|
GPAC: Guidelines and Protocols Advisory Committee Hypertension - Detection, Diagnosis and Management Effective Date: February 15, 2008 Summary | Flow Sheet | Patient Guide | Full Guideline in PDF Recommendations and TopicsScopeThis guideline focuses on the detection, diagnosis and management of hypertension (HT) in non-pregnant adults (age 19 years and older). Hypertension in each category is defined by an elevation of the systolic or diastolic threshold or both.  PART 1: Detection and DiagnosisBlood Pressure Assessment A baseline blood pressure (BP) should be established in all adults and reassessed periodically, commensurate with age and the presence of other risk factors.1 Details of proper technique and equipment are included in Appendix A. Blood pressure monitoring should be rigorous in those patients who:
* Target organ damage includes: cerebrovascular disease, coronary heart disease (CHD), left ventricular hypertrophy (LVH), chronic kidney disease (CKD), peripheral vascular disease and hypertensive retinopathy. Algorithm for the Detection and Diagnosis of Hypertension (see Algorithm 1) Investigations and Risk Assessment
** Detection of microalbuminuria as an indicator of kidney damage may be helpful when choosing a management strategy for hypertension. Currently, there is some evidence showing that angiotensin converting enzyme inhibitors (ACEI) do improve cardiovascular outcomes for patients with microalbuminuria.3 Algorithm 1: Detection and diagnosis of hypertension * Rule out exogenous factors, for example: NSAIDS, steroids, oral contraceptives, decongestants, alcohol, stimulants, salt, sleep apnea ** Assess BP for the diagnosis of hypertension:
*** Investigations and risk assessment: Urinalysis; blood chemistry (potassium, sodium, creatinine/estimated glomerular filtration rate); fasting blood glucose; fasting total cholesterol; high-density lipoprotein; low-density lipoprotein; triglycerides; standard 12 lead electrocardiogram; microalbuminuria (albumin/creatinine ratio); Framingham risk assessment (10-year CHD risk) or UKPDS risk assessment if Type II Diabetes. Note: 24-hour ambulatory blood pressure measurement may provide information on white-coat hypertension and may also be helpful in assessing patients with apparent drug resistance, hypotensive symptoms with antihypertensive medications, episodic hypertension and autonomic dysfunction.4 PART 2: ManagementA flow sheet is included in this guideline (Appendix D) to help facilitate care for your hypertensive patients. The Framingham Risk Assessment Chart (Appendix B) is designed to estimate 10-year coronary heart disease (CHD) risk in adults who do not have heart disease or diabetes. For the purpose of this guideline, CHD risk is used as a proxy for cardiovascular disease risk. The risk of stroke is approximately 25% of CHD risk.5 The risk factors included in the Framingham calculation are: gender, age, total cholesterol, HDL cholesterol, systolic blood pressure, treatment for hypertension and cigarette smoking. The Framingham Risk Assessment Chart is a useful tool for estimating CHD risk in hypertensive patients, and may help inform your treatment decisions. Blood Pressure Readings and the Management of Hypertension The management of essential hypertension requires patient lifestyle management and/or therapeutic intervention to work towards the following blood pressure readings: Table 1: Desirable blood pressure readings* † ‡ * The benefits of initiating antihypertensive therapy when mild to moderate hypertension is first diagnosed after the age of 80 years are still uncertain.7 Treatment can be continued with caution in previously treated patients after the age of 80 years. † The risk of a systolic blood pressure in the range of 140 to 160 and/or a diastolic blood pressure in the range of 90 to 100, in the absence of target organ damage or other risk factors, is small and may not outweigh the potential harms of pharmacologic treatment in all patients. ‡ Exercise caution in patients who have a diastolic BP close to 60, and regardless of BP, reassess the need for treatment if hypotensive symptoms exist. Review patient at monthly intervals until BP is in the desired range for two consecutive visits. Then review every 3-6 months (as long as the patient remains stable). At each visit:
At least annually:
As a diagnosis is being established, provide adequate explanation and support to patients so that they clearly understand the nature and significance of this condition, and that they have the primary responsibility for the management of their blood pressure. Provide patients with information on available community support, such as those offered by the Heart and Stroke Foundation, including self-management courses (see Hypertension Patient Guide). Offer and review the following lifestyle recommendations at each visit:
Pharmacologic Treatment An effective, individualized plan for the management of hypertension requires that benefits are considered along with potential harms. Periodically, consideration may be given to discontinuing or reducing antihypertensive medications to assess the appropriate level of pharmacologic management. 1. Indications for drug therapy in uncomplicated hypertension1 The benefits of pharmacologic treatment in people with mild hypertension (an average blood pressure between 140/90 and 160/100), and a 10-year CHD risk of less than 20% are unclear (Table 2). Use clinical judgement when recommending therapy for this patient group. Pharmacologic treatment in addition to lifestyle modification is recommended for patients with an average blood pressure ≥ 160/100, even in the absence of other major cardiovascular risk factors. Table 2: Benefits of blood pressure lowering with medication in patients with mild hypertension8 2. Treatment of uncomplicated hypertension Consider monotherapy with a low-dose thiazide diuretic as first-line treatment. If blood pressure is not adequately controlled, use combination therapy by adding one or more of the following agents:
