Hypertension Management: Key Recommendations

Hypertension
management:
key recommendations
This presentation is adapted with permission from the National Heart Foundation of Australia
(National Blood Pressure and Vascular Disease Advisory Committee). Guide to management of hypertension 2008.
www.heartfoundation.org.au
Guide to management of hypertension 2008. Updated December 2010
Summary of presentation
1 Background
1 Background
2 Key recommendation
areas
1 Background
areas
Measurement
of blood
pressure
(BP)
1 Background
areas
Diagnosis
and
classification
Measurement
of blood
pressure
(BP)
1 Background
areas
Diagnosis
and
classification
Assessment
Measurement
of blood
pressure
(BP)
1 Background
areas
Diagnosis
and
classification
Assessment
Measurement
of blood
pressure
(BP)
Absolute
risk
1 Background
areas
Diagnosis
and
classification
Assessment
Measurement
of blood
pressure
(BP)
Absolute
risk
When to
intervene
1 Background
Diagnosis
and
classification
areas
Assessment
Measurement
of blood
pressure
(BP)
Lifestyle
advice
Absolute
risk
When to
intervene
1 Background
areas
Diagnosis
and
classification
Drug
treatment
Assessment
Measurement
of blood
pressure
(BP)
Lifestyle
advice
Absolute
risk
When to
intervene
1 Background
areas
Diagnosis
and
classification
Drug
treatment
Assessment
Measurement
of blood
pressure
(BP)
3 Development
process
Lifestyle
advice
Absolute
risk
When to
intervene
1 Background
areas
Diagnosis
and
classification
Drug
treatment
Assessment
Measurement
of blood
pressure
(BP)
3 Development
process
Lifestyle
advice
Absolute
risk
4 Endorsing organisations
When to
intervene
Background
G
Hypertension is common:
I
The most frequently managed chronic problem in general

practice1
I 1 in 3 Australians are diagnosed with hypertension2
G
Hypertension is serious:
Major risk factor for stroke and coronary heart disease3
I Major contributor to chronic heart failure (CHF), chronic kidney
disease and its progression3
I
1. Australian Institute of Health and Welfare, Australias Health 2008

2. AusDiab 2005, The Australian Diabetes, Obesity and Lifestyle Study, Tracking the Accelerating Epidemic:
Its Causes and Outcomes, Australian Diabetes Institute 2006
3. Levy D, Larson MG, Vasan RS, et al. The progression from hypertension to congestive heart failure.
JAMA 1996; 275: 1557-1562
Background
G
Hypertension is an arbitrary term

I
Generally, the lower the BP, the lower the risk

I Decision to treat is based on absolute risk or evidence of
end-organ damage not levels of blood pressure alone.
Background
G
Whats new in the 2008 guide?

I
Revised recommendations based on new evidence

I Revised treatment targets
I Revised recommendations for drug treatment of uncomplicated
hypertension
I Revised format for quick reference guide.
Key recommendation areas
Measurement
of blood
pressure
(BP)

Diagnosis
and
classification
Measurement
of blood
pressure
(BP)

Diagnosis
and
classification
Assessment
Measurement
of blood
pressure
(BP)

Diagnosis
and
classification
Assessment
Measurement
of blood
pressure
(BP)
Absolute
risk

Diagnosis
and
classification
Assessment
Measurement
of blood
pressure
(BP)
Absolute
risk
When to
intervene

Diagnosis
and
classification
Assessment
Measurement
of blood
pressure
(BP)
Lifestyle
advice
Absolute
risk
When to
intervene

Diagnosis
and
classification
Drug
treatment
Assessment
Measurement
of blood
pressure
(BP)
Lifestyle
advice
Absolute
risk
When to
intervene
1. Measurement of BP
G
Use recommended technique every time

I
Use regularly validated and serviced sphygmomanometer

I Measure BP on both arms on first measurement
I Ensure patient is seated and relaxed
I Measure sitting and standing if orthostatic hypotension
is suspected
I Use right cuff size
I Repeat and average two readings
2. Diagnosis and classification

G
Obtain BP measurement outside clinic if possible

I Ambulatory monitoring
and/or
I Self-measurement at home
2. Diagnosis and classification

G
Diagnosis should be based on multiple BP

measurements taken on separate occasions
Review at intervals determined by both BP category

and absolute risk
Click to see table
3. Assessment
G
Why assess all patients with hypertension?

