HYPERTENSION :

Definition, Classification, Diagnosis & Prevention

Candra Wibowo
Nephrology Division, Medical School of Trisakti University Jakarta
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JNC 7, 2002
Publication of many new observ. studies & clinical trials Need new, clear & concise guideline useful Need simply classification JNC 6 reports were not being used to max benefit

CVD events
Risk CVD begins at 115/75 mmHg 40-70 yrs : 20/10 mmHg at beginning 115/75 mmHg have 2 x > 50 yrs : systolic > 140 mmHg much more important than diastolic 55 yrs w/ normotensi 90% lifetime risk for developing HPT HPT continuous, consistent & independent of heart attack, heart failure, stroke, kidney dis. PRE HYPERTENSION : ( 2x) risk progression to hypertension should be health promotion life style modifications STAGE 2 & 3 STAGE 2 : simply & prognosis 2 = 3
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ESC/ESH, 2003
1. Flexible approach to def & treat 2. Goal is reduction BP long term CVD risk 3. Pre hypertension pts anxious & intrusive lifestyle changes, medical visits & lab. test 4. Pre hypertension looking at idea the whole life was a pre-death experience

69% pts aware to HPT in USA 36% pts aware to HPT in UK

Daniel Levy, Framingham,2004

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2007 Guidelines for the management of arterial hypertension

European Heart Journal (2007) 28, 14621536

The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)
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Denitions & classication of BP levels

Category
Optimal Normal High normal Grade 1 hypertension Grade 2 hypertension Grade 3 hypertension Isolated systolic hypertension

Systolic
<120 120129 130139 140159 160179 >180 >140 and and/or and/or and/or and/or and/or and

Diastolic
<80 8084 8589 9099 100109 >110 <90

Isolated systolic hypertension should be graded (1 ,2,3) according to systolic blood pressure values in the ranges indicated,provided that diastolic values are <90 mmHg. Grades 1 , 2and 3 correspond to classication in mild, moderate and severe hypertension, respectively. These terms have been now omitted to avoid confusion with quantication of total cardiovascular risk.

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Denitions & Classication of BP Levels

Category
Optimal Normal High normal Grade 1 hypertension Grade 2 hypertension Grade 3 hypertension Isolated systolic hypertension

Systolic
<120 120129 130139 140159 160179 >180 >140 and and/or and/or and/or and/or and/or and

Diastolic
<80 8084 8589 9099 100109 >110 <90

Isolated systolic hypertension should be graded (1 ,2,3) according to systolic blood pressurevalues in the ranges indicated, provided that diastolic values are <90 mmHg. Grades 1 , 2and 3 correspond to classication in mild, moderate and severe hypertension, respectively. These terms have been now omitted to avoid confusion with quantication of total cardiovascular risk.

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CLASSIFICATION OF BOOD PRESSURE FOR ADUTS AGED 18 YRS OR OLDER

JNC 6 1997, WHO-ISH 1999, ESH/ESC 2003, ESH/ESC 2007 Category Optimal Normal High-normal Systolic < 120 < 130 130 -139 Diastolic < 80 < 85 85 89 120 - 139 80 -89 Prehypertension Systolic < 120 Diastolic < 80 JNC 7 2002 Category Normal

Borderline hypertens
Grade I (mild) Grade 2 (moderate) Grade 3 (severe)

140 - 149 90 94
140 - 159 90 99 160 - 179 100 109 180 110

140 - 159 90 - 99
160 100

Stage I
Stage II

Isolated systolic hypertension

Subgroup borderline

>140
> 140

< 90
< 90

>140

< 90

Isolated systolic hypertension

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TREATMENT OF HYPERTENSION
Life style modification Not at Goal BP (<140/90 mmHg for those with DM or CKD) Initial drug choices Hypertension without compelling indications Hypertension with compelling indications

