CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF HYPERTENSION

                                                                                   

           

                                                                                          

High blood pressure is a leading cause of death around the world, and its prevalence continues to rise. It affects more than 1 billion people worldwide and is a major risk factor for stroke, heart failure, and kidney diseases.

• About one third of adults in most communities in the developed and developing world have hypertension. Hypertension is the most common chronic condition dealt with by primary care physicians and other health practitioners.

• The success of treating hypertension has been limited, and despite well-established approaches to diagnosis and treatment, in many communities fewer than half of all hypertensive patients have adequately controlled blood pressure.   

HYPERTENSION IN THE BLACK PATIENT

• Hypertension is a particularly common finding in black people.
• Hypertension occurs at a younger age and is often more severe in terms of blood pressure levels in black patients than in whites.  
• A higher proportion of black people are sensitive to the blood pressure–raising effects of salt in the diet than white patients, and this—together with obesity, especially among women—may be part of the explanation for why young black people tend to have earlier and more severe hypertension than other groups.
• Black patients with hypertension 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 patients to have differing blood pressure responses to the available antihypertensive drug classes: they usually respond well to treatment with calcium channel blockers and diuretics but have smaller blood pressure reductions with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and b-blockers. However, appropriate combination therapies provide powerful antihypertensive responses that are similar in black and white patients.

EVALUATING THE HYPERTENSIVE PATIENT                           

Before starting treatment for hypertension, it is useful to evaluate the patient more thoroughly. The three methods are personal history, physical examination, and selective testing. In other words it is individualized.

Physical examination 

At the first visit it is important to perform a complete physical examination because often getting care for

hypertension is the only contact that patients have with a medical practitioner.  Measuring blood pressure. Document the patient’s weight and height and calculate body mass index.

Signs of heart failure: This diagnosis strongly influences the choice of hypertension therapy. Left ventricular hypertrophy can be suspected by chest palpation, and heart failure can be indicated by distended jugular veins, an enlarged liver, and peripheral edema.

Waist circumference: Independent of weight, this helps determine whether a patient has the metabolic syndrome or is at risk for type 2 diabetes. Risk is high when the measurement is >102 cm in men or >88 cm in women.  

Neurologic examination: This may reveal signs of previous stroke and affect treatment selection.

Eyes: The optic fundi should be checked for hypertensive or diabetic changes and the areas around the eyes for findings such as xanthomas.

Pulse: It is important to check peripheral pulse rates; if they are diminished or absent, this can indicate

peripheral artery disease.

Several other tests can be carried out which are not discussed here.

GOALS OF HYPERTENSION TREATMENT

1. The goal of treatment is to manage hypertension and to deal with any other identified risk factors for cardiovascular disease, including glucose intolerance or diabetes, obesity, lipid disorders and smoking.
2. The treatment goal for systolic blood pressure is usually <140 mm Hg and for diastolic blood pressure <90 mm Hg. In the past, guidelines have recommended treatment values of <130/80 mm Hg for patients with diabetes, chronic kidney disease, and coronary artery disease. Evidence to support this lower target in patients with these conditions has not been substantiated, so the goal of <140/90 mm Hg should generally be used.

NONPHARMACOLOGIC TREATMENT
Several lifestyle interventions have been shown to reduce blood pressure. These strategies are beneficial in preventing and managing most of the other cardiovascular risk factors.

1. Weight loss: In patients who are overweight or obese, weight loss is helpful in treating hypertension, diabetes, and lipid disorders. Substituting fresh fruits and vegetables for more traditional diets are of great benefits.
2. Salt reduction: Reduction of salt intake is recommended because it can reduce blood pressure and decrease the need for medications in patients who are “salt sensitive,” which may be a fairly common finding in black communities.
3. Exercise: Regular aerobic exercise can help reduce blood pressure. Patients should be encouraged to walk, use bicycles, climb stairs, and pursue means of integrating physical activity into their daily routines.
4. Alcohol consumption: Up to 2 drinks a day can be helpful in protecting against cardiovascular events but greater amounts of alcohol can raise blood pressure and should therefore be discouraged. The question is how do you measure this? According to Prof. O. O. Akinkugbe (the doyen of Hypertension in Nigeria) physicians are advised to suggest to patients not to take alcohol at all.
5. Cigarette smoking: Stopping smoking will not reduce blood pressure, but since smoking by itself is such a major cardiovascular risk factor, patients must be strongly urged to discontinue this habit.

