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1999 WHO-ISH Hypertension Practice Guidelines for Primary Care Physicians

1999 WHO-ISH Hypertension Practice Guidelines for Primary Care Physicians. World Health Organization INTERNATIONAL SOCIETY OF HYPERTENSION. Working Group: Practice Guidelines. John Chalmers (Australia, Chairman) Paul Chusid (USA) Jay N Cohn (USA)

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1999 WHO-ISH Hypertension Practice Guidelines for Primary Care Physicians

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  1. 1999 WHO-ISHHypertension Practice Guidelinesfor Primary Care Physicians • World Health Organization • INTERNATIONAL SOCIETY OF HYPERTENSION

  2. Working Group: Practice Guidelines • John Chalmers (Australia, Chairman) • Paul Chusid (USA) • Jay N Cohn (USA) • Lars H Lindholm (Sweden, Writing Coordinator) • Ingrid Martin (WHO, Switzerland) • Karl-Heinz Rahn (ISH, Germany) • Peter Sleight (WHL, UK)

  3. WHO-ISH HypertensionGuidelines Subcommittee • Michael Alderman (USA) • Kikuo Arakawa (Japan) • Lawrie Beilin (Australia) • John Chalmers(Australia, Chairman) • Serap Erdine (Turkey) • Masatoshi Fujishima (Japan) • Pavel Hamet (Canada) • Lennart Hansson (Sweden) • Lewis Landsberg (USA) • Frans Leenen (Canada) • Lars H Lindholm (Sweden) Liu Lisheng (China) AFB Mabadeje (Nigeria) Stephen MacMahon (Australia) Giuseppe Mancia (Italy) Ingrid Martin (Switzerland) Albert Mimran (France) Karl-Heinz Rahn (Germany) Arturo Ribeiro (Brazil) Peter Sleight (UK) Judith Whitworth (Australia) Alberto Zanchetti (Italy)

  4. The WHO-ISH Guidelines are written for a global audience from communities that vary widely in the nature of their health system and in the availability of resources. • The goal, however, remains universally the same, that is to lower BP and other risk factors in order to reduce the risk of CVD. 4 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  5. Global Goal 5 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  6. What is the Goalof the Practice Guidelines? • To lower blood pressure (BP) and other risk factors in order to reduce the risk of cardiovascular disease (CVD) 6 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  7. Why is Hypertension Management Needed? (1) • 600 million hypertensives in the world • 3 million die annually as a direct result of hypertension

  8. Why is Hypertension Management Needed? (2) • The Rule of Halves • Only 1/2 have been diagnosed • Only 1/2 of those diagnosed have been treated • Only 1/2 of those treated are adequately controlled • Thus, only 12.5% overall are adequately controlled

  9. What is New? 1999 WHO-ISH 1993 WHO-ISH JNC-VI Definition of > 140/90 >140/90 >140/90 hypertension Levels Grade 1,2,3 Mild, Moderate, Stage 1,2,3 Severe Decision Not based on BP BP to treat BP alone, but assessment of total CV risk Target BPs <130/85 <130/80 <140/90 <140/90 (elderly) <140/90 (elderly) 9

  10. 1999 WHO-ISH 1993 WHO-ISH JNC-VI Suitable first-line 6 drug 5 drug 2-3 drug drug therapy classes classes classes Combination Low dose Low dose therapy combinations combinations recommended if may be used to monotherapy initiate therapy inadequate What is New? 10 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  11. Why BP <130/85 mm Hgand Not <140/90 mm Hg? (1) • The relationship between CV risk and BP is continuous • Today, more than 50% of all hypertensives have BP >160/90 mm Hg and 75% have BP >140/90 • The major determinant of the risk reduction conferred by antihypertensive therapy is the BP level attained

  12. Why BP <130/85 mm Hgand Not <140/90 mm Hg? (2) • In diabetics, there is a clear benefit of lowering BP <85 mm Hg • The HOT Study showed that lowering BP < 85 mm Hg did not increase CV risk • The goal should be to attain normalBP (<130/85 mm Hg)

  13. Questions to be Answered (1) • What is high blood pressure? • Clinical evaluation - what should be done? • Which factors influence prognosis? • Do patients benefit from antihypertensive treatment? • How should hypertension be managed? 13 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  14. Questions to be Answered (2) • Which drug treatments should be used? • What treatment goal should be set and how should patients be followed up? • How should hypertension during pregnancy be handled? • How should hypertension in Type-2 diabetics be handled? 14 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  15. What is High Blood Pressure? • BP levels are continuously related to the risk of CVD • Definition of hypertension or raised BP is arbitrary • Even within the normotensive range, people with the lowest BP levels have the lowest rates of CVD