Stage 1 Thiazide type diuretics Consider ACE-I, ARB, BB, CCB or combination

Stage 2 2 drugs combination for most

Drugs for compelling indication

Not at Goal BP Optimize dosages or add additional drugs

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INTERVENTIONS TO HELP IMPROVING ADHERENCE

Educate pts & fam. on the consequences of hypertension and the benefits of lifestyle & drug therapy Counsel on side effects Tailor pill-taking to fit pts daily habits (same time/place/situation) Simplify drug and lifestyle regime (e.g. once daily dosing) Ensure regime is affordable Involve fam. & friends in lifestyle & medication adherence Maintain regular BP follow-up Encourage pts responsibility/autonomy in monitoring BP and adjusting prescriptions
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Lifestyle Recommendations for Prevention of Hypertension for NON-Hypertensive Individuals

1. Healthy diet: high in fresh fruits, vegetables, but low fat dairy products, & in saturated fat also salt in accordance. 2. Regular physical activity: accumulation of 30-60 minutes of moderate intensity dynamic exercise 4-7x/week. 3. Low risk alcohol consumption (2 drinks/day or 14x/week for men & 9x/week for women) 4. Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2) 5. Waist Circumference < 102 cm (90 cm in Asia Pacific) for men < 88 cm (80 cm in Asia Pacific) for women 6. Restriction of salt intake 100 mmol/day in individuals considered salt-sensitive, such as: Canadians of African descent, age over 45, individuals with impaired renal function or with diabetes. 7. Smoke free environment
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Lifestyle Recommendations for Treatment of Hypertension

1. Healthy diet: high in fresh fruits, vegetables & low fat dairy products, low in saturated fat and salt in accordance with the DASH diet 2. Regular physical activity: optimum 30-60 minutes of moderate cardiorespiratory activity 4/week 3. Reduction in alcohol consumption in those who drink excessively 4. Weight loss ( 5 Kg) in those who are over weight (BMI>25) 5. Waist Circumference < 102 cm (90 cm in Asia Pacific) for men < 88 cm (80 cm in Asia Pacific) for women 6. In individuals considered salt-sensitive, such as: Canadians of African descent, age over 45, individuals with impaired renal function or with diabetes. Restrict salt intake to less than 100 mmol/day 7. Smoke free environment
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Lifestyle Recommendations for Hypertension:

Dietary
Dietary Sodium

Fresh Fruits Vegetables Low Fat dairy products Low fat diet in accordance with the DASH diet

Restrict to target range of 65-100 mmol/day (Most of the salt in food is hidden and
comes from processed food)

Dietary Potassium
If required, daily dietary intake >80 mmol

Calcium supplementation
No conclusive studies for hypertension

Magnesium supplementation
No conclusive studies for hypertension http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html

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Lifestyle Recommendations for Hypertension:

Physical Activity
Should be prescribed to reduce blood pressure F I T T
Frequency - Four or more days per week Intensity Time Type - Moderate - 30-60 minutes Dynamic exercise - Walking, jogging - Cycling - Non-competitive swimming

For patients who are prescribed pharmacological therapy: exercise should be prescribed as adjunctive therapy
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Lifestyle Recommendations for Hypertension:

Alcohol
Low risk alcohol consumption
0-2 drinks/day Men: maximum of 14 drinks/week Women: maximum of 9 drinks/week
1 drink = one beer, or 1 glass of wine or 1 ounce of 40% spirit

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Lifestyle Recommendations for Hypertension:

Stress Management
Stress management
Hypertensive patients in whom stress appears to be an important issue Behaviour Modification Individualized cognitive behavioral interventions are more likely to be effective when relaxation techniques are employed

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Lifestyle Recommendations for Hypertension:

Weight Loss
Hypertensive and all patients BMI over 25 for hypertension - Encourage weight reduction - Healthy BMI: 18.5-24.9 kg/m2 Waist Circumference < 102 cm (90 cm in Asia Pacific) for men < 88 cm (80 cm in Asia Pacific) for women
For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects. Weight loss strategies should employ a multidisciplinary approach and include dietary education, increased physical activity and behavioural modification.