Note:
Consideration should also be given to the addition of low-dose ASA therapy in hypertensive patients with a Framingham risk score of ≥ 20% who are between 50 and 70 years-of-age. Avoid using ASA in patients with a history of hemorrhagic stroke. Blood pressure must be well controlled.11,12 3. First-line treatment for hypertension complicated by co-morbid conditions1 It is important to control co-morbid conditions optimally when managing hypertension. Pharmacologic treatment must be chosen with even more care in these individuals. The following table lists recommended medications for consideration when individualizing antihypertensive drug therapy. See Appendix F for a list of commonly prescribed antihypertensive medications in each class. Table 3: First-line treatment of hypertension complicated by co-morbid conditions 4. Contraindications to antihypertensive medications Table 4: Contraindications to antihypertensive medications The investigation and management of secondary causes of hypertension is beyond the scope of this guideline. Please consult current medical texts for investigation and management advice, or consider referral to an appropriate specialist. For some examples of secondary causes of hypertension, refer to Appendix G. RationaleThe following subsections include a brief overview of the literature used to generate recommendations for this guideline. The final subsection provides the methodology used for obtaining evidence and describes the types of evidence used throughout this guideline. Hypertension (HT) remains a major public health issue in Canada. Although the diagnosis and treatment of HT appears simple, this disease remains poorly managed; for example, it is estimated that only 50% of Canadians with hypertension are aware of their diagnosis and that only 16% of Canadians with hypertension have adequate BP control.1 Combined, heart disease and stroke are the leading cause of death, accounting for one in three deaths in BC.13 Hypertension is a significant and controllable risk factor for heart disease, stroke, heart failure, renal disease and recurrent cardiovascular events.6 Hypertension is also the most common indication in Canada for visits by adults to physicians.14 The benefits of lowering blood pressure in certain settings with lifestyle changes and certain drugs have been well documented. Reductions in mortality,6,8,15 cardiovascular events,4,8,15,16 left ventricular hypertrophy,4 stroke and myocardial infarction,8,15,17 dementia,18,19 deterioration of renal function,4,15,20 renal failure20 and incidence of diabetes15 have all been associated with successful treatment of hypertension. Evidence: Evidence was obtained through a systematic review of peer-reviewed literature (up to May, 2007) using the databases MEDLINE, PubMed, EBSCO, Ovid, and the Cochrane Collaboration's Database for Systematic Reviews. Clinical practice guidelines from other jurisdictions for the prevention and management of hypertension, diabetes, chronic kidney disease, dyslipidemia, congestive heart failure, cerebrovascular disease and overweight/obesity were also reviewed (up to May 2007). Recommendations are based on large, randomized controlled trials (RCTs) wherever possible. Lifestyle recommendations are based on large, prospective cohort trials. References
ResourcesThe BC HealthGuide Online provides detailed information on managing hypertension. Web site: www.bchealthguide.org (search word: high blood pressure) The Heart and Stroke Foundation of Canada offers excellent materials for the control of lifestyle factors that contribute to hypertension, heart disease, stroke and kidney disease. This includes public recommendations for the control of high blood pressure, the Blood Pressure Action Plan™ (an online e-tool to help you control your blood pressure), a body mass index calculator, a risk factor calculator and specific dietary information. Web site: www.heartandstroke.ca. Telephone: 1 888 473-4636 (Toll free) (BC/Yukon division office) The Canadian Hypertension Society has more detailed information regarding hypertension and blood pressure. Web site: www.hypertension.ca. Dial-A-Dietitian provides accessible, quality information to the public and health information providers throughout British Columbia about nutrition. Registered dietitians provide nutrition consultation by phone. Web site: www.dialadietitian.org. Telephone 1 800 667-3438 (Toll free) or 604 732-9191 (Greater Vancouver) American Heart Association Web site: www.americanheart.org (search word: high blood pressure) Mayo Clinic Web site: www.mayoclinic.com (search word: high blood pressure) Healthy Heart Society of BC Web site: www.heartbc.ca/public/BP.htm AppendicesAppendix A: Recommended Technique for Measuring Blood Pressure Appendix B: Framingham Instruction Sheet and Risk Assessment Chart Appendix C: Home Blood Pressure Monitoring Worksheet Appendix D: Hypertension Care Flow Sheet Appendix E: Dietary Approaches to Stop Hypertension (DASH) Appendix F: Antihypertensive Drugs Appendix G: Examples of Secondary Causes of Hypertension SponsorsThis guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission. This guideline is based on scientific evidence current as of the effective date. The principles of the Guidelines and Protocols Advisory Committee are to:
DisclaimerThe Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems. PDF Format Some documents on this Web site are in PDF format and require a PDF reader. If you do not have Adobe Acrobat Reader Version 7.0 or the most recent version of another PDF reader, you can download Adobe Acrobat Reader by clicking on the 'Get Acrobat Reader' icon.
|
 |
|
|
|||
