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© Ministry of Health, Malaysia 2010

First published 2010

Disease Control Division


Ministry of Health, Malaysia
Level 6, Block E10, Parcel E
Federal Government Administration Centre
62590 PUTRAJAYA

Tel: 03-8883 4145 Fax: 03-8888 6277


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HYPERTENSION GUIDELINE
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

WORKING GROUP
CHAIRPERSON Dr. Robaayah Zambahari
Dr. Abdul Rashid A. Rahman Senior Consultant Cardiologist,
Professor of Medicine & Clinical Pharmacology National Heart Institute,
and Senior Consultant Physician, Kuala Lumpur
Cyberjaya University College of Medical
Sciences and An Nur Specialist Hospital, Dr. Zaleha Abdullah Mahdy
Selangor Professor and Senior Consultant Obstetrician
& Gynaecologist,
SECRETARY Hospital Universiti Kebangsaan Malaysia,
Dr. Sunita Bavanandan Kuala Lumpur
Consultant Nephrologist,
Kuala Lumpur Hospital, Dr. Hj. Azhari Rosman
Kuala Lumpur Consultant Cardiologist & Electrophysiologist,
National Heart Institute,
HYPERTENSION GUIDELINE WORKING GROUP

Dr. Anis Salwa Kamaruddin Kuala Lumpur


Principal Assistant Director,
Desease Control Division, Dr. Chua Chin Teong
Ministry of Health, Consultant Nephrologist,
Putrajaya Selangor

Dr. Chia Yook Chin Dr. Faridah Aryani Md. Yusof


Professor of Primary Care Medicine and Clinical Trial Pharmacist and
Senior Consultant Primary Care Physician, Pharmacoeconomist,
University Malaya Medical Centre, Clinical Research Centre,
Kuala Lumpur Kuala Lumpur Hospital,
Kuala Lumpur
Dr. Fan Kin Sing
Consultant Nephrologist, Dr. Guna Segaran
Gleanagles Intan Medical Centre, Consultant Obstetrician and
Kuala Lumpur Gynaecologist,
Damansara Specialist Hospital,
Dr. Ghazali Ahmad Selangor
Consultant Nephrologist and
Head of Department, Dr. Khoo Kah Lim
Department of Nephrology, Consultant Cardiologist,
Kuala Lumpur Hospital, Pantai Medical Centre,
Kuala Lumpur Kuala Lumpur

Dr. Khoo Ee Ming Dr. Lim Yam Ngo


Professor of Primary Care Medicine and Consultant Paediatric Nephorologist,
Senior Consultant Primary Care Physician, Kuala Lumpur Hospital,
University Malaya Medical Centre, Kuala Lumpur
Kuala Lumpur
Dr. Yap Piang Kian
Dr. Khalid Yusoff Consultant Physician & Endocrinologist,
Professor of Medicine and Subang Jaya Medical Centre,
Senior Consultant Cardiologist Selangor
University Technology MARA, Selangor
EDITORS
Associate Professor Dr. Anis Safura Ramli Dr. Feisul Idzwan Mustapha
Consultant Family Medicine Specialist, Public Heath Specialist and
Head of Primary Care Medicine Discipline, Senior Principal Assistant Director,
Faculty of Medicine, Disease Control Division,
Universiti Teknologi MARA (UiTM), Ministry of Health, Malaysia
Sungai Buloh Campus
Dr. Norhayati Ab. Shatar
Dr. Ng. Kien Keat Medical Officer,
Senior Lecturer & Family Medicine Specialist, Principal Assistant Director,
Primary Care Medicine Discipline, Disease Control Division,
Faculty of Medicine, Ministry of Health, Malaysia
Universiti Teknologi MARA (UiTM),
Sungai Buloh Campus

Dr. Mastura Ismail


Consultant Family Medicine Specialist,
Klinik Kesihatan Seremban 2, Negeri Sembilan

CONTRIBUTORS

EDITORS & CONTRIBUTORS


Professor Dr. Teng Cheong Lieng Dr. Ambigga Devi S. Krishnapillai
Senior Consultant Family Medicine Specialist, Senior Lecturer & Family Medicine Specialist,
International Medical University (IMU), Bukit Jalil Universiti Teknologi Mara (UiTM), Sungai Buloh

Associate Professor Dr. Tong Seng Fah Dr. Maizatullifah Miskan


Consultant Family Medicine Specialist, Senior Lecturer & Family Medicine Specialist,
Universiti Kebangsaan Malaysia (UKM), Bangi Universiti Teknologi Mara (UiTM), Sungai Buloh

Associate Professor Dr. Anis Safura Ramli Dr. Ng Kien Keat


Consultant Family Medicine Specialist, Senior Lecturer & Family Medicine Specialist,
Universiti Teknologi Mara (UiTM), Sungai Buloh Universiti Teknologi Mara (UiTM), Sungai Buloh

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
Dr. Mastura Ismail Dr. Mazapuspavina Md. Yasin
Consultant Family Medicine Specialist, Senior Lecturer & Family Medicine Specialist,
Klinik Kesihatan Seremban 2, Negeri Sembilan Universiti Teknologi Mara (UiTM), Sungai Buloh

Dr. Suhazeli Abdullah Dr. Farnaza Ariffin


Consultant Family Medicine Specialist, Senior Lecturer & Family Medicine Specialist,
Klinik Kesihatan Marang, Terengganu Universiti Teknologi Mara (UiTM), Sungai Buloh

Dr. Verna Lee Kar Mun Dr. Nafiza Mat Nasir


Senior Lecturer & Family Medicine Specialist, Senior Lecturer & Family Medicine Specialist,
International Medical University (IMU), Bukit Jalil Universiti Teknologi Mara (UiTM), Sungai Buloh

Dr. Chew Boon How


Senior Lecturer & Family Medicine Specialist,
Universiti Putra Malaysia (UPM), Serdang

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TABLE OF CONTENTS
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

Hypertension Guideline Working Group ii

Editors & Contributors iii

Introduction v

Topic 1 Introduction & Overview of Hypertension Burden in Malaysia 1

Topic 2 Diagnosis and Management of Pre-hypertension 21

Topic 3 Diagnosis and Management of Stage 1 Hypertension 31

Topic 4 Diagnosis and Management of Stage 2 Hypertension & 43


TABLE OF CONTENTS

Resistant Hypertension

Topic 5 Diagnosis and Management of Stage 3 Hypertension 53

Topic 6 Hypertension and Diabetes 63

Topic 7 Hypertension and Metabolic Syndrome 73

Topic 8 Hypertension and Cardiovascular Disease 79

Topic 9 Hypertension and Stroke 87

Topic 10 Hypertension in the Elderly 101

Topic 11 Hypertension in Pregnancy 107

Topic 12 Hypertension and Oral Contraceptive Pills 117

Topic 13 Hypertension and Hormone Replacement Therapy 121

Topic 14 Workshop on Blood Pressure Measurement 129


(Techniques & Skills)

Appendix Pre-test and Post-test questionnaires (MCQs) 135


INTRODUCTION
The Clinical Practice Guidelines (CPG) on the Management of Hypertension (3rd Edition) was
published in February 2008 and the Quick Reference (QR) for Health Care Providers was published
in January 2010.

OBJECTIVE
This Training Module is developed to assist the ‘trainers’ to:
1. Deliver the key content and messages of the CPG systematically.
2. Demonstrate the applicability of CPG recommendations in clinical practice via interactive case
discussions.
3. Offer implementation strategies for effective hypertension management based on key elements
of the Wagner Chronic Care Model.

This document contains the following:


1. CD-ROM containing the powerpoint presentations.
2. Introduction and summary of training module content.
3. Interactive case discussions in the beginning of each topic.
4. Pre-test and post-test questionnaire (MCQs).
5. Evaluation feedback of the training session.

Target Audience:
All levels of health care providers involved with the care of hypertensive patients in both primary
care and secondary care settings.

INTRODUCTION
Clinical Questions
In tandem with the main CPG, the clinical questions to be addressed in this training module include:
1. What are the current best practices in the management of a patient with hypertension?
2. How can hypertension management be done in tandem with the overall strategy to manage
global vascular risk of a patient?
3. How can we improve the outcome of care for hypertensive patients?

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
Key Recommendations for Successful Implementation of this Training
Module:
1. Use interactive group discussion methods, rather than didactic way of teaching.
2. Gauge the learning and language used (English/Malay/Others) to the level of target audience
(suited to various levels of health care providers).
3. Use problem-based facilitating methods.
4. Encourage participants to familiarize themselves with the CPG and the QR prior to the training
session (prerequisite).
5. Emphasize teamwork.
6. Allow participants to express their ideas, concerns and expectations openly.
7. Address issues constructively.
8. Obtain systematic feedback from participants.