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LIFESTYLE MODIFICATIONS TO MANAGE HYPERTENSION

Modification
Weight reduction Adopt DASH eating plan (Dietary Approaches to Stop Hypertension) Dietary sodium reduction Physical activity

Recommendation
Maintain normal body weight (BMI 18.5-24.9) Consume a diet rich in fruits, vegetables & low fat dairy products with a reduced content of saturated & total fat Reduce dietary sodium intake to no more than 100 mEq/L (2.4 g sodium or 6 g sodium chloride) Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week) Limit consumption to no more than 2 drinks per day (1 oz or 30 ml ethanol, eg, 24 oz beer, 10 oz wine or 3 oz 80 proof whiskey) in most men and no more than 1 drink per day in women and lighter weight persons

Approximate systolic reduction, range

5-20 mmHg/10 kg weight loss 8-14 mmHg

2-8 mmHg

4-9 mmHg

Moderation of alcohol consumption

2-4 mmHg

JNC VII, 2002

Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults

Intervention
Sodium intake Weight Alcohol intake Exercise*

Change
- 100 mmol/day - 4.5 kg - 2.7 drinks/day 3 times/week

SBP/DBP
-5.8 / -2.5 -7.2 / -5.9 -4.6 / -2.3 -7.4 / -5.8

Dietary patterns

DASH diet

-11.4 / -5.5

* 1- Exercise and Hypertension. Medicine & Science in Sports & Exercise. 36(3):533-553, March 2004. 2- Result of aggregate and metaanalyses of short term trials. Miller ER et al. J Clin Hyper 1999: Nov/Dec:191-8.

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Lifestyle Therapies in Hypertensive Adults:

Summary
Intervention
Sodium restriction Weight loss Waist Circumference Alcohol restriction Exercise Dietary patterns Smoking cessation

Target
65-100 mmol/day BMI <25 kg/m2 < 102 (90) cm for men < 88 (80)cm for women Less or equal to 2 drinks/day at least 4 times/week DASH diet Smoke free environment

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Indications for Pharmacotherapy

Strongly consider prescription if: Average DBP equal or over 90 mmHg and: Hypertensive Target-organ damage (or CVD) or Independent cardiovascular risk factors Elevated systolic BP Cigarette smoking Abnormal lipid profile Strong family history of premature CV disease Truncal obesity Sedentary Lifestyle Average DBP equal or over 80 mmHg in a patient with diabetes
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INITIAL TREATMENT RECOMMENDATIONS ON CKD

Renal insufficiency GFR < 60 Cr serum > 1.4

130/80 mmHg

Microalbuminuria (early abnormality)

130/80 mmHg

ACE Inh or ARB Start & titrate to max tolerable dose

Proteinuria

Diabetes mellitus
K/DOQI NKF, 2002

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ANTIHYPERTENSIVE DRUGS USED ON SEVERAL CLINICAL CONDITIONS

Population
General

Target (mmHg)
< 140/90

Nonpharmacologic
Low salt diet, exercise

Pharmacologic treatment
Beta blockers Diuretics

CKD (including diabetic nephropathy)

With proteinuria (> 1 g/dl) With proteinuria (< 1 g/dl) Without proteinuria
With HD With PD

< 125/75 < 130/80

<130/85 < 140/90 < 140/90 < 125/75 < 130/85

Low salt diet Low salt diet

Low salt diet Low salt & water diet, UF Low salt & water diet, UF Low salt diet Low salt diet

ACE Inh, ARB (diuretics) ACE Inh, ARB (diuretics) ACE Inh, ARB (diuretics)
All agents, except diuretics All agents, except diuretics ACE Inh, ARB, CCB (diuretics) ACE Inh, ARB, CCB (diuretics)
K/DOQI NKF, 2002

ESRD

RRT

With proteinuria (> 1 g/dl) Without proteinuria (< 1 g/dl)

