hypertension update which guideline to follow l.
Skip this Video
Download Presentation
Hypertension update Which guideline to follow?

Loading in 2 Seconds...

play fullscreen
1 / 32

Hypertension update Which guideline to follow? - PowerPoint PPT Presentation

  • Uploaded on

Hypertension update Which guideline to follow?. Dr Sunita Dodani Department of Family Medicine Aga Khan University Karachi, Pakistan February 23,2003. Presentation outline. World Wide Epidemic: Some Figures Epidemiological Transition & Hypertension Data From Developing Countries EMRO Work

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Hypertension update Which guideline to follow?' - foy

Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
hypertension update which guideline to follow

Hypertension updateWhich guideline to follow?

Dr Sunita DodaniDepartment of Family MedicineAga Khan UniversityKarachi, PakistanFebruary 23,2003

presentation outline
Presentation outline
  • World Wide Epidemic: Some Figures
  • Epidemiological Transition & Hypertension
  • Data From Developing Countries
  • EMRO Work
  • Statistics From Pakistan: NHSP
  • Hypertension Guidelines
    • Currently available guidelines
    • Similarities in guidelines
    • Differences in guidelines
presentation outline3
Presentation outline
  • Hypertension Guidelines (Cont’d)
    • Still Unanswered Questions
    • What is needed in Pakistan
    • Epidemiologic research
    • Which guideline to follow?
    • JNC VI guideline (1994)
    • Risk stratification
worldwide epidemic some figures
Worldwide Epidemic: Some Figures
  • affect all ages, but primarily occurs in adults.
  • 20% prevalence,approximately 690m people have hypertension world wide
  • major risk factor for stroke, coronary heart disease and kidney failure
  • 30% of deaths worldwide (15 million) are due to cardiovascular diseases
  • 5 million deaths / year worldwide due to strokes alone, with another 30 million suffering from its disabling effects.

(Geneva, Switzerland November 15-16, 1999)

epidemiological transition hypertension
Epidemiological Transition & Hypertension
  • Developing countries experiencing rapid health transition, escalating relative and absolute burdens of CVD
  • Determinants of transition

a)demographic (increased life expectancy)

b)lifestyle changes

c)urbanization, industrialization and globalization

epidemiological transition hypertension cont d
Epidemiological Transition & Hypertension (Cont’d)
  • In developing countries ,steady increase in hypertension prevalence over the last 50 years, more in urban than in rural areas(WHO report 2002)

WHO Regions

eastern mediterranean region emr
Eastern Mediterranean region (EMR)

(Jordan, Iran, Srilanka, Pakistan, Egypt Oman, Saudi Arabia , Bangladesh etc)

  • Paucity of large, authentic, epidemiological studies
  • Limited data available in the form of small studies
  • Majority of studies done have shortcomings

differing examination techniquesdiffering diagnostic criteria

screening blood pressure values used

The studies are not representative of the total population Limited to single centers or single community

EMR (cont'd…)

  • Majority of third world countries lack

sufficient national estimates of the

prevalence of hypertension

  • In developing countries ,steady increase

in hypertension prevalence over the last 50

years, more in urban than in rural areas

emr some prevalence figures
EMR…. Some prevalence figures
  • Saudi Arabia 10-15%

(EMRO bulletin 2001)

Riyadh city 15.4% (27% unaware)

  • Bangladesh (> 70 yrs) 65%

(multi center trail, hypertension study group, 2000)

  • Egypt (national estimates) 26%

> 70 yrs 56.6%

(Ibrahim MM , Cairo university Egypt, 1998)

  • Iran(population based) 18%

(Sarraf-Zadegan N, East Mediterr Health J 1999)

hypertension figures in pakistan
Hypertension figures in Pakistan

National Health Survey of Pakistan


  • Some data available, some in re-analysis phase
  • 10.8 million hypertensives(pop 91m,1991)

5.5 million men

5.3 million women

  • 12 million hypertensives(pop 130m,1998)
  • 17.9% ( 15 yrs)

21.5%………….. Urban

16.2%………….. Rural

hypertension figures in pakistan12
Hypertension figures in Pakistan

NHSP ( 1990-1994)

  • 58%( 65 yrs females)
  • 1 in every 3 Pakistanis (>45 yrs)
  • Prevalence is lower in females than males at younger ages, but exceed after 35-44 yrs of age

(This cross over is at later age in US population)

  • >3% of the hypertensive patients have BP controlled to the conventional recommendations of under 140/ 90 mmHg
hypertension figures in pakistan13
Hypertension figures in Pakistan

Prevalence of hypertension (PMRC)




hypertension figures in pakistan14
Hypertension figures in Pakistan

Prevalence of hypertension (PMRC)




early detection awareness treatment
Early detection,awareness & treatment

(Need for guidelines)

  • help to limit the subjective element in decision making & assist clinicians to provide better care
  • define the best clinical decisions and the minimal level of acceptable care in order to ensure appropriate quality
  • formulated based upon the evidence collected from available literature, and agreement among experts in areas where literature is deficient
hypertension guidelines
Hypertension Guidelines
  • Several guidelines for the management of hypertension were published in the last few years
  • Many were recent revisions and updated versions of old ones, modified according to new evidence from clinical trials
  • Provided answers to many clinical questions.a)Isolated systolic hypertension in the

elderly is dangerous & should be


b)aggressive lowering of blood pressure is

required in patients with risk factors

hypertension guidelines17
Hypertension Guidelines

JNC VI 1994

{Hypertension Detection and Follow-up Program (HDFP)}

WHO/ISH 1999

British hypertension Society 1999

{Medical Research Council (MRC)}

Canadian Cardiac Society 1999


Pakistan hypertension league 1998

(First Report of National Task Force)

hypertension guidelines18
Hypertension Guidelines
  • These four major guidelines are based on the strong evidence from almost the same literature and the large randomized mega trials, they agree and disagree on a number of important issues
hypertension guidelines19
Hypertension Guidelines

These guidelines agree on many aspects

1.All guidelines agree upon the definition of hypertension.

