Guidelines for Management of Mild Hypertension

Cross River State Ministry of Health

Clinical Guidelines & Audit Unit

June 2004

INTRODUCTION

This guideline is designed for the management of patients with mild hypertension since there is often uncertainty among clinicians on how best to manage the condition.

The guideline is not meant for management of moderate or severe hypertension. The decision on the modality of treatment should not be based on the level of blood pressure alone but also on the presence of other risk factors; concomitant diseases such as diabetes, target organ damage, cardiovascular or renal diseases, as well as other aspects of the patients’ personal, medical and social condition.

CLINICAL PRESENTATION

Symptoms   

Most times, hypertension does not present with any symptoms. Occasionally the patient may complain of headache, poor or inability to sleep. A history of risk factors such as smoking, alcohol intake, family history of hypertension is important here.

Signs

The key clinical sign in uncomplicated hypertension is a raised blood pressure above the normal range as defined below.

Diagnostic criteria

Mild hypertension is defined as a systolic blood pressure of 140 to 159 mmHg and/or diastolic of 90 to 99 mmHg.^1[D}

Note – At least three readings are needed to confirm diagnosis. Single reading may be unreliable.

Investigations

Individuals with mild blood pressure elevation should have a physical examination and basic laboratory investigations performed as part of initial assessment. These investigations will help to:

q       identify secondary causes of hypertension,

q       determine the presence of target organ damage,

q       assess the extent of damage if any,

q       identify other cardiovascular risk factors and clinical conditions that may influence prognosis and treatment.

The investigations to be carried out include:

1.      Haemoglobin level

2.      Urea / Electrolytes / Creatinine

3.      Urinalysis for proteinuria

4.      Chest X-ray

5.      Electrocardiography

6.      Fasting blood sugar

7.      Lipid profile (if possible)

Treatment

Young and middle-aged adults (18 – 59 years).

Advice on lifestyle modification^{2 [A1]}:

—    Weight reduction^{3 [A1]} 

—    Decreased salt intake^{4 [A1], 5 [C]}

—    Encourage exercises (gradual build up exercise)^{6 [B]}

—    Reduction in alcohol intake^{7 [B]}

—    Cessation of smoking^{8 [B]}

—   Diet – decreased intake of fats from animal sources^{9 [A1]}

Life style modifications should be applied for the first 3 months.

If still hypertensive i.e. systolic of ≥ 140mmHg and/or diastolic of ≥ 90mmHg then institute drug treatment^{10 [D]}

Elderly (≥ 60 years).

At ≥140mmHg systolic, and diastolic of ≥90mmHg, drug treatment is indicated only if there is co-morbidity e.g. diabetes, heart disease – otherwise use life style modification as for young and middle-ages adults.

For isolated Systolic Hypertension in the elderly where Blood Pressure ≥160mmHg systolic and diastollic ≤ 90mmhg, institute drug treatment,¹¹ as well as life style modification.

Note: When the readings fall into 2 categories, the higher level determines the person’s blood pressure grading.

DRUG TREATMENT 

First line

Thiazide diuretic^* (low dose) e.g. Bendrofluazide^12[B]. Increase dose as necessary and review response in 3 months. If no satisfactory reduction, any other class of antihypertensive may be added as necessary bearing in mind any associated co-morbidity e.g.

For diabetes mellitus                                    -            ACE inhibitors^{13 [A1]}

Ischaemic heart disease                  -                       Ca channel blockers and/or

β – blockers

Renal disease                                   -                       ACE Inhibitor or α – blockers

Left ventricular hypertrophy             -                        ACE Inhibitors^{14 [A1]}

Heart failure                                       -                       ACE Inhibitors                                   

*A peer reviewer has commented on the likelihood that thiazides raise blood sugar. This, however, has not been shown to cause diabetes mellitus.

TREATMENT GOALS

The treatment aims at reducing the blood pressure to:

Systolic           -           ≤ 130mmHg

Diastolic          -           ≤ 85mmHg

in the young and middle-aged adults as well as diabetics and

Systolic           -           ≤ 140mmHg

Diastolic          -           ≤ 90mmHg

in the elderly.

FOLLOW-UP

Follow-up is generally sufficient once patients are stabilized. There should be Regular monitoring of

q       Weight

q       Blood Pressure

q       Review of life style

q       Check for end organ complications

q       Adherence to treatment.