MULTIPLE RISKS FACTORS INTERVENTION STRATEGY TO SLOW THE PROGRESSION OF RENAL DISEASE

INTERVENTION Control BP ACE-I / AII RB therapy Control glucose (DM) Protein intake intervention

LEVEL I

LEVEL II

LEVEL III

Salt intake intervention

Fluid intake intervention Control lipid No cigarette Avoid regular NSAID Control homocystein Control hyperinsulinemia Use antioxidant Correct anemia Avoid hypokalemia Control hyperphosphatemia Low dose aspirin Estrogen replacement
Renal benefit General/CV benefit Hebert, et al, Kidney Int. 2001

AVERAGE NUMBER OF ANTIHYPERTENSIVE AGENTS NEEDED FOR PTS TO ACHIEVE TARGET BP

Clinical Trial Target BP
(mmHg)

UKPDS
ABCD MDRT HOT AASK

DBP <85
DBP <75 MAP <92 DBP <80 MAP <92 1 4 2 3 No. Antihypertension agents

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Choice of Pharmacological Treatment

Associated risk factors? or Target organ damage/complications? or Concomitant diseases/conditions? NO
Treatment in the absence of compelling indication

YES
Individualized Treatment (with compelling indications)

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Choice of pharmacological treatment for hypertensive pts without compelling indications:

Treatment of Systolic Diastolic hypertension

Treatment of Isolated Systolic hypertension

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Treatment of Adults with Systolic-Diastolic Hypertension without Compelling Indications

TARGET <140 mm Hg systolic and < 90 mmHg diastolic
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy

Thiazide

ACE-I

ARB

Longacting CCB

Betablocker*

* Not indicated as first line therapy over 60

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Considerations Regarding the Choice of First-Line Therapy

Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent ACE-I are not recommended (as monotherapy) for black patients without another compelling indication Beta adrenergic blockers are not recommended for patients over 60 years without another compelling indication

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Combination Therapy for Systolic-Diastolic Hypertension without Compelling Indications

If partial response to monotherapy

1. Dual Combination Therapy

CONSIDER Non adherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect? Resistant Hypertension?

2. Triple or Quadruple Therapy

If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).
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Useful Dual Combinations

For additive hypotensive effect in dual therapy : Combine an agent from column 1 with any in column 2
Column 1 Thiazide diuretic Long-acting calcium channel blocker* Column 2 Beta adrenergic blocker ACE Inhibitor ARB

* Caution should be exercised when using a non DHP-CCB and a beta-blocker

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Useful Triple Therapy Combinations

For additive hypotensive effect in triple therapy : Combine 2 agents from Column 1 with any in Column 2
Column 1 Column 2

Thiazide diuretic
Long-acting calcium channel blocker*

Beta adrenergic blocker

ACE Inhibitor ARB

* Caution should be exercised when using a non DHP-CCB and a beta-blocker

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Summary: Treatment of Systolic-Diastolic Hypertension without Compelling Indications

TARGET <140 mm Hg systolic and < 90 mmHg diastolic
Lifestyle modification therapy

Thiazide diuretic

ACE-I

ARB

Long-acting CCB

Betablocker*

CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect?

Dual Combination

Triple or Quadruple Therapy RENAL REGISTRY CENTER

* Not indicated as first line therapy over 60

Choice of pharmacological treatment for hypertensive pts with compelling indications

Treatment of diastolic-systolic hypertension Treatment of isolated systolic hypertension

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Treatment Algorithm for Isolated Systolic Hypertension without Compelling Indications

TARGET <140 mmHg Systolic BP
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy

Thiazide diuretic

ARB

Long-acting DHP CCB

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Combination therapy for Isolated Systolic Hypertension without Compelling Indications

If partial response to monotherapy
Dual combination Combine agents from two adjacent classes Thiazide diuretic ARB Long-acting DHP CCB

CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect?

Triple or quadruple therapy

If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha adrenergic blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).