  16. Relative Risk of CHD and Stroke in Relation to Patient’s Usual Diastolic BP 16 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  17. New (1999) WHO-ISH Definitionsand Classification of BP Levels Category Systolic BP Diastolic BP (mm Hg) (mm Hg) Optimal BP <120 <80 Normal BP <130 <85 High-Normal 130-139 85-89 Grade 1 Hypertension (mild) 140-159 90-99 Subgroup: Borderline 140-149 90-94 Grade 2 Hypertension (moderate) 160-179 100-109 Grade 3 Hypertension (severe) >180 >110 Isolated Systolic Hypertension >140 <90 Subgroup: Borderline 140-149 <90

  18. Clinical Evaluation - What Should Be Done? • Confirm elevation of BP • Exclude or identify secondary causes of hypertension • Determine presence of target organ damage and quantify extent • Search for other CV risk factors and clinical conditions that may influence prognosis and treatment

  19. How to Record BP (1) • Measure BP several times on separate occasions with the patient in sitting position • Use a mercury sphygmomanometer or other non-invasive device 19 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  20. How to Record BP (2) • Measure BP several times on several occasions • Allow the patient to sit for several minutes before measuring BP • Use a cuff with a bladder that is 12-13 cm X 35 cm, larger for fat arms • Use phase 5 Korotkoff sounds (disappearance) to measure diastolic BP • Measure BP in both arms at first visit • Measure BP in standing position in elderly subjects and diabetic patients • Place sphygmomanometer cuff at heart level, whatever the position of the patient 20 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  21. Multiple BP Measurements Recommended • Because BP is characterized by large spontaneous variations, diagnosis should be based on multiple BP measurements taken on several separate occasions 21

  22. Minimum RoutineInvestigations • Clinical and family history • Full physical examination as described in medical textbooks • Laboratory investigations, including: • urinalyses for blood, protein, and glucose • microscopic examination of the urine • blood chemistry for potassium, creatinine, fasting glucose, and total cholesterol • Electrocardiography (ECG) 22

  23. “Isolated” Office Hypertension • In some patients office BP is persistently elevated whereas daytime BP outside clinic environment is not. Continuing debate whether “isolated” office hypertension (“white coat hypertension”) is an innocent phenomenon or carries an increased risk of CVD 23

  24. Ambulatory BP Monitorings Should be Considered, if: • Unusual variability of BP over the same or different visits • “Isolated” office (“white coat”) hypertension in subjects with low CV risk • Symptoms suggesting hypotensive episodes • Hypertension resistant to drug treatment 24

  25. Ambulatory BP Monitoring • BP values obtained by home measurement or ambulatory monitoring are several mm Hg lower than office measurement • Average 24 hour or home BP values around 125/80 mm Hg = office BP 140/90 mm Hg • Reliable information about long-term prognostic value of ambulatory and home monitoring is awaited 25 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  26. Which Factors Influence Prognosis? (1) • Decisions should not be made on BP alone, but also on presence of other risk factors, target organ damage, and concomitant diseases, as well as on other aspects of patients’ personal, medical, social, economic, ethnic, and cultural characteristics 26 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  27. Which Factors Influence Prognosis? (2) • Risk factors of CVD • I. Used for risk stratification • II. Other factors adversely influencing prognosis • Target organ damage (TOD) • Associated clinical conditions (ACC) 27 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  28. Which Factors Influence Prognosis? (3) Risk factors for CVD • I. Used for risk stratification • Levels of systolic and diastolic blood pressure (Grades 1-3) • Men >55 years • Women >65 years • Smoking • Total cholesterol >6.5 mmol/L (250 mg/dl) • Diabetes • Family history of premature cardiovascular disease 28 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  29. Which Factors Influence Prognosis? (4) Risk factors for CVD • II. Other factors adversely influencing prognosis • Reduced HDL cholesterol • Raised LDL cholesterol • Microalbuminuria in diabetes • Impared glucose tolerance • Obesity • Sedentary lifestyle • Raised fibrinogen • High risk socioeconomic group • High risk ethnic group • High risk geographic region 29 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  30. Which Factors Influence Prognosis? (5) Target organ damage (TOD) • Left ventricular hypertrophy (electrocardiogram, echocardiogram, or radiogram) • Proteinuria and/or slight elevation of plasma creatinine concentration 106-177 mmol/L (1.2-2.0 mg/dl) • Ultrasound or radiological evidence of atherosclerotic plaque (carotid, iliac, and femoral arteries, aorta) • Generalised or focal narrowing of the retinal arteries 30 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  31. Which Factors Influence Prognosis? (6) Associated clinical conditions (ACC) • Cerebrovascular disease • Ischaemic stroke • Cerebral haemorrhage • Transient ischaemic attack (TIA) • Heart disease • Myocardial infarction • Angina pectoris • Coronary revascularisation • Congestive heart failure 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 31