I
Identify all CVD risk factors

I Calculate absolute risk (see later)
I Detect end-organ damage
I Detect co-morbid conditions
I Identify causes of secondary hypertension
G
If secondary hypertension is suspected, consider specialist

referral.
3. Assessment
G
A thorough evaluation of all patients includes:

I
Taking a full medical history

I Performing a physical examination, with
particular attention to CVD system
I Undertaking initial investigations
I Urine dip stick
for proteinuria and microalbuminuria
I Blood analysis
I ECG
I Undertaking further investigations as indicated
I Calculating absolute cardiovascular risk
G
See full guide for further details
4. Absolute cardiovascular risk (AR)

G
Why assess AR in all patients?

I
To determine optimal management plan

I To identify other modifiable risk factors that require management
I To communicate degree of urgency for reducing BP to patients

G
What is AR?
I
Probability (as a %) of someone

experiencing a CVD event
(heart attack or stroke)
I Current risk calculators underestimate
cardiovascular risk in Aboriginal,
Torres Strait Islander, Maori, and
Pacific Islander peoples

G
Who is at high (>15%) AR?

G
Group A
Patients aged
75 years and older
For almost all
individuals aged
75 years,
the absolute risk of
a cardiovascular event
>15 %
in the next 5 years

G
Group A
Group B
Patients aged
75 years and older
Patients with existing

cardiovascular disease
Assume risk of
cardiovascular event
>15%
in the next 5 years
if either of the following
is present: symptomatic
or left ventricular
hypertrophy
For almost all

individuals aged
75 years,
>15 %
in the next 5 years

G
Group A
Group B
Group C
Patients aged
75 years and older
Patients with existing

Assume risk of
cardiovascular event
>15%
in the next 5 years
if either of the following
is present: symptomatic
or left ventricular
hypertrophy
Patients with
associated clinical
conditions
and/or
end-organ disease
(including diabetes,
coronary heart disease,
chronic kidney disease
see guide)
Assume >15 %
in the next 5 years
For almost all

individuals aged
75 years,
>15 %
in the next 5 years

Australian cardiovascular risk chart (See full guide for information on how to use the chart)
5. When to intervene
Management
of hypertension
aims to:
Reduce BP
Reduce absolute
cardiovascular risk
Minimise end-organ
damage
Management
of hypertension
aims to:
Reduce BP
Reduce absolute
cardiovascular risk
Minimise end-organ
damage
Decision to
intervene should
be based on:
A thorough
assessment
(Section 3)
Absolute
cardiovascular risk
Evidence of
end-organ damage
Management
of hypertension
aims to:
Reduce BP
Reduce absolute
cardiovascular risk
Minimise end-organ
damage
Decision to
intervene should
be based on:
Lifestyle risk
reduction is
indicated for all
patients
A thorough
assessment
(Section 3)
Especially those
with high normal
BP or
hypertension
Absolute
cardiovascular risk
Evidence of
end-organ damage
6. Lifestyle advice
G
Indicated for all patients with hypertension,

regardless of drug therapy:
I
30 minutes moderate activity on most days

of the week
I Smoking cessation
I Healthy weight: waist <94 cm for men and
<80 cm for women, BMI <25 kg/m2
I Dietary salt restriction: 4 g/day
I Limited alcohol: two standard drinks per day for
men or one standard drink per day for women.
(See the full guide for more information
on lifestyle modification)
7. When to initiate drug treatment

Are any of the following present?
Grade 3 hypertension (SBP 180 mmHg and/or DBP 110 mmHg)
Isolated systolic hypertension with widened pulse pressure
(SBP 160 mmHg and DBP 70 mmHg)
Associated conditions or target-organ damage (See table 3 in the full guide)

YES
Start drug treatment immediately
(See figure 3 in the full guide:
Initiating drug treatment)
Lifestyle modification
Manage associated conditions
NO
Confirmed hypertension grades 12
(SBP 140179 mmHg or DBP 90109 mmHg)
All other adults
Assess 5-year absolute cardiovascular risk (See figure 1
in the full guide)