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Key implementation strategies to improve outcome for patients with


MANAGEMENT OF HYPERTENSION (3rd Edition)

chronic conditions in primary care (Adapted from the Wagner Chronic Care
Model and WHO Innovative Care for Chronic Conditions Framework):

Key Elements Implementation Strategies Level of actions

Delivery system • Redesign the delivery system using MESO LEVEL*


redesign multidisciplinary care teams, supported by • District Health Office
mutually understood care plan and • Primary Health Care
pathways.* Team
• Define roles and tasks among team
members.*
• Stratify patients by risks and provide case
management for those who are most at risk.*
• Involve secondary care specialists and
create mutually agreed shared care plans for
patients with severe complications and
end-stage disease.*
INTRODUCTION

Clinical information • Develop national# and local chronic disease MACRO LEVEL#
systems registries.* • Policy makers
• Use electronic medical record and
appointment system.* MESO LEVEL*
• Use electronic prescribing, reminder and • Primary Health Care
alerts on potential drug interaction and test Team
results.*
• Create paper-based registries and MICRO LEVEL*
comprehensive medical records in resource- • Individual doctors and
limited setting.* allied health care
providers

Decision support • Embed evidence-based clinical guidelines MESO LEVEL*


recommendations into the structure of • Primary Health Care
day-to-day decision-making process e.g. Team
electronic reminders, academic detailing,
etc.* MICRO LEVEL*
• Make patients aware of the evidence- • Individual doctors and
based guidelines recommendations e.g. allied health care
treatment targets, choice of therapy, etc.* providers

Patient self- • Empower patients and their families with MESO LEVEL*
management knowledge, skills and confidence to take • Primary Health Care
support effective control over their chronic Team
• Provide self-management tools, and
routinely assess problems and MICRO LEVEL*
accomplishments.* • Individual doctors and
• Establish ongoing collaborative effort allied health care
between care team and patients for providers
long term benefit.* • Patients and families
Key Elements Implementation Strategies Level of actions

Healthcare • Become the agent of change to transform ALL LEVELS@


organization chronic disease care.@
involvement • Restructure health care system and policy MACRO LEVEL#
with a clear focus to improve chronic • Policy makers
disease care.#
• Create universal funding mechanism to MESO LEVEL*
improve access and equity.# • Primary Health Care
• Provide incentives for achieving clinical Team
targets, enhancing preventive care, or other
quality improvement activities.#
• Perform ongoing clinical audit as part of
quality assurance programme to improve
chronic care quality.*

Community • Develop link with community resources MESO LEVEL*


resources which provide self-management support • Primary Health Care
e.g. self-help groups, non-governmental Team
organizations, etc.*
MICRO LEVEL*
• Individual doctors and
allied health care
providers
• Patients and families

INTRODUCTION
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

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TRAINING MODULE FOR HEALTH CARE PROVIDERS

Summary of Training Module Content


MANAGEMENT OF HYPERTENSION (3rd Edition)

Teaching
Duration
No Topic Objective Content Learning
(minutes)
Method

1. Introduction • To provide an overview of • Epidemiology of Hypertension Lecture 60


& Overview HPT burden in Malaysia • Definition and classification of (45 minutes
of CPG on • To provide the knowledge hypertension introductory
Hypertension based regarding definition, • Measurement of blood pressure lecture +
Management diagnosis, assessment, • Diagnosis and assessment 15 minutes
CV risk stratification and • Cardiovascular risk stratification Q&A)
management of HPT • Algorithm for the management of
• To offer implementation hypertension
strategies for effective • Lifestyle modification advice
hypertension management • Pharmacological Agents
based on key elements of • The Wagner Chronic Care Model
the Wagner Chronic Care • Roles and responsibilities of
Mode multidisciplinary care team in
managing hypertension
• Roles and responsibilities of
INTRODUCTION

patients in self-managing
hypertension
• Key messages

2. Diagnosis and • To highlight the importance • Case scenario 1 Interactive 60


management of opportunistic screening • Management based on CPG case (45 minutes
of Pre- for Pre-hypertension recommendation discussion interactive
hypertension • To highlight the importance • Summary of evidence for the discussion +
of therapeutic lifestyle recommendation 15 minutes
modification in the • Key messages Q&A)
management of
Pre-hypertension

3. Diagnosis and • To highlight the importance • Case scenario 2 Interactive 60


management of opportunistic screening • Management based on CPG case (45 minutes
of Stage 1 of blood pressure recommendation discussion interactive
Hypertension • To highlight the importance • Summary of evidence for the discussion +
of performing CV risk in recommendation 15 minutes
guiding treatment • Key messages Q&A)

4. Diagnosis and • To highlight the importance • Case scenario 3 Interactive 60


management of combination treatment • Management based on CPG case (45 minutes
of Stage 2 in the management of recommendation discussion interactive
Hypertension Stage 2 Hypertension • Summary of evidence for the discussion +
and Resistant • To highlight the importance recommendation 15 minutes
Hypertension of identifying resistant • Key messages Q&A)
hypertension

5. Diagnosis and • To highlight the importance • Case scenario 4 Interactive 60


management of hypertensive urgencies • Management based on CPG case (45 minutes
of Stage 3 and emergencies recommendation discussion interactive
Hypertension • To highlight the importance • Summary of evidence for the discussion +
of assessing for target organ recommendation 15 minutes
damages/complications • Key messages Q&A)
Teaching
Duration
No Topic Objective Content Learning
(minutes)
Method

6. Hypertension • To highlight the importance • Case scenario 5 Interactive 60


and Diabetes of aggressive BP control in • Management based on CPG case (45 minutes
Mellitus Diabetes recommendation discussion interactive
• To highlight the appropriate • Summary of evidence for the discussion +
choice of pharmacological recommendation 15 minutes
treatment according to • Key messages Q&A)
current evidence

7. Hypertension • To highlight the importance • Case scenario 6 Interactive 60


and Metabolic of diagnosing MetS • Management based on CPG case (45 minutes
Syndrome • To highlight the importance recommendation discussion interactive
(MetS) of treating HPT in MetS • Summary of evidence for the discussion +
recommendation 15 minutes
• Key messages Q&A)

8. Hypertension • To appreciate HPT as a • Case scenario 7 Interactive 60


and major risk factor to many • Management based on CPG case (45 minutes
Cardiovascular cardiovascular diseases recommendation discussion interactive
Disease • To make an appropriate • Summary of evidence for the discussion +
choice of recommendation 15 minutes
anti-hypertensive • Key messages Q&A)
medication in patients
with concomitant
cardiovascular disease
• To be aware of the
targets for treatment

9. Hypertension • To highlight the danger of • Case scenario 8 Interactive 60

INTRODUCTION
and Stroke rapid reduction of BP in • Management based on CPG case (45 minutes
patients with acute stroke recommendation discussion interactive
• To highlight the appropriate • Summary of evidence for the discussion +
choice of pharmacological recommendation 15 minutes
treatment according to • Key messages Q&A)
current evidence

10. Hypertension • To highlight the importance • Case scenario 9 Interactive 60

TRAINING MODULE FOR HEALTH CARE PROVIDERS


in the Elderly of treating systolic • Management based on CPG case (45 minutes MANAGEMENT OF HYPERTENSION (3rd Edition)
HPT in elderly recommendation discussion interactive
• To address the issues of • Summary of evidence for the discussion +
polypharmacy in elderly recommendation 15 minutes
• Key messages Q&A)

11. Hypertension • To highlight the • Case scenario 10 Interactive 60


in Pregnancy classifications of • Summary of evidence for the case (45 minutes
Hypertension in Pregnancy recommendation discussion interactive
• To highlight the importance • Summary of evidence for the discussion +
of identifying those at risks recommendation 15 minutes
of developing Hypertension • Key messages Q&A)
in Pregnancy

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TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

Teaching
Duration
Topic Objective Content Learning
(minutes)
Method

12. Hypertension • To highlight the important • Case scenario 11 Interactive 60


and Oral interaction between BP • Management based on CPG case (45 minutes
Contraceptive and OCP recommendation discussion interactive
Pills • Summary of evidence for the discussion +
recommendation 15 minutes
• Key messages Q&A)

13. Hypertension • To highlight the important • Case scenario 12 Interactive 60


and Hormone interaction between BP • Management based on CPG case (45 minutes
Replacement and HRT recommendation discussion interactive
Therapy • Summary of evidence for the discussion +
recommendation 15 minutes
• Key messages Q&A)

14. Workshop on • To demonstrate accurate • Hands-on skills training Workshop 5 60


BP techniques of BP Lecture:
measurement measurements Lecture 20 minutes
INTRODUCTION

(technique followed by Hands-on:


and skills) hands-on 40 minutes
training

15. Assessment • To test the knowledge of • 15 T/F MCQs Pre-test and 60


of knowledge participants pre and post • 15 Single Best Answer (SBA) post test
training Questions questionnaire
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Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

PRESENTATION OUTLINE

• Epidemiology of Hypertension
• Definition
• Measurement of Blood Pressure
• Diagnosis & Classification
• Evaluation & Assessment
• Management Algorithm
• Cardiovascular Risks Stratification
• Therapeutic Lifestyle Modification
• Pharmacological Agents
• The Wagner Chronic Care Model
• Key messages

Slide 2
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

GLOBAL BURDEN FOR HYPERTENSION

An Estimated 972 million individuals worldwide suffer from hypertension in the year 2000.
Kearney et al.