  32. Which Factors Influence Prognosis? (7) Associated clinical conditions (ACC) • Renal disease • Diabetic nephropathy • Renal failure, plasma creatinine concentration >177 mmol/L (>2.0 mg/dl) • Vascular disease • Dissecting aneurysm • Symptomatic arterial disease • Advanced hypertensive retinopathy • Haemorrhages or exudates • Papilloedema 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 32

  33. Which FactorsInfluence Prognosis? (8) Typical 10 year risk of stroke or myocardial infarction • Low risk = <15 percent • Medium risk = 15-20 percent • High risk = 20-30 percent • Very high risk = 30 percent or higher 33

  34. Which FactorsInfluence Prognosis? (9) • Example 1: 65-year old man with diabetes, TIAs, and BP of 145/90 mm Hg will have annual risk of major CVD event 20 times greater than 40-year old man with same BP but without diabetes or history of CVD 34

  35. Which FactorsInfluence Prognosis? (10) • Example 2: 40-year old man with BP of 170/105 mm Hg will have risk of major CV event 2-3 times greater than man of same age with BP of 145/90 mm Hg and similar other risk factors 35

  36. Stratifying Risk - Quantifying Prognosis 36 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  37. Do Patients Benefit from Antihypertensive Treatment? (1) • Yes, the randomized trials conducted to date have shown clear evidence of a lower incidence of major CVD events after high BP was treated with anti-hypertensive drugs. 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 37

  38. Do Patients Benefit from Antihypertensive Treatment? (2) • There is as yet no evidence that the main benefit of treating hypertension is due to a particular drug property rather than to lowering BP per se. 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 38

  39. Effects of Antihypertensive Treatment in Randomised Controlled Trials 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 39

  40. Absolute Effects of Antihypertensive Treatment 10/5 mm Hg 20/10 mm Hg Low risk patients <5 <9 Medium risk patients 5-7 8-11 High risk patients 7-10 11-17 Very high risk patients >10 >17 Patient Group Absolute treatment effects (CVD events prevented per 1000 patients years) 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 40

  41. Larger Risk Reductions? • The estimates of antihypertensive benefits shown were reported from trials of about 5 years duration. • It is possible that long-term treatment over decades might produce larger risk reductions. 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 41

  42. Management Strategy (1) • Initiate lifestyle measures wherever appropriate in all patients, including those who require drug treatment • Smoking cessation • Weight reduction • Moderation of alcohol consumption • Reduction of salt intake • Increased physical activity 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 42

  43. High Risk Medium Risk Low Risk Management Strategy (2) • Is patient at: Very High Risk 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 43

  44. High Management Strategy (3) • Stratify Risk Very High Begin drug treatment Begin drug treatment 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 44

  45. Management Strategy (4) • Stratify risk Medium Low Monitor BP & other risk factors for 3-6 months Monitor BP & other risk factors for 6-12 months SBP >140 or DBP >90 Begin drug treatment SBP <140 or DBP <90 Continue to monitor SBP >150 or DBP >95 Begin drug treatment SBP <150 or DBP <95 Continue to monitor 45 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

  46. Principles of Drug Treatment (1) • Use a low dose of one drug to initiate therapy • If good response and tolerability but inadequate control increase the dose of the first drug • If little response or poor tolerability change to another drug class 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 46

  47. Principles of Drug Treatment (2) • It is often preferrable to add a small dose of a second drug rather than increase the dose of the first drug • Use long-acting drugs providing 24-hour efficacy on a once daily basis. Improves adherence to therapy and minimizes BP variability. 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 47

  48. Principles of Drug Treatment (3) • More evidence of beneficial CVD effects with older drugs (e.g., diuretics and beta-blockers) • Evidence of benefit with newer drugs (e.g., ACE inhibitors and calcium antagonists) is accumulating. 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 48

  49. Principles of Drug Treatment (4) • There are six maindrug classes used worldwide - diuretics, beta-blockers, ACE inhibitors, calcium antagonists, alpha blockers, and angiotensin II antagonists. 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 49

  50. Principles of Drug Treatment (5) • All 6 classes are suitable for the initiation and maintenance of BP lowering therapy, but the choiceof drugs will be influenced by cost and by many factors for special groupsof patients. In some parts of the world, reserpine and methyldopa arealso used frequently. 1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS 50

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