YES
NO

High
(>15%)
Confirmed hypertension grades 12

(SBP 140179 mmHg or DBP 90109 mmHg)
All other adults
Assess 5-year absolute cardiovascular risk (See figure 1
in the full guide)
Moderate
(10 15%)
Low
(<10%)
Monitor BP
Reassess 5-year absolute
cardiovascular risk in 612 mths
Monitor BP
SEE NEXT SLIDE

SEE NEXT SLIDE

Moderate
(10 15%)
Monitor BP
Low
(<10%)
Monitor BP

Moderate
(10 15%)
Monitor BP
Low
(<10%)
Monitor BP
LOW <10%
SBP 140150 mmHg

DBP <90 mmHg
Continue monitoring

Moderate
(10 15%)
Monitor BP
Low
(<10%)
Monitor BP
LOW <10%
MODERATE 10 15%
SBP <140 mmHg

DBP <90 mmHg
Continue monitoring
SBP 140150 mmHg

DBP <90 mmHg
Continue monitoring

Moderate
(10 15%)
Monitor BP
Low
(<10%)
Monitor BP
LOW <10%
MODERATE 10 15%
SBP <140 mmHg

DBP <90 mmHg
Continue monitoring

(See figure 3 in full guide:
SBP 140 mmHg

DBP 90 mmHg
SBP 140150 mmHg

DBP <90 mmHg
Continue monitoring
SBP 150 mmHg

DBP 90 mmHg
7. Drug treatments
G
The benefit from drug treatments is mainly due to BP

lowering (not mechanism of action)
In uncomplicated hypertension, these are equally effective

as first-line treatment (see figure 3 in full guide):
I
ACE inhibitor (or angiotensin II receptor antagonist)

I Calcium channel blocker
I Low-dose thiazide diuretics
(for people aged 65 years and older)
7. Drug treatments
FIRST CHOICE
ACE inhibitor (or angiotensin ll receptor antagonist)*
or
* ACE inhibitors and angiotensin II

receptor antagonists have been
shown to be equally efficacious in
prevention of cardiovascular end
points, and in lowering BP.
Thiazide diuretics are not
recommended for younger patients
due to risk of diabetes associated
with long-term use.
See table 7 in full guide for
information regarding choice of
antihypertensive agent in patients
with comorbid and associated
conditions.
See page 25 in full guide for
information on combination therapy.
7. Drug treatments
FIRST CHOICE
or
Calcium channel blocker
or

with long-term use.
conditions.
7. Drug treatments
FIRST CHOICE
or
or
Low-dose thiazide diuretic (consider for people aged 65 years only)
or

with long-term use.
conditions.
7. Drug treatments
FIRST CHOICE
or
or
or
If target BP not reached

ACE inhibitor (or angiotensin ll receptor antagonist)* + calcium channel blocker
or

with long-term use.
conditions.
7. Drug treatments
FIRST CHOICE
or
or
or

or
ACE inhibitor (or angiotensin ll receptor antagonist)* + low-dose thiazide diuretic
or

with long-term use.
conditions.
7. Drug treatments
FIRST CHOICE
or
or
or

or
or

+ calcium channel blocker + low-dose thiazide diuretic

with long-term use.
conditions.
7. Drug treatments
FIRST CHOICE
or
or
or

or
or

+ calcium channel blocker + low-dose thiazide diuretic

Consider seeking specialist advice

with long-term use.
conditions.
7. Drug treatments
G
Treat to recommended target level

Patient group
People with proteinuria >1 g/day
(with or without diabetes)
Target (mmHg)
<125 / 75
7. Drug treatments
G

Patient group
Target (mmHg)

<125 / 75
People with associated condition/s or

end-organ damage:*
Coronary heart disease
Diabetes
Chronic kidney disease
Proteinuria (>300 mg/day)
Stroke / TIA
<130 / 80
* Specific lower BP targets have not

been established for other high-risk
groups (e.g. those with peripheral
arterial disease, those with familial
hypercholesterolaemia or those at
high risk of cardiovascular disease)
due to the current lack of evidence
from clinical trials. Targets will be set
when evidence becomes available.
7. Drug treatments
G