Global burden of hypertension: analysis of worldwide data. Lancet 2005; 365 (9455):217-23
Slide 3
THE RISING EPIDEMIC OF HYPERTENSION

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA


National Health Morbidity Surveys I, II & III (1986-2006)

Slide 4
NHMS III : AWARENESS RATE

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)

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MANAGEMENT OF HYPERTENSION (3rd Edition)
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

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TRAINING MODULE FOR HEALTH CARE PROVIDERS

Slide 6
Slide 5
NHMS III : TREATMENT RATES

NHMS III : CONTROLLED RATE


Slide 7
DEFINITION

Hypertension is defined as persistent elevation of systolic BP of 140 mmHg or greater


and/or diastolic BP of 90 mmHg or greater.

Slide 8
INITIAL ASSESSMENT

Initial BP (mmHg) Follow-up recommended to confirm diagnosis and/or


Systolic Diastolic review response to treatment.

< 130 and < 85 Recheck in one year


130-139 and 85-89 Recheck within 3-6 months

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA


Confirm within two months and treat if medium, high or very
140-159 and/or 90-99
high risks
160-179 and/or 100-109 Evaluate within one month and treat when confirmed
Look for symptoms and sign of hypertensive urgency or
180-209 and/or 110-119 emergency, if asymptomatic, evaluate within one week and
treat whan confirmed

≥ 210 and/or ≥ 120 Initiate drug treatment immediately

Slide 9
DIAGNOSIS & CLASSIFICATION

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
Category Systolic (mmHg) Diastolic (mmHg)

Optimal < 120 and < 80


Diagnosis of
Prehypertension 120-139 and/or 80-89 hypertension is
made based on the
Stage 1 HPT 140-159 and/or 90-99 average of two or
more readings,
Stage 2 HPT 160-179 and/or 100-109 taken at two or
more visits to the
Stage 3 HPT ≥ 180 and/or ≥ 110 health care
providers

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Slide 10
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

EVALUATION

EVALUATION OF NEWLY DIAGNOSED HYPERTENSIVE PATIENTS

Evaluation should include through history, physical examination and relevant


investigations.

Three main objectives:

1. To exclude secondary causes of hypertension

2. To ascertain the presence of target organ damage (TOD)

3. To assess lifestyle and identity other cardiovascular risk factors and/or concomitant
disorders that may affect treatment and prognosis.
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

Slide 11
MEDICAL HISTORY

• duration and level of elevated BP if known


• symptoms of secondary causes of hypertension
• symptoms of target organ damage, e.g. coronary heart disease (CHD) and
cerebrovascular disease
• symptoms of concomitant disease that will affect prognosis or treatment, e.g. diabetes
mellitus, renal disease and gout
• family history of hypertension, CHD, stroke, diabetes, renal disease or dyslipidaemia
• dietary history including salt, fat, caffeine and alcohol intake
• drug history of either prescribed or over-the-counter medication (NSAIDS, nasal
decongestants) and herbal treatment
• lifestyle and environmental factors that will affect treatment and outcome, e.g.
smoking, physical activity, work stress and excessive weight gain since childhood
Slide 12
PHYSICAL EXAMINATIONS

• general examination: height, weight and waist circumference


• two or more BP measurements separated by two minutes with the patient either supine
or seated; and after standing for at least one minute
• measure BP on both arms
• fundoscopy
• look for carotid bruit, abdominal bruit, presence of peripheral pulses and radio-femoral
delay
• cardiac examination
• chest examination for evidence of cardiac failure
• abdominal examination for renal masses, aortic aneurysm and abdominal obesity
• neurological examination to look for evidence of stroke
• signs of endocrine disorders, e.g. Cushing syndrome, acromegaly and thyroid disease

Slide 13

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA


BASELINE INVESTIGATIONS

• Full blood count


• Urinalysis
• Urine albumin excretion or albumin/creatinine ratio
• Renal profile and serum uric acid
• Fasting blood sugar
• Fasting lipid profile
• Electrocardiogram (ECG)
• Chest X-ray (if clinically indicated)

Note : Should be repeated 6-12 monthly thereafter (except for Chest X-Ray)

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MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 14
CARDIOVASCULAR RISK FACTORS

• Hypertension
• Cigarette smoking
• Central obesity (waist circumference > 90 cm for men, > 80 cm for women)
• Physical inactivity
• Dyslipidaemia
• Diabetes mellitus
• Microalbuminuria
• Estimated GFR < 60 mL/min
• Age (> 55 years for men, > 65 years for women)
• Family history of premature cardiovascular disease (men < 55 years or women < 65 years)

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Slide 15
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MANAGEMENT OF HYPERTENSION (3rd Edition)

SECONDARY CAUSES

• Sleep apnoea
• Drug-induced or drug-related
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Chronic steroid therapy and Cushing syndrome
• Phaeochromocytoma
• Acromegaly
• Thyroid or parathyroid disease
• Coarctation of the aorta
• Takayasu Arteritis

Slide 16
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

TARGET ORGAN DAMAGE & COMPLICATIONS

MANIFESTATIONS OF TOD/TARGET ORGAN COMPLICATION (TOC)

Organ System Manifestations

Left ventricular hypertrophy (LVH), coronary heart disease (CHD),


Cardiac
heart failure

Cerebrovascular Transient ischaemic attack (TIA), stroke

Peripheral Absence of one or more major pulses in extremities (except


vasculature dorsalis pedis) with or without intermittent claudication

GFR < 60ml/min/1.73m2, proteinuria (≥1+), microalbuminuria (2 out


Renal
of 3 positive tests over a period of 4-6 months)

Retinopathy Haemorrhages or exudates, with or without papilloedema


Slide 17
ALGORITHM FOR THE MANAGEMENT OF HYPERTENSION

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MANAGEMENT OF HYPERTENSION (3rd Edition)
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA
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Slide 18
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MANAGEMENT OF HYPERTENSION (3rd Edition)

CARDIOVASCULAR RISK STRATIFICATION

Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)

SBP 120-139
and/or Low Medium High Very High
DBP 80-89

SBP 140-159
and/or Low Medium High Very High
DBP 90-99

SBP 160-179
and/or Medium High Very High Very High
DBP 100-109
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

SBP 180-209
and/or High High Very High Very High
DBP 100-119

SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120

Risk Level Risk of major CV event in 10 years Management

Low < 10% Lifestyle changes

Drug treatment and lifestyle


Medium 10-20%
changes

Drug treatment and lifestyle


High 20-30%
changes

Drug treatment and lifestyle


Very High > 30%
changes
TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal Failure)
Risk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinical
atherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke)
MI: Mycardial Infarction

Legend: Green Yellow Orange Red


Slide 19
BLOOD PRESSURE TREATMENT TARGETS

Target blood
Category
pressure (mmHg)
Uncomplicated hypertension < 140/90
Hypertension in high risk groups: DM, History of CVD < 130/80
Diabetics with proteinuria of > 1g/24 hours < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.

Slide 20
THERAPEUTIC LIFESTYLE MODIFICATION

Therapeutic lifestyle modification is the first line treatment in all patients

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA


with hypertension.

Weight As far as possible aim for an ideal Body Mass Index [Weight
reduction (kg)/Height2 (m)] – for Asians, the normal range has been proposed
to be 18.5 to 23.5 kg/m2. However a weight loss as little as 4.5 kg
significantly reduces BP

Salt An intake of < 100 mmol of sodium or 6g of sodium chloride a


intake day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or
3 teaspoonfuls of monosodium glutamate)

Alcohol Standard advice is to restrict intake to no more than 21 units for


intake men and 14 units for women per week (1 unit equivalent to 1/2 a
pint of beer or 100 ml of wine or 20 ml of proof whisky)

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)

Physical General advice on cardiovascular health would be for “milder”


activity exercise, such as brisk walking for 30 – 60 minutes at least 3
times a week

A diet rich in fruits, vegetables and dairy products with reduced


Diet
saturated and total fat can substantially lower BP (11/6 mmHg in
hypertensive patients and 4/2 mmHg in patients with high normal
BP)

Smoking
cessation Cessation of smoking is important in the overall management of
the patients with hypertension in reducing cardiovascular risk

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MANAGEMENT OF HYPERTENSION (3rd Edition)

ANTIHYPERTENSIVE AGENTS

Minimum Maximum
Formulation dose dose Remarks

Diuretics

Chlorothiazide 250 mg OD 500 mg OD • Potassium should be closely


Hydrochlorothiazide 25 mg OD 200 mg OD monitored.
Amiloride/hydrochlorothiazide 1 tablet OD 4 tablet OD • Used with care in patient with gout.
5mg/50mg
Indapamide SR 1.5 mg OD 1.5 mg OD • Potassium sparing diuretics may
Indapamide 2.5 mg OD 2.5 mg OD cause hyperkalemia if given with
Triamterene/hydrochlorothiazide 1 tablet BD 2 tablet BD ACEIs/ARBs/renal insufficiency.
50mg/25mg

ß-blockers

Atenolol 50 mg OD 100 mg OD • Contraindicated in patient with


INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

Bisoprolol 5 mg OD 10 mg OD COAD, severe Peripheral


Metoprolol 50 mg BD 200 mg BD Vascular Disease and heart
Propranolol 40 mg BD 320 mg BD block.