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Summary: Treatment of Isolated Systolic Hypertension without Compelling Indications

TARGET <140 mmHg Systolic BP
Lifestyle modification therapy

Thiazide diuretic

ARB

Long-acting DHP CCB

*If blood pressure is still not controlled, or there are adverse effects, other classes of anti hypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).
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CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect?

Dual combination

Triple or Quadruple* combination

Choice of pharmacological treatment for hypertensive pts with compelling indications

Individualized treatment

Compelling indications: Smoking Ischemic Heart Disease Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI Left Ventricular Systolic Dysfunction Cerebrovascular Disease Left Ventricular Hypertrophy Non Diabetic Chronic Kidney Disease Renovascular Disease
Diabetes Mellitus With Diabetic Nephropathy Without Diabetic Nephropathy Global Vascular Protection for Hypertensive Patients Statins Aspirin
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Treatment of Hypertension for Pts Using Tobacco

Smoking

Beta-blocker

The benefits of treating smokers with beta-blockers remain uncertain in the absence of a specific indications like angina or post-MI

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Treatment of Hypertension in Pts with Ischemic Heart Disease

Stable angina

1. Beta-blocker 2. Long-acting CCB

ACE-I is recommended in ALL patients with established CAD

Caution should be exercised when combining a non DHP-CCB and a beta-blocker If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or Diltiazem)
Short-acting nifedipine

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Treatment of Hypertension in Pts with Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
Recent myocardial infarction

Beta-blocker and ACE-I

If beta-blocker contraindicated or not effective YES Long-acting DHP CCB (Amlodipine, Felodipine)

Heart Failure ? NO Long-acting CCB

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Treatment of Hypertension with Left Ventricular Systolic Dysfunction

Systolic cardiac Dysfunction
ACE-I if ACE-I intolerant: ARB
and Beta-Blocker

If additional therapy is needed: Diuretic* for CHF class III-IV: Aldosterone Antagonist If ACE-I and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination

Non dihydropyridine CCB

If additional antihypertensive therapy is needed:

ACE-I / ARB Combination Long-acting DHP-CCB (Amlodipine or Felodipine)

Beta-blockers used in clinical were bisoprolol, carvedilol and metoprolol. Physicians who are not yet experienced in the use of beta-blockers should consider initiation of treatment in conjunction with a physician experienced in heart failure management particularly for NYHA Class III-IV patients

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Treatment of Hypertension for Pts with Cerebrovascular Disease

Strongly consider blood pressure reduction in all pts after the acute phase of non disabling stroke or TIA
An ACE-I / diuretic combination is preferred

Stroke TIA

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Treatment of Hypertension in Pts with Left Ventricular Hypertrophy

Hypertensive pts with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events.

Left ventricular hypertrophy

- ACE-I - ARB, - CCB - Diuretic - BB (below age 60)*

Vasodilators: Hydralazine, Minoxidil Can Increase LVH

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Treatment of Hypertension in Patients with Non Diabetic chronic kidney disease

Target BP: Nondiabetic: < 130 mmHg systolic and < 80 mmHg diastolic Proteinuria: > 1 g/day: < 125 / 75 mmHg

Renal disease

1. ACE-I 2. Alternate if ACE-I not tolerated: ARB

Additive therapy: Thiazide diuretic. Alternate: If vol. overload: loop diuretic

Combination with other agents

ACE-I/ARB: Bilateral renal artery stenosis

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Treatment of Hypertension in association with Renovascular Disease

Renovascular disease
Does not imply specific treatment choice

Caution in the use of ACE-I/ARB in bilateral renal artery stenosis or unilateral disease with solitary kidney

Close follow-up and early intervention (angioplasty and stenting or surgery) should be considered for patients with: uncontrolled hypertension despite therapy with three or more drugs, or deteriorating renal function, or bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney), or recurrent episodes of flash pulmonary edema.
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Treatment of Hypertension for Patients with Diabetes Mellitus