Patient group
Target (mmHg)

<125 / 75
People with associated condition/s or

end-organ damage:*
Diabetes
Stroke / TIA
<130 / 80
People with none of the following:

Diabetes
Stroke / TIA
<140 / 90
or lower
if tolerated
* Specific lower BP targets have not

been established for other high-risk
groups (e.g. those with peripheral
arterial disease, those with familial
hypercholesterolaemia or those at
high risk of cardiovascular disease)
due to the current lack of evidence
from clinical trials. Targets will be set
when evidence becomes available.
7. Drug treatments
G
How to achieve target BP:

I
Start with lowest dose of first drug

I If drug not tolerated, change to a different class
I If target BP not reached, add second low-dose drug
(different class)
I If target BP still not achieved and both drugs well tolerated,
increase doses
I Trial each dose regimen for at least 6 weeks
G
If necessary, use drugs from different classes in

combination to achieve target BP.
I
See full guide for details of combination therapy

I About 5075% of patients will not achieve BP targets with
monotherapy
7. Drug treatments
G
If BP remains elevated despite maximal doses of at least

two appropriate agents, reassess for:
I
Non-adherence
I Undiagnosed secondary hypertension
I Hypertensive effects of other drugs
I Treatment resistance due to sleep apnoea
I Undisclosed use of alcohol or recreational drugs
I Unrecognised high salt intake
I White coat hypertension
I Technical factors affecting measurement
I Volume overload, especially with chronic kidney disease (CKD)
7. Drug treatments
G
Most effective combination:

ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
Calcium channel
blocker
Particular role in the

presence of diabetes or lipid
abnormalities
7. Drug treatments
G
Other effective combinations include:

ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
Thiazide diuretic
Particular role in the presence

of heart failure or post stroke
7. Drug treatments
G

ACE inhibitor
or Angiotensin ll
receptor antagonist
ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
PLUS
Thiazide diuretic

Beta-blocker
Recommended postmyocardial infarction or in

people with heart failure
7. Drug treatments
G

ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
Thiazide diuretic

ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
Beta-blocker

Beta-blocker
PLUS
Dihydropyridine calcium
channel blocker

of coronary heart disease
7. Drug treatments
G

ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
Thiazide diuretic

ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
Beta-blocker

Beta-blocker
PLUS
channel blocker

Thiazide diuretic
PLUS
Calcium channel
blocker
7. Drug treatments
G

ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
Thiazide diuretic

ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
Beta-blocker

Beta-blocker
PLUS
channel blocker

Thiazide diuretic
PLUS
Calcium channel
blocker
Thiazide diuretic
PLUS
Beta-blocker
Not recommended in people

with glucose intolerance,
metabolic syndrome or
established diabetes
7. Drug treatments
G
Avoid the following combinations:

ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
Potassium-sparing
diuretic
Due to risk of hyperkalaemia
7. Drug treatments
G

ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
Potassium-sparing
diuretic
Verapamil
PLUS
Beta-blocker
Due to risk of heart block
7. Drug treatments
G

ACE inhibitor
or Angiotensin ll
receptor antagonist
PLUS
Potassium-sparing
diuretic
Verapamil
PLUS
Beta-blocker
Due to risk of heart block
Angiotensin ll
receptor antagonist
In a large trial, combination therapy

did not reduce cardiovascular death
or morbidity in patients with vascular
disease or diabetes, but increased
the risk of hypotensive symptoms,
syncope and renal dysfunction
ACE inhibitor
PLUS
7. Drug treatments
G
Once a combination regimen is established as long-term

therapy, a fixed combination preparation may be more
convenient
Co-morbidities may either favour or limit the use of

particular drug classes
I
See table 7 in full guide for further details
Strategies to maximise adherence to treatment

recommendations should be used
I
See table 8 in full guide for further details
Hypertension quick reference

guide 2008
G
Designed as a practical tool for

use in general practice
The quick reference guide is

a summarised version of the
full guide including key
recommendations and
treatment tables and
algorithms
Guide development process