Calcium Channel Blockers (CCBs)

Amlodipine 5 mg OD 10 mg OD • Verapamil may reduce heart rate


Diltiazem 30 mg TDS 60 mg TDS and use with care with ß-blockers
Diltiazem SR 90 mg BD 90 mg BD
Felodipine 2.5 mg OD 10 mg OD
Lercanidipine 10 mg OD 20 mg OD
Nifedipine 10 mg TDS 30 mg TDS
Nifedine SR 30 mg OD 120 mg OD
Verapamil 80 mg BD 240 mg TDS
Verapamil CR 200 mg OD 200 mg BD

ACE Inhibitors (ACEIs)

Captopril 25 mg BD 50 mg TDS • Contraindicated in pregnancy and


Enalapril 2.5 mg OD 20 mg BD bilateral renal artery stenosis
Lisinopril 5 mg OD 80 mg OD • Check serum creatinine before
Perindopril 2 mg OD 8 mg OD initiation and repeat 2 weeks after
Ramipril 2.5 mg OD 10 mg OD initiation
Quinapril 2.5 mg OD 40 mg BD • ACEIs should be stopped if rise in
creatinine > 30% from baseline

Angiotensin Receptor Blockers (ARBs)

Candesartan 8 mg OD 16 mg OD • Contraindicated in pregnancy and


Irbesartan 150 mg OD 300 mg OD bilateral renal artery stenosis
Losartan 50 mg OD 100 mg OD
Telmisartan 20 mg OD 80 mg OD
Valsartan 80 mg OD 160 mg OD
Olmesartan 20 mg OD 40 mg OD

Miscellaneous
Prazosin (α-blocker) 0.5 mg BD 10 mg BD • Doxazosin is useful in patient
Doxazosin 1 mg OD 16 mg OD with benign prostatic hypertrophy
Labetalol 100 mg BD 800 mg TDS • In elderly, start Labetolol with
Carvedilol 12.5 mg OD 50 mg OD 50mg BD
Methyldopa 125 mg BD 1 gm BD
Slide 22
PHARMACOLOGICAL MANAGEMENT OF STAGE 1 HYPERTENSION

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA


Slide 23
CHOICE OF FIRST LINE MONOTHERAPY

In patients with newly diagnosed uncomplicated hypertension who have no compelling


indications, choice of first line monotherapy includes ACEIs, ARBs, CCBs and Diuretics.

β-blockers are no longer recommended for first line monotherapy in this group of
patients.

However, it may be considered in younger people, particularly those who are intolerant or

TRAINING MODULE FOR HEALTH CARE PROVIDERS


contraindicated to ACEI or ARB, women of child bearing potential and patients with MANAGEMENT OF HYPERTENSION (3rd Edition)
evidence of increased sympathetic drive.

13
14

Slide 24
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

PHARMACOLOGICAL MANAGEMENT OF STAGE 2 HYPERTENSION


Initiating therapy with the right combination of at least 2 drugs is
recommended.

EFFECTIVE ANTIHYPERTENSIVE COMBINATION

Effective combination Comments

ß-blockers + diuretics Benefits proven in the elderly, cost-effective. However, may


increase the risk of new onset diabetes

ß-blockers + CCBs Relatively cheap, appropriate for concurrent CHD

CCBs + ACEls/ARBs Appropriate for concurrent dysliplidaemias and diabetes


mellitus

ACEls + diuretics Appropriate for concurrent heart failure, diabetes mellitus and
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

stroke

ARBs + diuretics Appropriate for concurrent heart failure and diabetes mellitus

Slide 25
CHOICE OF HYPERTENSIVE AGENTS IN PATIENTS WITH CONCOMITANT
CONDITIONS

Peripheral
Concomitant disease Diuretics ß-blockers ACEIs CCBs α-blockers ARBs

Diabetes mellitus (without nephropathy) + +/- +++ + +/- ++


Diabetes mellitus (with nephropathy) ++ +/- +++ ++* +/- +++
Gout +/- + + + + +
Dyslipidaemia +/- +/- + + + +
Coronary heart disease + +++ +++ ++ + ++
Heart failure +++ +++# +++ +@ + +++
Asthma + - + + + +
Peripheral vascular disease + +/- + + + +
Non-diabetic renal impairment ++ + +++ +* + ++
Renal artery stenosis + + ++$ + + ++$
Elderly with no co-morbid conditions +++ + + +++ +/- +
Very elderly (> 80 years old) with no +++ + ++ + +/- +
co-morbid conditions
The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice
+/- Use with care
- Contraindicated
* Only non-dihydropyridine CCB
# Metoprolol, bisoprolol, carvedilol – dose needs to be gradually titrated
@ Current evidence available for amlodipine and felodipine only
$ Contraindicated in bilateral renal artery stenosis
Slide 26
RESISTANT HYPERTENSION

If BP is still > 140/90 mmHg with combination of 3 drugs (including a diuretic at near
maximal doses) - check on the possible causes of resistant HPT:
• Non-compliance
• Secondary hypertension
• White coat hypertension
• Excessive salt or liquorice intake
• Drug interaction
• Complications of long standing hypertension e.g nephrosclerosis, loss of aortic
distensibility and atherosclerotic renal artery stenosis

Slide 27

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA


SEVERE HYPERTENSION

Severe hypertension is defined as BP > 180/110mm Hg


(persistent elevation after 30 minutes bed rest)

Possible clinical scenarios

Asymptomatic severe Hypertensive Hypertensive


HPT urgencies emergencies
• Incidental findings • Presents with grade III • Presents with
• Non-specific or IV retinal changes, symptoms and signs
symptoms like or proteinuria ≥ 2+, of TOC e.g. acute
headache, dizziness, but no overt organ heart failure,
lethargy failure subarachnoid
haemorrhage, acute
Management Management coronary syndromes

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
• Most can be • Initial treatment
managed as should aim for 25% Management
outpatient reduction in BP over • All patient should be
• Review existing drug 24 hours but not admitted
regime and lower than 160/90mm • Aim to reduce BP by
compliance Hg 25% over 3-12 hours
• For newly-diagnosed, • Combination therapy but not lower than
consider admission is often necessary 160/90 mmHg
for evaluation (see table below) • Best achieved with
• For established HPT, • Admit patient if BP parenteral drugs
admit if compliance remain > 180/110
remains a problem mmHg

15
16

Slide 28
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

THE CHRONIC CARE MODEL


INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

Slide 29
6 ELEMENT OF CHRONIC CARE MODEL

No. Elements Explanation

1. Health care Create policies with a clear focus to improve chronic disease care.
organization Goals, values & incentives to care providers must be aligned
& policies with payers & MOH
2. Community Patients & care providers need linkages with community
resources resources such as home care, exercise program and support
groups
3. Self Empower patients with knowledge and skills to enhance
management confidence to self-care. Build quality relationship through
support effective communication
4. Delivery system Multi-disciplinary practice team with clear division of labour;
redesign planned management and visits
5. Decision support Translate evidence based clinical practice guideline
recommendations into daily clinical practice and improve access
to specialist expertise
6. Clinical Computerized system to remind & prompt actions; support
information shared care among multiple professionals, provide feedback to
system health care personel and track progress
Slide 30
Multi Disciplinary
Roles and Responsibilities
Team Members

Doctors • Lead the multidisciplinary team


• Negotiate and create care pathways to work with other members
of the team
• Perform a complete history and physical examination
• Review investigation results
• Ascertain the presence or absence of TOD/TOC
• Identify other CV risk factors and/or concomitant disorders that
affect treatment and prognosis
• Assess global CV risks for individual patient
• Exclude secondary causes of HPT in suspected cases
• Explain to patient regarding achievement of control targets
• Make therapeutic decisions
• Emphasize the advice given by other allied team members
• Assess and address patient’s ideas, concerns and expectations
• Offer psychosocial support where appropriate