PREVENTION

        I.      Healthy life style

      II.      Check Blood Pressure at every opportunity, especially among the high risk group and at least once a year. Examples of those at risk include

q       The obese

q       Smokers

q       Diabetics

q       Those with a family history of hypertension

References

1.      WHO / ISH Guidelines for management of Hypertension 1999

2.      Elmer PJ, Grimm R Jr, Laing B, Grandits G, Svendsen K, Van Heel N, Betz E, Raines J, Link M, Stamler J. Lifestyle intervention: results of the Treatment of Mild Hypertension Study (TOMHS). Preventive Medicine 1995; 24(4): 378-88

3.      Mulrow CD,  Chiquette E, Angel L, Cornell J, Summerbell C, Anagnostelis B, Brand M, Grimm R Jr. Dieting to reduce body weight for controlling hypertension in adults. (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update Software

4.      Hooper L, Bartlett C, Davey Smith G, Ebrahim S. Reduced dietary salt for prevention of cardiovascular disease  (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update Software

5.      Forte JG, Miguel JM, Miguel MJ, de Padua F, Rose G Salt and blood pressure: a community trial. Journal of Human Hypertension 1989; 3(3) 179-84

6.     Martin J, Dubbert PM, Clishman WC: Controlled trial of aerobic exercise in hypertension. Circulation. 1990; 81: 1560 – 1567

7.      Puddey IB, Beillin, LJ, Vandongen R, Rouse IL, Rogers P: Evidence for a direct effect of alcohol consumption on BP in normotensive men: a randomized control trial. Hypertension. 1985; 7(5): 707 – 713

8.      Leistikow B N, Shipley M J. Might stop smoking reduce injury death risks: a meta-analysis of randomized controlled trials. Preventive Medicine. 1999. 28. 255-259 

9.      Hooper L, Summerbell CD, Higgins JPT, Thompson RL, Clements G, Capps N, Davey Smith G, Riemersma RA, Ebrahim S. Reduced or modified dietary fat for preventing cardiovascular disease (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update software

10. The Treatment of Mild hypertension Research Group. The treatment of mild hypertension study: A randomized placebo-controlled trial of a nutritional hygienic regimen along with various drug monotherapies. Arch. Intern. Med. 1991; 151: 1413 – 1423

11. Perry HM Jr, Davis BR, Price TR, Applegate WB, Fields WS, Guralnik JM, Kuller L, Pressel S, Stamler J, Probstfield JL. Effect of treating isolated systolic hypertension on the risk of developing various types and subtypes of stroke: the Systolic Hypertension in the Elderly Program (SHEP). JAMA 2000; 284(4): 465-71

12.  Saveli, P et al: Efficacy of difficult drug classes used to initiate antihypertension in black subjects: Results of a RCT Johannesburg – Archiv of Int. Med.; 161 (201) 965 – 971.

13.  Kshirsagar AV, Joy MS, Hogan SL, Falk RJ, Colindres RE. Effect of ACE inhibitors in diabetic and nondiabetic chronic renal disease: a systematic overview of randomized placebo-controlled trials. American Journal of Kidney Diseases [Online] 2000; 35(4): 695-707

14.  Schmieder RE, Schlaich MP, Klingbeil AU, Martus P. Update on reversal of left ventricular hypertrophy in essential hypertension (a meta-analysis of all randomized double-blind studies until December 1996). Nephrology Dialysis Transplantation, 1998; 13(3): 564-9

APPENDIX 1

Diagnostic Criteria¹

Classification of BP for Adults age 18 years and older

APPENDIX 2

Levels of Evidence

A1       Systematic review of randomised controlled trials

A2       Individual RCTs > 80% follow up

B          Systematic reviews of cohort or case-control studies with homogeneity, large individual cohort or case –control study, RCTs with <80% follow up.

C         Case-series and poor quality cohort or case-control studies.

D         Expert opinion without explicit critical appraisal.

ACKNOWLEDGEMENTS

Guidelines Development Group

1.       Dr Angela Oyo-Ita                            Community Physician, UCTH

2.       Dr Philip E. Bassey                         Asst. Director Public Health MOH

3.       Dr Esu Oyo-Ita                                Director of Medical Services MOH

4.       Dr Charles Iwara                             Assistant Director Medical Services MOH.

5.       Dr Victor Ansa                                 Consultant Physician, UCTH

6.       Dr A.E Offiong                                 Chief Medical Officer, MOH

7.       Dr Kuma P.                                     Senior Medical Officer, General Hospital, Calabar

8.       Dr Martin Meremikwu                       Associate Professor Paediatrics Unical (EHCAP Nigeria

Coordinator)

Consultant

Dr Cyprian Okoro of London School of Hygiene & Tropical Medicine and EHCAP, Liverpool School of Tropical Medicine.

Peer Review

This guideline (Treating of Uncomplicated Typhoid Fever was peer-reviewed by Prof. S.J. Utsalo, Department of Microbiology, University of Calabar, Calabar Nigeria.

Support

  The Cross River State Ministry of Health

  Effective Health Care Alliance Programme, Liverpool School of Tropical Medicine*

  The UK Department for International Development (DFID) supports EHCAP

  Institute of Tropical Diseases Research and Prevention