Hypertension Guidelines

This section of the site on hypertension guidelines even though relevant and worth reading to ordinary readers including hypertension patients, it is also targeted at medical practitioners who deal with hypertension management on a daily basis.

Hypertension guidelines are designed for the more effective management of hypertension in clinical practice. They are refereed to by doctors and practitioners time and again in treating and dealing with with specific types of hypertension such as malignant hypertension and pulmonary hypertension symptoms.

7.1 million people die from high blood pressure on an annual basis worldwide. The causes of hypertension are not fully known. Added to that hypertension symptoms are not always present and often surface when its getting very late. Management of hypertension is therefore a worldwide issue with most of diagonised hypertensives inadequately controlled. This is critical for the purposes of hypertension treatment.

hypertension guidelinesHypertension guidelines are updated on a regular basis and it follows that the leading institution to issue guidelines is the UN's World Health Organization (WHO). The American Heart Association also publishes guidelines on hypertension as well as some institutions in the UK such as the National Institute for Health and Clinical Excellence a part of the NHS. Other many health and medical institutions at a national level in different countries may also release own guidelines.

Guidelines for hypertension amongst other specific things are designed and meant to;

  • Help doctors how they should find out whether a person has hypertension
  • Reveal how lifestyle factors such as smoking, diet, eating habits, and body exercise can affect hypertension
  • Guide practitioners on the use of medications for lowering blood pressure
  • How practitioners would access risk of cardiovascular disease in persons with high blood pressure
  • Guide practitioners on monitoring hypertension
  • Help with hypertension screening
  • Help with managing hypertension during pregnancy
  • Dealing with resistance to blood pressure treatment

At the WHO level in 1999 there were some guidelines in use which were eventually updated in 2003 after some key weaknesses were pointed within the medical community;

  1. Possible lack of applicability to developing countries where there are limited resources.
  2. Possible involvement of pharmaceutical interests evidenced by strong bias and emphasis on use of pharmacological (drug) therapy to lower blood pressure.
  3. Hypertension diet has been shown to significantly reduce or even eliminate blood pressure.
  4. Lack of documentary evidence supporting the guidelines
  5. Failure to an extent of the guidelines to reflect the needs of both practitioners and patients

The said update of the guidelines that followed in 2003 emphasized an evidence based process for recommendations. The group of experts involved this time represented key constituencies namely general practitioners, doctors, nurse practitioners and specialists. Potential conflict of interest was also fully disclosed and would be fully disclosed going forward. All expenses for the 2003 hypertension guidelines update were paid for by the WHO itself.

Evidence that is showing up supporting the various hypertension guidelines on hypertension management indicate that of all disease burden facing the globe today; hypertension holds a 4.5% stake and is present in both developed and developing societies. The current prevalence of hypertension in developing country's urban societies is as high as those recorded in developed countries.

The WHO 2003 update on guidelines for hypertension further argues that it is increasingly evident that risks of stroke, ischemic heart disease and renal failure are not confined to a subset of the population with particularly high levels of blood pressure. The risks rather occur in a continuum, affecting even those below average levels of BP.

The World Health Organisation in its hypertension guidelines notes that when deciding on hypertensive management in patients; more than blood pressure numbers should be taken into account but also the presence of other cardiovascular risk factors, target organ damage and associated clinical conditions.

The UN notes that there is obviously a strong link between high blood pressure and cardiovascular disease as blood pressure induced cardiovascular risk rises continuously across the whole blood pressure range.

The following are some guidelines issued in 2006 (but still valid in early 2010) by the British NHS. Please note that hypertension guidelines are constantly updated based on new findings and development of new drugs for treatment amongst other things and should constantly be checked for relevancy;