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA


Slide 31
Multi Disciplinary
Roles and Responsibilities
Team Members

Nurses • Conduct anthropometric measurements


• Coordinate baseline/ relevant investigations
• Assess lifestyle – diet, exercise and smoking status
• Educate patient regarding hypertension, cardiovascular risks and
potential complications
• Educate patient regarding control targets
• Counsel patient regarding therapeutic lifestyle modification

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
• Arrange follow-up as per care pathway
• Track and remind defaulters
• Assess and address patient’s ideas, concerns and expectations
• Offer psychosocial support where appropriate

17
18

Slide 32
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

Multi Disciplinary
Roles and Responsibilities
Team Members

MA • Conduct anthropometric measurements


• Coordinate baseline/ relevant investigations as agreed in the care
pathway
• Assess lifestyle – diet, exercise and smoking status
• Continue drug treatment if BP controlled
• Discuss with doctor if BP not controlled
• Educate patient regarding hypertension, cardiovascular risks and
potential complications
• Educate patient regarding control targets
• Counsel patient regarding therapeutic lifestyle modification
• Arrange follow-up as per care pathway
• Track and remind defaulters
• Assess and address patient’s ideas, concerns and expectations
• Offer psychosocial support where appropriate
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

Slide 33
Multi Disciplinary
Roles and Responsibilities
Team Members

Pharmacists • Educate patient regarding antihypertensive medication, its


potential benefits and side effects
• Monitor side-effects
• Assess adherence to medication
• Assess and address patient’s ideas, concerns and expectations of
the medications

Dieticians • Perform detail dietary assessment


• Educate patient regarding calorie intake
• Counsel regarding healthy dietary habit
• Counsel regarding weight management where appropriate
• Assess and address patient’s ideas, concerns and expectations
Slide 34
KEY LEARNING POINTS

• Hypertension (HPT) is defined as persistant elevations of SBP of ≥ 140mmHg and/or


DBP ≥ 90 mmHg
• In 2006, prevalence of HPT in Malaysia was 42.6% among those aged ≥ 30 years
• HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be
measured at every chance encounter
• Untreated or sub-optimally controlled HPT leads to increased cardiovascular,
cerebrovascular and renal morbidity and mortality
• A SBP of 120-139 and/or DBP of 80-90mm Hg is defined as pre-HPT and should be
treated in certain high risk groups
• Therapeutics lifestyle changes should be recommended for all individuals with HPT and
pre-HPT
• Decision to commence pharmacological treatment should be based on global
cardiovascular risks and not on the level of blood pressure (BP) per se
• In patients with newly diagnosed uncomplicated HPT who have no compelling
indications, choice of first line monotherapy includes ACEIs, ARBs, CCBs and Diuretics.
ß-blockers are no longer recommended as first line monotherapy

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA


• Only 26% of treated patients achieve target BP
• Combination therapy is often required ti achieve target and may be instituted early

Slide 35
KEY PRACTICE POINTS

• Produce a prepared, proactive health care team to manage chronic conditions


• Create effective clinical information systems e.g. disease registry, comprehensive
medical records
• Translate CPG recommendations into daily clinical practice
• Empower patients to self-manage their conditions
• Perform continuous quality improvement activities e.g. Clinical Audit

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)

19
MANAGEMENT OF HYPERTENSION (3rd Edition)
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

20
TRAINING MODULE FOR HEALTH CARE PROVIDERS
22

Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Mr. A • Divorced with 3 children


• 38 years old • Delivery Man
• Male

VISIT 1
Case 1
• Present to the clinic with acute URTI symptoms
• BP 138/88 mmHg
• Smoking 20 cig x 20 years
• Beer 1-2/day
• Sedentary lifestyle
• Father hypertensive, hyperlipidaemic, AMI and CABG (age 68).
• Wt 91kg, Ht 170cm, BMI 31.5, WC 97cm
INTERACTIVE CASE DISCUSSION 1
DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION

Slide 2
DISCUSSION POINT

• How do you confirm the diagnosis?


• What would you do next?

Slide 3
HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be
measured at every chance encounter.

RECOMMENDATIONS FOR FOLLOW-UP BASED ON INITIAL BLOOD


PRESSURE MEASUREMENTS FOR ADULTS

Initial BP (mmHg) Follow-up recommended to confirm diagnosis and/or


Systolic Diastolic review response to treatment.

< 130 and < 85 Recheck in one year


130-139 and 85-89 Recheck within 3-6 months
Confirm within two months and treat if medium, high or very
140-159 and/or 90-99
high risks
160-179 and/or 100-109 Evaluate within one month and treat when confirmed
Look for symptoms and sign of hypertensive urgency or
180-209 and/or 110-119 emergency, if asymptomatic, evaluate within one week and
treat whan confirmed

≥ 210 and/or ≥ 120 Initiate drug treatment immediately


Slide 4
VISIT 1: FURTHER ACTIONS

• Explain to him that his BP is slightly high (best is < 120/80 mmHg). Explain the
significance of the reading and the importance of confirming the diagnosis
• Assess cardiovascular risk factors:
- Smoking
- Obesity
- Sedentary lifestyle
- FH of hypertension and CVD
• Order further tests:
- UFEME
- Fasting lipids
- Renal profile
- ECG
• Arrange follow-up visit in 3 month

Slide 5

DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION


VISIT 2: BP REVIEW

INTERACTIVE CASE DISCUSSION 1


• Mr. A came back to the clinic after 3 months
• BP checked again in this visit – 138/88 mmHg (no change)
• Renal profile and serum uric acid – normal
• Fasting glucose normal
• Fasting lipid profile normal
• Urinalysis and UACR - normal
• ECG – normal

Slide 6
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

DIAGNOSIS AND CLASSIFICATION OF HYPERTENSION

Mr. A’s average BP taken at the 2 visits = 138/88 mmHg

Category Systolic (mmHg) Diastolic (mmHg)

Optimal < 120 and < 80


Diagnosis of
Prehypertension 120-139 and/or 80-89 hypertension is
made based on the
Stage 1 HPT 140-159 and/or 90-99 average of two or
more readings,
Stage 2 HPT 160-179 and/or 100-109 taken at two or
more visits to the
Stage 3 HPT ≥ 180 and/or ≥ 110 health care
providers

23
24

Slide 7
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

DEFINITION OF PREHYPERTENSION

Prehypertension is a defined as systolic BP (SBP) 120 to 139 or dictolic BP (SBP) 80 to 89


mmHg, based on 2 or more properly measured seated BP readings on each of 2 or more
office visits.11

Slide 8
DISCUSSION POINT 2

• How do you manage Mr. A?


INTERACTIVE CASE DISCUSSION 1
DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION

Slide 9
ALGORITHM FOR THE MANAGEMENT OF HYPERTENSION
Slide 10
CARDIOVASCULAR RISK STRATIFICATION

Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)

SBP 120-139
and/or Low Medium High Very High
DBP 80-89

SBP 140-159
and/or Low Medium High Very High
DBP 90-99

SBP 160-179
and/or Medium High Very High Very High
DBP 100-109

SBP 180-209
and/or High High Very High Very High
DBP 100-119

DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION


SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120

Legend: Green Yellow Orange Red

INTERACTIVE CASE DISCUSSION 1


Slide 11
Therapeutic lifestyle intervention should recommended for all patients with preHPT.

There is presently inadequate evidence for pharmacological intervention in preHPT patients


at low or moderate total CV risks.

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)

Slide 12
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. A

• Educate regarding the diagnosis of Prehypertension and his CV risk stratification –


medium risk
• Empower patient to self-manage through therapeutic lifestyle modification using
motivational interviewing techniques - MR. A is motivated to stop smoking, reduce his
alcohol intake and reduce his weight
• Refer to the smoking cessation clinic
• Provide information and leaflet on DASH eating plan
• Review after 3 months and assess CV risks annually

25
26

Slide 13
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

DISCUSSION POINT 3

• How do you deliver therapeutic lifestyle modification advice?


• How can you influence him to change his unhealthy lifestyle?