2. The type of routine tests needed for the evaluation of hypertensive patients

3. The need for global risk assessment & the target blood pressure

4. The importance of life style modification

5. Individualization of antihypertensive therapy

6. Need for indefinite follow-up

hypertension guidelines20

JNC VI 1994

WHO/ISH 1999

BHS 1999

1.Drug therapy in mild hypertensives if BP remains  140/90 after non pharmacological treatment

Continuing monitoring without medication for subjects without other risk factors if pressures are not greater than 150/95 mm H

Add drug therapy if BP is greater than 160/90

2.Recommend diuretics or B-blocker as initial drug therapy

all classes of medication are suitable initial therapy, despite the lack of morbidity and mortality data

Diuretics as first line therapy

Hypertension Guidelines

Differences in the guidelines

hypertension guidelines21
Hypertension Guidelines

Still Unanswered Questions

  • how to avoid over treatment of patients at very low risk?
  • what is the best simple approach for accurate cardiovascular risk assessment?

Decisions to initiate therapy are based on the absolute cardiovascular risk profile of the hypertensive patient

? risk assessment are based on the Framingham data

? risk scoring equations are incomplete & complicated

?do not account for racial and genetic differences.

hypertension guidelines22
Hypertension Guidelines

Still Unanswered Questions

  • management of patients with uncomplicated mild hypertension

? duration period of observation

? the number of office visits

? blood pressure measurements

? the average blood pressure threshold during the period of monitoring

  • role of ambulatory blood pressure is not settled
  • how to adjust for racial, genetic, geographic, age gender and socioeconomic differences
hypertension guidelines23
Hypertension Guidelines

Still Unanswered Questions

  • optimal blood pressure reduction

? what is the desired level of blood pressure

? It is not necessarily the same level in all


? Race, age and gender may influence our target

blood pressure.

? We might need more aggressive reduction in

blood pressure in special groups, e.g., diabetics,

blacks and patients with end-organ damage.

hypertension guidelines24
Hypertension Guidelines

Population data:Priorities in Epidemiologic research

  • define the magnitude of the hypertension problem in Pakistan with evidenced based data
  • prevalence among different age groups, geographic areas, socioeconomic classes and the influence of factors like gender, ethnicity
  • Its risk factors e.g. Obesity, excessive salt intake, alcohol intake, psychosocial stress, low levels of education, poor SES, should be recognized & examined
hypertension guidelines25
Hypertension Guidelines

Epidemiologic research

  • the type and prevalence of hypertensive cardiovascular complications. might be influenced by environment, race and other demographic characteristics
  • identify the susceptible groups which are most vulnerable to complications
  • How close are these complications related to the level of blood pressure and what are the other mechanisms involved
  • develop methods to improve detection and control of hypertension
hypertension guidelines26
Hypertension Guidelines

which guideline to follow?

  • Considering several meta analysis
  • outcome data from major clinical trial

strongest outcome data support the JNC VI recommendations

hypertension guidelines27
Hypertension Guidelines

Table 1 – Classification of Blood Pressure*




(mm Hg)

(mm Hg)

Normal Values of Blood Pressure**


less than 120

less than 80


less than 85

less than 130

High normal

130 - 139

85 - 89

Stages of Hypertension**


140 - 159

90 - 99

Stage 1

Stage 2


100 - 109

160 - 179

Stage 3


180 or higher

110 or higher


hypertension guidelines28
Hypertension Guidelines

Risk factors stratification

  • In populations & in individual patients, the benefit from antihypertensive treatment is determined by the absolute cardiovascular risk
  • Blood pressure by itself is a very weak predictor of risk or benefit from treatment
  • simple but accurate risk assessment tools for estimating cardiovascular risk, similar to that in the New Zealand guidelines
hypertension guidelines29
Hypertension Guidelines

Presentation available at




presentation references
Presentation references
  • Ramsay LE. Williams B, Johnston GD, et al. Guidelines for management of hypertension: report from the third working party of the British Hypertension Society. J Hum Hypertens 1000; 13:569-592.
  • Fieldman RD, Campbell N, Larochell P. Burgess ED, et al. 1999 Canadian recommendations for the management of hypertension CMAJ 1999; 161 (12 suppl): S1-S17
  • Joint National Committee on Prevention, Detection, Evaluation, and treatment of High Blood Pressure. The Sixth report. Arch Intern Med 1997; 157:2413-2446.
presentation references31
Presentation references
  • Carretero OA. Oparil S. Essential hypertension Part II: treatment. Circulation 2000; 101:446-453.
  • Reddy KS. Implementation of international guidelines on hypertension: the Indian experience.Clin Exp Hypertens. 1999 Jul-Aug;21 (5-6):693-701.
  • O’Brien E. Critical appraisal of the JNC VI, WHO/ISH and BHS guidelines for essential hypertension.Expert Opin Pharmacother. 2000 May;1(4):675-82.