DRUG TREATMENT OF HYPERTENSION
 Starting treatment: Treatment with drugs should be started in patients with blood pressures >140/90 mm Hg in whom lifestyle treatments have not been effective. Treatment, drug treatment can be delayed for some months in patients with stage 1 hypertension who do not have evidence of abnormal cardiovascular findings or other risk factors. 
In patients with stage 2 hypertension (blood pressure ≥160/100 mm Hg), drug treatment should be started immediately after diagnosis, usually with a 2-drug combination, without waiting to see the

effects of lifestyle changes.
For patients older than 80 years, the suggested threshold for starting treatment is at levels ≥150/90 mm Hg. Thus, the target of treatment should be <140/90 mm Hg for most patients but <150/90 mm Hg for older patients (unless these patients have chronic kidney disease or diabetes, when <140/90 mm Hg can be considered).

Most patients will require more than one drug to achieve control of their blood pressure especially in the rural area.  In general, increase the dose of drugs or add new drugs at approximately 2- to 3-week intervals. In general, the initial doses of drugs chosen should be at least half of the maximum dose so that only one dose adjustment is required thereafter. It is generally anticipated that most patients
should reach an effective treatment regimen, whether 1, 2, or 3 drugs, within 6 to 8 weeks.
If the untreated blood pressure is at least 20/10 mm Hg above the target blood pressure consider starting treatment immediately with 2
drugs.
The Choice of drugs:
This should be influenced by the age, ethnicity/race, and other clinical characteristics of the

patient. Other factors are conditions (eg, diabetes and coronary
disease) associated with the hypertension or pregnancy.

Long-acting drugs that need to be taken only once daily are preferred to shorter-acting drugs
that require multiple doses. This is because patients are more likely to follow a simple treatment regimen. Same reason applies when more than one drug is prescribed, the use of a combination
product with two appropriate medications in a single tablet can simplify treatment for patients,

although these products can sometimes be more expensive than individual drugs. Once-daily
drugs can be taken at any time during the day, most usually either in the morning or in the
evening before sleep.

DRUG SELECTION IN HYPERTENSIVE PATIENTS WITH OR WITHOUT OTHER MAJOR CONDITIONS

ASH/ISH Hypertension Guidelines

Patient Type	First Drug	Add Second Drug If Needed to Achieve a BP <140/90 mm Hg	If Third Drug is Needed to Achieve a BP of <140/90 mm Hg
A. When hypertension is the only or main condition
Black patients (African ancestry): All ages	CCBa or thiazide diuretic	ARBb or ACE inhibitor (If unavailable can add alternative first drug choice)	Combination of CCB + ACE inhibitor or ARB + thiazide diuretic
White and other non-black Patients: Younger than 60	ARBb or ACE inhibitor	CCBa or thiazide diuretic	Combination of CCB + ACE inhibitor or ARB + thiazide diuretic
White and other non-black patients: 60 y and older	CCBa or thiazide diuretic (Although ACE inhibitors or ARBs are also usually effective)	ARBb or ACE inhibitor (or CCB or thiazide if ACE inhibitor or ARB used first)	Combination of CCB + ACE inhibitor or ARB + thiazide diuretic
B. When hypertension is associated with other conditions
Hypertension and diabetes	ARB or ACE inhibitor Note: in black patients, it is acceptable to start with a CCB or thiazide	CCB or thiazide diuretic Note: in black patients, if starting with a CCB or thiazide, add an ARB or ACE inhibitor	The alternative second drug (thiazide or CCB)
Hypertension and chronic kidney disease	ARB or ACE inhibitor Note: in black patients, good evidence for renal protective effects of ACE inhibitors	CCB or thiazide diureticc	The alternative second drug (thiazide or CCB)
Hypertension and clinical coronary artery diseased	b-Blocker plus ARB or ACE inhibitor	CCB or thiazide diuretic	The alternative second step drug (thiazide or CCB)
Hypertension and stroke historye	ACE inhibitor or ARB	Thiazide diuretic or CCB	The alternative second drug (CCB or thiazide)
Hypertension and heart failure	Patients with symptomatic heart failure should usually receive an ARB or ACE inhibitor + b-blocker + diuretic + spironolactone regardless of blood pressure. A dihydropyridine CCB can be added if needed for BP control
Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel blocker; eGFR, estimated glomerular filtration rate. a CCBs are generally preferred, but thiazides may cost less. b ARBs can be considered because ACE inhibitors can cause cough and angioedema, although ACE inhibitors may cost less. c If eGFR <40 mL/min, a loop diuretic (eg, furosemide or torsemide) may be needed. d Note: If history of myocardial infarction, a b-blocker and ARB/or ACE inhibitor are indicated regardless of blood pressure. e Note: If using a diuretic, there is good evidence for indapamide (if available).