Slide 14
THERAPEUTIC LIFESTYLE MODIFICATION

Weight Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a
reduction weight loss as little as 4.5 kg significantly reduces BP
INTERACTIVE CASE DISCUSSION 1
DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION

An intake of < 100 mmol of sodium or 6g of sodium chloride a


Salt
intake day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or
3 teaspoonfuls of monosodium glutamate)

Standard advice is to restrict intake to no more than 21 units for


Alcohol
intake men and 14 units for women per week (1 unit equivalent to 1/2 a
pint of beer or 100ml of wine or 20ml of proof whisky)

Physical General advice on cardiovascular health would be for “milder”


activity exercise, such as brisk walking 30 mins daily

A diet rich in fruits, vegetables and dairy products with reduced


Diet saturated and total fat can substantially lower BP (11/6 mmHg in
hypertensive patients and 4/2 mmHg in patients with high normal BP)

Smoking Cessation of smoking is important in the overall management of


cessation the patients with hypertension in reducing cardiovascular risk

Slide 15
MOTIVATIONAL INTERVIEWING

A collaborative person centred guidance strategy to elicit and strengthen motivation to


change. The goal is to increase intrinsic motivation, rather than to impose it externally. The
‘spirit’ of Motivational Interviewing:
• Collaborative: partnership between patients and health care providers
• Evocative: evocating patient’s own motivation for change
• Honouring autonomy: acceptance that patient make his/her own choice

Rollnick S, Miller WR, Butler CC. Motivational interviewing in health care: Helping patients change behaviour.
New York: Guilford Press, 2008
Slide 16
MOTIVATIONAL INTERVIEWING USING CHANGE STRUCTURED CONSULTATION

CHECK : checking patient perspectives


HEAR : hearing what the patient says
AVOID : avoiding unsolicited advice
NOTE : noting the patient’s intentions and goals
GIVE : giving feedback to the patient when requested
END : ending the interview with a summary of the patient’s plan

Slide 17
http:/www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf.

DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION


INTERACTIVE CASE DISCUSSION 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

27
28

Slide 18
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

BEWARE OF HIDDEN SALTS

• Most salts/sodium are added during


food processing, cooking and eating
• Very little are naturally occuring in diet
INTERACTIVE CASE DISCUSSION 1
DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION

Slide 19
http:/www.moh.gov.my/v/diet
Slide 20

DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION


INTERACTIVE CASE DISCUSSION 1
Slide 21
SUMMARY OF EVIDENCE

• 37% of Malaysian population has Pre-HPT (NHMS II, 1996)


• 2/3 of patients with pre-HPT progressed to stage 1 Hypertension over 4 year period
(TROPHY Study)
• Pre-HPT tends to cluster with other CVD risk factors

TRAINING MODULE FOR HEALTH CARE PROVIDERS


• Obesity and weight gain contributes to the progression MANAGEMENT OF HYPERTENSION (3rd Edition)
• All pre-HPT should be managed with therapeutic lifestyle modification
• Decisions regarding pharmacological treatment should be based on individual’s global
CVD risk

29
30

Slide 22
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

KEY LEARNING POINTS

• HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be


measured at every chance encounter
• PreHPT is defined as SBP 120-139 and/or DBP 80-89 mmHg, based on ≥ 2 BP readings
at ≥ 2 clinic visits
• Therapeutics lifestyle changes should be recommended for all individuals with HPT and
pre-HPT
• Decision to commence pharmacological treatment should be based on global
cardiovascular risks and not on the level of blood pressure (BP) per se
• There is presently inadequate evidence for pharmacological intervention in preHPT
patients at low or moderate total CV risks
INTERACTIVE CASE DISCUSSION 1
DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION
32

Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Mr. MN • Married with 3


• 40 years old children
• Male • Clerk

VISIT 1

• Came to the clinic c/o of sore throat Case 2


• Otherwise well – no other symptom
• Smoker – 20 cigarettes a day
• Temperature 36.5° C, BP 150/90 mmHg
• Throat and chest examinations – unremarkable
• Diagnosis of viral URTI was made and symptomatic treatment was given
INTERACTIVE CASE DISCUSSION 2
DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION

Slide 2
DISCUSSION POINT 1

• What would you do now?


• How do you explain your plan to the patient?

Slide 3
HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be
measured at every chance encounter.

RECOMMENDATIONS OF FOLLOW-UP BASED ON INITIAL BLOOD


PRESSURE MEASUREMENTS FOR ADULTS

Initial BP (mmHg) Follow-up recommended to confirm diagnosis and/or


Systolic Diastolic review response to treatment.

< 130 and < 85 Recheck in one year


130-139 and 85-89 Recheck within 3-6 months
Confirm within two months and treat if medium, high or very
140-159 and/or 90-99
high risks
160-179 and/or 100-109 Evaluate within one month and treat when confirmed
Look for symptoms and sign of hypertensive urgency or
180-209 and/or 110-119 emergency, if asymptomatic, evaluate within one week and
treat whan confirmed

≥ 210 and/or ≥ 120 Initiate drug treatment immediately


Slide 4
VISIT 1: FURTHER ACTIONS

• Explain to him that he has a raised BP (150/90 mmHg)


• Explain the significance of the reading and the importance of confirming the diagnosis
• Advise to stop smoking
• Negotiate the management plan:
1. Arrange to see the nurse/AMO for BP check within 1 month
2. Arrange baseline investigations
3. Arrange follow-up visit within 2 months

Slide 5
VISIT 2: BP REVIEW

DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION


• Mr. MN came back to the clinic after 2 months
• Feeling very well generally
• BP checked by nurse a month ago – 148/90 mmHg
• BP checked again in this visit – 150/92 mmHg

INTERACTIVE CASE DISCUSSION 2


Slide 6
DISCUSSION POINT 2

• What is the diagnosis?


• What is your next step of action?

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 7
DIAGNOSIS AND CLASSIFICATION OF HYPERTENSION

Mr. MN’s average BP taken at the 3 visits = 149/90 mmHg

Category Systolic (mmHg) Diastolic (mmHg)

Optimal < 120 and < 80


Diagnosis of
Prehypertension 120-139 and/or 80-89 hypertension is
made based on the
Stage 1 HPT 140-159 and/or 90-99 average of two or
more readings,
Stage 2 HPT 160-179 and/or 100-109 taken at two or
more visits to the
Stage 3 HPT ≥ 180 and/or ≥ 110 health care
providers

33
34

Slide 8
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

EVALUATION

EVALUATION OF NEWLY DIAGNOSED HYPERTENSIVE PATIENTS


Evaluation should include through history, physical examination and relevant
investigations.

Three main objectives:


1. To exclude secondary causes of hypertension.
2. To ascertain the presence of target organ damage (TOD).
3. To assess lifestyle and identity other cardiovascular risk factors and/or concomitant
disoders that may affect treatment and prognosis.

Slide 9
INTERACTIVE CASE DISCUSSION 2
DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION

VISIT 2: FURTHER HISTORY

• Still smoking 20 cigarettes a day and not ready to stop


• Eat out regularly with family and friends
• No time to do any exercise
• No significant past medical history
• Not on any regular medication
• Mother (aged 70) has hypertension
• No family history of heart attacks or strokes
• No symptoms to suggest target organ damage, e.g. chest pain, blurred vision
• No symptoms to suggest secondary causes of hypertension

Slide 10
VISIT 2: PHYSICAL EXAMINATION FINDINGS

• BMI 26 kg/m2
• Waist circumference (WC) 88 cm
• Fundoscopy normal
• Cardiovascular examinations – normal
• Chest examinations – normal
• Abdominal examinations – normal
• Neurological examinations – normal
Slide 11
BASELINE INVESTIGATIONS

• Full blood count


• Urinalysis
• Urine albumin excretion or albumin/creatinine ratio
• Renal profile and serum uric acid
• Fasting blood sugar
• Fasting lipid profile
• Electrocardiogram (ECG)
• Chest X-ray (if clinically indicated)

Note : Should be repeated 6-12 monthly thereafter (except for Chest X-Ray)

Slide 12

DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION


VISIT 2: BASELINE INVESTIGATION RESULTS

• Renal Profile and serum uric acid - normal


• Full Blood Count - normal
• Fasting Blood Sugar 5.4 mmol/l
• Fasting Lipid Profile:

INTERACTIVE CASE DISCUSSION 2


- Total cholesterol 6.7 mmol/l
- Triglycerides 2.0 mmol/l
- HDL 0.9 mmol/l
- LDL 3.4 mmol/l
• Urinalysis and UACR - normal
• ECG - normal

Slide 13
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

DISCUSSION POINT 3

• How do you manage Mr. MN?


• What is your next step of action

35
INTERACTIVE CASE DISCUSSION 2 MANAGEMENT OF HYPERTENSION (3rd Edition)
DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION

36
TRAINING MODULE FOR HEALTH CARE PROVIDERS

Slide 14
ALGORITHM FOR THE MANAGEMENT OF HYPERTENSION
Slide 15
CARDIOVASCULAR RISK STRATIFICATION

Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)

SBP 120-139
and/or Low Medium High Very High
DBP 80-89

SBP 140-159
and/or Low Medium High Very High
DBP 90-99

SBP 160-179
and/or Medium High Very High Very High
DBP 100-109

SBP 180-209
and/or High High Very High Very High

DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION


DBP 100-119

SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120

INTERACTIVE CASE DISCUSSION 2


Risk Level Risk of major CV event in 10 years Management

Low < 10% Lifestyle changes

Drug treatment and lifestyle


Medium 10-20%
changes

Drug treatment and lifestyle


High 20-30%
changes

Drug treatment and lifestyle


Very High > 30%
changes
TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal Failure)

TRAINING MODULE FOR HEALTH CARE PROVIDERS


Risk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinical
MANAGEMENT OF HYPERTENSION (3rd Edition)
atherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke)
MI: Mycardial Infarction

Legend: Green Yellow Orange Red

Slide 16
DISCUSSION POINT 4

• How do you deliver therapeutic lifestyle modification advice?