Threshold 130/80 mmHg and TARGET < 130 mmHg systolic and < 80 mmHg diastolic
with Nephropathy

Diabetes

Urinary albumin excretion rate equal or over 30 mg/day

without Nephropathy
Systolicdiastolic Hypertension Isolated Systolic Hypertension

Urinary albumin excretion rate less than 30 mg/day

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Treatment of Hypertension in Association with Diabetic Nephropathy

Threshold 130/80 mmHg TARGET < 130 mmHg systolic and < 80 mmHg diastolic
Urinary albumin excretion rate over 30 mg/day
DIABETES with Nephropathy Addition of one or more of Thiazide diuretic or Long-acting CCB

ACE-I or ARB
IF ACE-I and ARB are contraindicated or not tolerated, SUBSTITUTE Cardioselective BB or Long-acting CCB or Thiazide diuretic

3 - 4 drugs combination may be needed

If Creatinine over 150 mol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired RENAL REGISTRY CENTER

Treatment of Systolic-Diastolic Hypertension without Diabetic Nephropathy

Threshold 130/80 mmHg and TARGET < 130 mmHg systolic and < 80 mmHg diastolic
Urinary albumin excretion rate less than 30 mg/day
Diabetes without Nephropathy With Systolic diastolic Hypertension
ACE-Inhibitor or ARB or Thiazide diuretic IF ACE-I and ARB and Thiazide are contraindicated or not tolerated, SUBSTITUTE Cardioselective BB* or Long-acting CCB

Combination of first line agents

Addition of one or more of: Cardioselective BB or Long-acting CCB

* Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol More than 3 drugs may be needed to reach target values for diabetic patients RENAL REGISTRY CENTER

Treatment of Hypertension for Patients with Diabetes Mellitus: Summary

TARGET : below 130/80 mmHg (proteinuria < 1 g/24 hrs) below 125/75 mmHg (proteinuria > 1 g/24 hrs)
with Nephropathy ACE Inhibitor or ARB

Diabetes

without Nephropathy

ACE-Inhibitor or ARB or Thiazide diuretic

Combination Effective 2-drug combination

COMBINATION : ADD Cardioselective BB or Long-acting CCB or Thiazide diuretic, or an ACE-I with an ARB (or vice versa) More than 3 drugs may be needed to reach target values for diabetic patients If Creatinine over 150 mol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

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Vascular Protection for Hypertensive Pts: Statins

Statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 cardiovascular risks such as :
Male 55 y or older Smoking Type 2 Diabetes Total-C/HDL-C ratio of 6 or higher Premature Family History of CV disease Previous Stroke or TIA LVH ECG abnormalities Microalbuminuria or Proteinuria Peripheral Vascular Disease

ASCOT-LLA Lancet 2003;361:1149-58

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Vascular Protection for Hypertensive Pts : ASA

Consider low dose ASA

Caution should be exercised if BP is not controlled.

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Summary I
Regarding the treatment of hypertension, the recommendations endorse: Individualizing therapy consider concomitant risk factors and/or concurrent diseases (i.e., diabetes, CVD, renal disease) Treating to target BP treat aggressively to achieve individualized targets

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Summary II
Regarding the treatment of hypertension, the recommendations endorse: Lifestyle modification alone if effective to reach the goal value or in combination with pharmacological treatment

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Summary III
Regarding the treatment of hypertension, the recommendations endorse: Using combination therapy the addition of medications in combination to achieve BP targets is preferred over maximal dose titration or serially switching drugs Promoting adherence a multi-faceted approach should be used to improve adherence with both non pharmacological and pharmacological strategies

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Summary IV
Hypertension is a major factor responsible for progression of atherosclerotic disease. Therefore, a comprehensive treatment of hypertension should aim at CV risk reduction strategies, including management of all associated risk factors.

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Important Messages for the Management of Hypertension

Expedite the diagnosis of hypertension Assess the risk Treat to target Lifestyle Combination therapy Promote adherence

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