G
Developed by the National Blood Pressure and Vascular

Disease Advisory Committee of the Heart Foundation
I
Literature review conducted by experts on the Committee to

identify new evidence since 2004
I Recommendations were derived from the evidence and/or
consensus of the Committee
I Draft guide sent to endorsing organisations and key
stakeholders for comment (including a small
group of Victorian GPs in a focus group)
Take home messages

1 Management is determined by assessment of
absolute risk and evidence of end-organ damage
2 Treat to target blood pressure
3 Lifestyle modification is indicated for all
4 New recommendations for uncomplicated hypertension:
I
Begin drug monotherapy with any of:

I ACE inhibitor (or angiotensin II receptor antagonist)
I Calcium channel blockers
I Thiazide diuretics (consider for people aged 65 years or older only)
Endorsing organisations
The guide to management of hypertension is endorsed by:
G Royal Australian College of General Practitioners
G National Prescribing Service
G Internal Medicine Society of Australia and New Zealand
G Kidney Health Australia
G The National Stroke Foundation
How to get copies of the guide

G
The full guide, the quick reference guide and related

resources can be accessed online at
www.heartfoundation.org.au/information-forprofessionals/Clinical-Information/Pages/hypertension.aspx
Alternatively contact the Heart Foundations Health

Information Service on 1300 36 27 87 or
health@heartfoundation.org.au

Hypertension Management: Key Recommendations

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Hypertension Management: Key Recommendations

Diunggah oleh

Hak Cipta:

Format Tersedia

Hypertension

Guide to management of hypertension 2008. Updated December 2010

Guide to management of hypertension 2008. Updated December 2010

Guide to management of hypertension 2008. Updated December 2010

Guide to management of hypertension 2008. Updated December 2010

Guide to management of hypertension 2008. Updated December 2010

Guide to management of hypertension 2008. Updated December 2010

Guide to management of hypertension 2008. Updated December 2010

Guide to management of hypertension 2008. Updated December 2010

Guide to management of hypertension 2008. Updated December 2010

Guide to management of hypertension 2008. Updated December 2010

Guide to management of hypertension 2008. Updated December 2010

Guide to management of hypertension 2008. Updated December 2010

The most frequently managed chronic problem in general

1. Australian Institute of Health and Welfare, Australias Health 2008

Guide to management of hypertension 2008. Updated December 2010

Hypertension is an arbitrary term

Generally, the lower the BP, the lower the risk

Guide to management of hypertension 2008. Updated December 2010

Whats new in the 2008 guide?

Revised recommendations based on new evidence

Guide to management of hypertension 2008. Updated December 2010

Key recommendation areas

Guide to management of hypertension 2008. Updated December 2010

Key recommendation areas

Guide to management of hypertension 2008. Updated December 2010

Key recommendation areas

Guide to management of hypertension 2008. Updated December 2010

Key recommendation areas

Guide to management of hypertension 2008. Updated December 2010

Key recommendation areas

Guide to management of hypertension 2008. Updated December 2010

Key recommendation areas

Guide to management of hypertension 2008. Updated December 2010

Key recommendation areas

Guide to management of hypertension 2008. Updated December 2010

Key recommendation areas

Guide to management of hypertension 2008. Updated December 2010

Use recommended technique every time

Use regularly validated and serviced sphygmomanometer

Guide to management of hypertension 2008. Updated December 2010

2. Diagnosis and classification

Obtain BP measurement outside clinic if possible

Guide to management of hypertension 2008. Updated December 2010

2. Diagnosis and classification

Diagnosis should be based on multiple BP

Review at intervals determined by both BP category

Click to see table

Guide to management of hypertension 2008. Updated December 2010

Why assess all patients with hypertension?

Identify all CVD risk factors

If secondary hypertension is suspected, consider specialist

Guide to management of hypertension 2008. Updated December 2010

A thorough evaluation of all patients includes:

Taking a full medical history

See full guide for further details

Guide to management of hypertension 2008. Updated December 2010

4. Absolute cardiovascular risk (AR)

Why assess AR in all patients?

To determine optimal management plan

Guide to management of hypertension 2008. Updated December 2010

4. Absolute cardiovascular risk (AR)

Probability (as a %) of someone