• How do you commence pharmacotherapy?
• Which antihypertensive agent would you choose as first line?
• What is the target blood pressure?
• When would you see him again?

37
38

Slide 17
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

THERAPEUTIC LIFESTYLE MODIFICATION

Therapeutic lifestyle modification is the first line treatment in all patients with Hypertension

Weight Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a
reduction weight loss as little as 4.5 kg significantly reduces BP

An intake of < 100 mmol of sodium or 6g of sodium chloride a


Salt
intake day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or
3 teaspoonfuls of monosodium glutamate)

Standard advice is to restrict intake to no more than 21 units for


Alcohol
intake men and 14 units for women per week (1 unit equivalent to 1/2 a
pint of beer or 100ml of wine or 20ml of proof whisky)

Physical General advice on cardiovascular health would be for “milder”


INTERACTIVE CASE DISCUSSION 2
DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION

activity exercise, such as brisk walking 30 mins daily

A diet rich in fruits, vegetables and dairy products with reduced


Diet saturated and total fat can substantially lower BP (11/6 mmHg in
hypertensive patients and 4/2 mmHg in patients with high normal BP)

Smoking Cessation of smoking is important in the overall management of


cessation the patients with hypertension in reducing cardiovascular risk

Slide 18
PHARMACOLOGICAL MANAGEMENT OF STAGE 1 HYPERTENSION
Slide 19
CHOICE OF FIRST LINE MONOTHERAPY

• In patients with newly diagnosed uncomplicated hypertension who have no


compelling indications, choice of first line monotherapy includes ACEIs, ARBs, CCBs
and Diuretics
• β-blockers are no longer recommended for first line monotherapy in this group of
patients
• However, it may be considered in younger people, particularly those who are intolerant
or contraindicated to ACEI or ARB, women of child bearing potential and patients
with evidence of increased sympathetic drive

Slide 20
BLOOD PRESSURE TREATMENT TARGETS

DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION


Target blood
Category
pressure (mmHg)
Uncomplicated hypertension < 140/90
Hypertension in high risk groups: DM, History of CVD < 130/80

INTERACTIVE CASE DISCUSSION 2


Diabetics with proteinuria of > 1 g/24 hours < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.

Slide 21
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. MN

• Educate regarding the diagnosis of Stage 1 Hypertension, its associated CV risk

TRAINING MODULE FOR HEALTH CARE PROVIDERS


factors and potential complications MANAGEMENT OF HYPERTENSION (3rd Edition)
• Educate regarding BP treatment target < 140/90 mmHg, choice of medication –
potential benefits vs side effects
• Empower patient to self-manage through therapeutic lifestyle modification.
• Commence a single antihypertensive agent at low dose e.g. ACE Inhibitor
• Commence statin therapy for mixed dyslipidaemia
• Arrange Renal Profile to be done within 2 weeks (post ACEi)
• Review after 1 month

39
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Slide 22
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

VISIT 3: FOLLOW UP

• Mr. MN came for review after 1 month


• His Renal Profile was normal
• Feeling very well generally
• No side effect of ACE Inhibitor or statin
• Still smoking
• Dietary habit – no change
• Started to do some gardening and walk around his neighborhood BP checked again in
this visit – 146/86 mmHg
• BMI and WC – no change

Slide 23
INTERACTIVE CASE DISCUSSION 2
DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION

DISCUSSION POINT 5

• What is the state of his BP control?


• How would you manage Mr. MN at this stage?
• What is your next step of action?

Slide 24
PHARMACOLOGICAL MANAGEMENT OF STAGE 1 HYPERTENSION
Slide 25
VISIT 3: SUMMARY OF MANAGEMENT PLAN FOR MR. MN

• Educate regarding the state of his BP control - treatment target < 140/90 mmHg is still
not achieved
• Re-emphasize therapeutic lifestyle modification:
- Smoking cessation, healthy eating, exercise
• Increase the dose of ACE Inhibitor
• Recheck Renal Profile within 2 weeks
• Review after 1 month
- If well-controlled – continue treatment, review 3-6 monthly
- If uncontrolled – see algorithm for management of Stage 1 HPT
• Continue long-term follow up
• Assess CV risks annually

Slide 26

DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION


SUMMARY OF EVIDENCE

• Monotherapy can lower BP to < 140/90 mmHg in 40%- 60% of patients with mild to
moderate HPT
β-blockers – no longer recommended for 1 line monotherapy in newly diagnosed

INTERACTIVE CASE DISCUSSION 2



uncomplicated HPT
• Meta-analysis has shown that ß-blockers is not as effective in lowering BP and in
prevention of stroke compared to other agents
• Incidence of new-onset diabetes with β-blockers is also higher compared to other
drugs

Slide 27
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
KEY LEARNING POINTS

• HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be


measured at every chance encounter
• Stage 1 HPT is defined as SBP 140-159 and/or DBP 90-99 mmHg, based on ≥ 2 BP
readings at ≥ 2 clinic visits
• Therapeutic lifestyle changes should be recommended for all individuals with HPT and
pre-HPT
• Decision to commence pharmacologica treatment should be based on global
cardiovascular risks and not on the level of blood pressure (BP) per se
• In patients with newly diagnosed uncomplicated HPT who have no compelling
indicatons, choice of first line monotherapy includes ACEIs’ ARBs, CCBs and Diuretics.
ß-blockers are no longer recommended as first line monotherapy

41
INTERACTIVE CASE DISCUSSION 2 MANAGEMENT OF HYPERTENSION (3rd Edition)
DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION

42
TRAINING MODULE FOR HEALTH CARE PROVIDERS
44

Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Mr. NKH • Teacher


• 45 years old • Non-smoker
• Male

VISIT 1

• Came to the clinic with referral letter


• Found to have high BP in a health screening
Case 3
campaign (160/100 mmHg)
• Remained well & asymptomatic
• BP checked again in this visit – 164/100 mmHg

Slide 2
INTERACTIVE CASE DISCUSSION 3
DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION

DISCUSSION POINT 1

• What is your diagnosis?


• How would you evaluate his problem?

Slide 3
DIAGNOSIS

CLASSIFICATION OF BLOOD PRESSURE (adults ≥ 18 years)

Category Systolic (mmHg) Diastolic (mmHg)

Optimal < 120 and < 80


Diagnosis of
Prehypertension 120-139 and/or 80-89 hypertension is
made based on the
Stage 1 HPT 140-159 and/or 90-99 average of two or
more readings,
Stage 2 HPT 160-179 and/or 100-109 taken at two or
more visits to the
Stage 3 HPT ≥ 180 and/or ≥ 110 health care
providers
Slide 4
EVALUATION

EVALUATION OF NEWLY DIAGNOSED HYPERTENSIVE PATIENTS


Evaluation should include through history, physical examination and relevant
investigations.

Three main objectives:


1. To exclude secondary causes of hypertension.
2. To ascertain the presence of target organ damage (TOD).
3. To assess lifestyle and identity other cardiovascular risk factors and/or concomitant
disoders that may affect treatment and prognosis.

DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION


Slide 5
VISIT 1: FURTHER INFORMATION

• Exercised 3x/week
• Not known to have any medical problem
• No family history of premature CVD
• BMI= 22.8 kg/m2

INTERACTIVE CASE DISCUSSION 3


• Other physical examinations: unremarkable
• Normal ECG & urine analysis
• Normal diabetic & dyslipidaemia screening

Slide 6
DISCUSSION POINT 2

TRAINING MODULE FOR HEALTH CARE PROVIDERS


• How would you risk-stratify him? MANAGEMENT OF HYPERTENSION (3rd Edition)
• Can you estimate his 10-year CV risk?
• How would you manage this patient?

45
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Slide 7
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

CARDIOVASCULAR RISK STRATIFICATION

Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)

SBP 120-139
and/or Low Medium High Very High
DBP 80-89

SBP 140-159
and/or Low Medium High Very High
DBP 90-99

SBP 160-179
and/or Medium High Very High Very High
DBP 100-109
INTERACTIVE CASE DISCUSSION 3
DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION

SBP 180-209
and/or High High Very High Very High
DBP 100-119

SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120

Legend: Green Yellow Orange Red

Slide 8
10 YEAR CV RISK ESTIMATION

Risk Level Risk of major CV event in 10 years

Low < 10%

Medium 10-20%

High 20-30%

Very High > 30%

Legend: Green Yellow Orange Red


Slide 9
ALGORITHM FOR THE MANAGEMENT OF HYPERTENSION

DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION


INTERACTIVE CASE DISCUSSION 3
Slide 10
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

DISCUSSION POINT 3

• How do you commence pharmacotherapy?


