatment b. Manage associated conditions Review according to clinical context Patients with uncomplicated grade 1 hypertension new direct that lowering BP reduces stroke, CVD events and all cause mortality (Sundstrom et al 2014). Any of the following? a. BP persistently 160/100mmHg b. Family history of premature CVD c. Aboriginal or Torres Strait slander YES Start drug treatment SBP 140-159mmHg or DBP 90-99mmHg Consider starting drug treatment NO Review BP in 6 months s BP persistently 160/100mmHg? YES Start drug treatment SBP 130-139mmHg or DBP 85-90mmHg NO Review BP 140-159mmHg after 2 months of lifestyle advice Diagnosing Hypertension BP varies throughout the day, between days and between clinic visits. The more variation accounted for the more accurate the prediction of blood pressure Large body of recent showing that BP measures from home or over a 24 hour period (ambulatory) are better predictors of cardiovascular events. Clinic blood pressure measures are recommended for use in absolute cardiovascular risk calculators. Benefit over harms - f clinic blood pressure is 140/90mmHg, or hypertension is suspected ambulatory and/or home monitoring should be offered to confirm the blood pressure level. systematic reviews 4
Drug choice Large number of recent trials and systematic reviews further substantiate that the beneficial effects of antihypertensive drugs are due to blood pressure lowering per se and are largely independent of drug class and mechanism across a range of comorbid conditions. This guideline recommends that thiazide-like diuretics, calcium channel blockers, ACE inhibitors and ARBs are suitable first line drugs for the treatment of uncomplicated hypertension, either as monotherapy or in some combinations, noting any possible contra-indications or co-morbidities. Blood Pressure Treatment Targets 5
Hypertension and Stroke For patients with a history of transient ischaemic attacks or stroke, and grade 1 hypertension (>140-159/90-99mmHg) antihypertensive therapy is recommended to reduce overall cardiovascular risk. For patients with a history of transient ischaemic attacks or stroke any of the first line antihypertensive drugs that effectively reduce blood pressure are recommended. Benefit over harm Hypertension and Diabetes Benefit over harm Antihypertensive therapy is strongly recommended in patients with diabetes and systolic blood pressure 140mmHg. n patients with diabetes and hypertension any of the first line antihypertensive drugs that effectively lower blood pressure are recommended. Hypertension and Chronic Kidney Disease n patients with hypertension and chronic kidney disease any of the first line antihypertensive drugs that effectively reduce blood pressure are recommended. Benefit over harm When treating hypertension in patients with chronic kidney disease in the presence of micro or macro albuminuria* an ARB or ACE inhibitor should be considered as first line therapy. Dual renin-angiotensin system blockade is not recommended in patients with chronic kidney disease. n patients with chronic kidney disease, aldosterone antagonists should be used with caution in view of the uncertain balance of risks versus benefits. Weak - 6
Conclusion Rigorous method Recommendations reflect the evolving nature of Online publication Draft continuing to edit and resolve some issues 2010 National Heart Foundation of Australia Name of presentation in footer Slide 13 7