  • In hypertensive patients aged 55 or over, or black patients of any age, the first choice for initial therapy should be either a calcium-channel blocker or a thiazide-type diuretic.
  • In hypertensive patients younger than 55, the first choice for initial therapy should be an ACE inhibitor.
  • If initial therapy was with a calcium-channel blocker or a thiazide-type diuretic and a second drug is required, add an ACE inhibitor. If initial therapy was with an ACE inhibitor, add a calcium-channel blocker or a thiazide-type diuretic.
  • If treatment with three drugs is required, the combination of ACE inhibitor, calciumchannel blocker and thiazide-type diuretic should be used.
  • If blood pressure remains uncontrolled on adequate doses of three drugs, consider adding a fourth and/or seeking expert advice.
  • If a fourth drug is required, one of the following should be considered a higher dose of a thiazide-type diuretic or the addition of another diuretic (careful monitoring is recommended) or beta-blockers or selective alpha-blockers.
  • If blood pressure remains uncontrolled on adequate doses of four drugs and expert advice has not yet been obtained, this should now be sought.
  • In patients whose blood pressure is not controlled (ie over 140/90 mmHg) despite a treatment regimen including a beta-blocker, treatment should be revised according to the treatment algorithm
  • In patients whose blood pressure is well-controlled (ie 140/90 mmHg or lower) with a regimen which includes a beta-blocker, long-term management should be considered as part of their routine review. In these patients, there is no absolute need to replace the beta-blocker with an alternative agent.
  • When a beta-blocker is withdrawn, the dose should be stepped down gradually.Beta-blockers should not be withdrawn in patients with compelling indications forbeta-blockade, for example those who have symptomatic angina or who have had amyocardial infarction.
  • Provide appropriate guidance and materials about the benefits of drugs andthe unwanted side effects sometimes experienced in order to help patients makeinformed choices.
  • Offer drug therapy, adding different drugs if necessary, to achieve a target of 140/90 mmHg, or until further treatment is inappropriate or declined. Titratedrug doses as described in the British National Formular noting any cautions and contraindications.
  • Offer patients with isolated systolic hypertension (systolic BP >140 mmHg) the same treatment as patients with both raised systolic and diastolic blood pressure.
  • Offer patients over 80 years of age the same treatment as other patients over 55,taking account of any co-morbidity and their existing burden of drug use.
  • Where possible, recommend treatment with drugs taken only once a day.
    Prescribe non-proprietary drugs where these are appropriate and minimize cost.

In April 2008 for the first time ever the American Heart Association issued specific hypertension guidelines to assist patients and health care providers to deal with resistant hypertension that seems to stubbornly defy treatment.

According to the American Heart Association high blood pressure is said to be defiant if it remains above goal despite the taking of three medications to lower it. Hypertension that is under control but requires more medication i.e four or more drugs to treat is also called resistant to treatment. It is estimated that up to 30% of people with high blood pressure may actually be suffering from resistant hypertension.

The hypertension guidelines offer specific recommendations if resistant high blood pressure is to be treated;

Lifestyle factors

Weight - weigh loss has tremendous benefits to patients including use of less drugs. Obesity is associated with more severe hypertension. There is also relationship between caffeine and blood pressure which might result in spikes in blood pressure especially in hypertension-prone individuals like those who are obese

Sodium - Reducing salt intake to 2300mg per day or even 1500mg per day is immensely beneficial even in salt-sensitive patients. Links have been established between high dietary salt intake and hypertension. the association between salt and high blood pressure is well researched.

Alcohol - Heavy alcohol consumption should be strongly discouraged as it is associated with resistant high blood pressure. The association between alcohol and high blood pressure is well known to be harmful.

Medication factors

Withdraw interfering drugs - There are specific drugs that increase blood pressure such as aspirin that should be removed or withdrawn. A more effective regimen of drugs to reduce hypertension must be used.

Diuretics - have to used used effectively and in correct amounts. Hypertension clinics report treatment resistance associated with lack of or under use of diuretics for high blood pressure

Dose timing - patients taking any of their hypertensive drugs at bedtime have shown great benefit particularly lower nighttime blood pressure.

Adherence - some patients have a tendency to drop things and skip normal prescribed dosage and treatment regimes. Whilst it may prove expensive to implement case specific attention and management this may produce better results in dealing with hypertension treatment resistance in patients.

Multi-drug regimens - drug combination must be tailored to individual needs taking into account previous benefit, history of adverse effects, and other medical conditions that would include kidney disease, diabetes and others as well as patient financial limitations which might also play into adherence above.

Mineralocorticoid receptor antagonist - may provide considerable hypertensive benefit when added to existing multi-drug regimens.

As demonstrated above, hypertension guidelines are indispensable. They are essential for practitioners as well as for researching patients to know what affects their health and quest to control, reduce or eliminate high blood pressure.

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