• What drugs would you consider?
• What is his BP treatment target?
• When would you see him again?

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Slide 11
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

CHOICE OF PHARMACOTHERAPY

Pharmalogical management of stage 2 hypertension


Initiating therapy with the right combination of at least 2 drugs is recommended

Effective Combination

β-blockers + diuretics

β-blockers + CCBs

CCBs + ACEIs/ARBs

ACEIs + diuretics

ARBs + diuretics
INTERACTIVE CASE DISCUSSION 3
DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION

Slide 12
CHOICE OF ANTIHYPERTENSIVE AGENTS IN PATIENTS WITH
CONCOMITANT CONDITIONS

β-blockers Peripheral
Concomitant disease Diuretics ACEIs CCBs α-blockers ARBs

Diabetes mellitus (without nephropathy) + +/- +++ + +/- ++


Diabetes mellitus (with nephropathy) ++ +/- +++ ++* +/- +++
Gout +/- + + + + +
Dyslipidaemia +/- +/- + + + +
Coronary heart disease + +++ +++ ++ + ++
Heart failure +++ +++# +++ +@ + +++
Asthma + - + + + +
Peripheral vascular disease + +/- + + + +
Non-diabetic renal impairment ++ + +++ +* + ++
Renal artery stenosis + + ++$ + + ++$
Elderly with no co-morbid conditions +++ + + +++ +/- +
Very elderly (> 80 years old) with no +++ + ++ + +/- +
co-morbid conditions
The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice
+/- Use with care
- Contraindicated
* Only non-dihydropyridine CCB
# Metoprolol, bisoprolol, carvedilol – dose needs to be gradually titrated
@ Current evidence available for amlodipine and felodipine only
$ Contraindicated in bilateral renal artery stenosis
Slide 13
BLOOD PRESSURE TREATMENT TARGETS

Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
Hypertension in high risk groups < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.

DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION


Slide 14
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MR. NKH

• Explain to him that he has Stage 2 HPT and he has medium CV risk
• Deliver therapeutic lifestyle modification advice
• Educate regarding potential complications, the need to start medication and his
treatment target
• Initiate therapy with 2 drugs e.g. CCB + ACEi
• Review monthly until target BP is achieved

INTERACTIVE CASE DISCUSSION 3


• Review 3-monthly once target BP is achieved
• Re-assess CV risks annually

Slide 15
VISIT 2

• Mr. NKH continued his follow-up at a GP

TRAINING MODULE FOR HEALTH CARE PROVIDERS


• Treated with 3 anti-HPTs (Felodipine 10 mg od + FORTZAAR® 100-50) for 6 months MANAGEMENT OF HYPERTENSION (3rd Edition)
• Reason for re-visit: request to continue treatment
• BP remained uncontrolled (150/90 mmHg)
• Asymptomatic
• Normal physical examination

Slide 16
DISCUSSION POINT 4

• What is your diagnosis?


• What are the possible causes would you consider?
• How would you evaluate this patient?

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Slide 17
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

RESISTANT HYPERTENSION

BP remains > 140/90 mmHg *with 3 anti-HPTs (including if possible a diuretic)


* > 130/80 mmHg in patients with diabetes or chronic kidney disease

• Possible causes:
- Non-compliance
Pseudoresistance
- White coat HPT
- Poor diet control*
- Complications of long standing HPT
- Secondary HPT

*excessive sodium intake, excessive liquorice intake and drug interactions

Slide 18
INTERACTIVE CASE DISCUSSION 3
DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION

EVALUATION OF RESISTANT HYPERTENSION

• Exclude pseudoresistant:
- Is patient adherent with prescribed regimen?
- Obtain home/ ambulatory BP to exclude white coat effect
• Identify contributing lifestyle factors & drug interaction:
- Obesity, physical inactivity, excessive alcohol/ salt intake, low-fiber diet, NSAIDs &
stimulants etc
• Look for secondary causes of HPT
• Exclude complications of long-standing HPT

Slide 19
VISIT 2: FURTHER INFORMATION

• Mr. NKH is compliant with the treatment regime


• No sleeping problem identified
• No White Coat effect detected
• Like to enjoy taking high salt diet
• Normal renal profile
• Normal U/S ABD & KUB
• No secondary causes/complications of HPT detected
Slide 20
DISCUSSION POINT 5

• How would you manage this patient?


• How would you maximize his concordance to the treatment plan?
• When would you consider to refer this patient?

Slide 21

DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION


VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. NKH

• Explain to him that he has resistant hypertension


• Strengthen therapeutic lifestyle modification advice
• Reverse contributing factors (reduce salt intake)
• Re-educate regarding his potential complications & treatment target
• Continue & optimize his current treatment regime (CCB + ARB + Diuretic)
• Review monthly until target BP is achieved
• Review 3-monthly once target BP is achieved
• Re-assess CV risks annually

INTERACTIVE CASE DISCUSSION 3


Slide 22
WAYS TO ACHIEVE TREATMENT CONCORDANCE

• Develop rapport with patients


• Regard patients as partners in managing their conditions
• Educate patient regarding their conditions
• Influence behaviour change through motivational interviewing skills

TRAINING MODULE FOR HEALTH CARE PROVIDERS


• Check on drug adverse effects regularly MANAGEMENT OF HYPERTENSION (3rd Edition)
• Adhere to CPG recommendations

Slide 23
RESISTANT HPT : WHEN TO REFER?

• Refer to specialist for known or suspected secondary cause(s) of hypertension


• Refer to specialist if BP remains uncontrolled after 6 months of treatment
• Refer if you are not sure

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Slide 24
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

KEY LEARNING POINTS

• Stage 2 HPT is defined as SBP 160-179 and/or DBP 100-109 mmHg, based on ≥ 2 BP
readings at ≥ 2 clinic visits
• Therapeutics lifestyle changes should be recommended for all individuals with HPT and
pre-HPT
• Combination of at least 2 drugs is recommended once diagnosis is confirmed
• Once BP is controlled, most patients will require lifelong treatment
• If BP is still > 140/90 mmHg with 3 drugs (including diuretics at optimal doses), patients
by definition have resistant HPT
INTERACTIVE CASE DISCUSSION 3
DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION
53
54

Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Mdm. ZBL • Married with 5


• 48 years old children
• Smoker • Housewife

VISIT 1
• Came to the clinic c/o mild, intermittent throbbing
headaches
• No alarm symptom Case 4
• Diagnosed to have HPT 10 years ago
• Defaulted on her follow up since the last 5 years
as she felt well
• BMI 25 kg/m2, Waist Circumference (WC) 80cm
• BP 194/110 mmHg
INTERACTIVE CASE DISCUSSION 4
DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION

Slide 2
DISCUSSION POINT 1

• What further history would you elicit from this patient?


• Comment on the physical examination findings?
• Give other relevant physical examinations needed to be performed?
• What investigations would you arrange for this patient?

Slide 3
VISIT 1: FURTHER HISTORY

• Smokes 10 cigs a day for the past 20 years


• Loves to cook and family loves her food
• No time to do any exercise - busy with family routines
• Has been buying her antihypertensive ‘tablets’ from the pharmacy on and off
• Currently not on any medication
• Mother (aged 75) has hypertension
• No family history of heart attack or stroke
• No symptoms to suggest target organ damage (e.g. chest pain, blurred vision)
• No symptoms to suggest secondary causes of HPT
Slide 4
VISIT 1: FURTHER EXAMINATION FINDINGS

• Cardiovascular examination – S1 S2 heard, Grade 2 systolic murmur best heard at left


sternal edge
• Respiratory examination-normal
• Other systems revealed no significant abnormality

Slide 5
FUNDOSCOPY

Grade III hypertensive


retinopathy - note the flame
hemorrhage (ruptured

DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION


microaneurysm) directly superior
to the optic disc (pale area at 5
o'clock). The white lesions
(arrow) are well demarcated and
represent hard exudates
(increased vessel permeability).

INTERACTIVE CASE DISCUSSION 4


There is no papilledema.

Slide 6
VISIT 1: FURTHER EXAMINATION FINDINGS

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
• BP checked again after 30 minutes bed rest: 190/108 mmHg

Slide 7
URGENT INVESTIGATIONS

• Electrocardiogram (ECG)
• Urinalysis (UFEME)
• Random blood glucose

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Slide 8
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

VISIT 1: INVESTIGATION RESULTS

• Urinalysis – proteinuria 2+

Slide 9
ECG RESULTS

ECG showed the


presence of LVH – tall R
wave in V6 with T wave
inversions in V4-V6
(strain patterns)
INTERACTIVE CASE DISCUSSION 4
DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION

Slide 10
DISCUSSION POINT 2

• What is the diagnosis?


• How many target organ damages/ complications has she got?
• Could you estimate her global CV risk?
• How would you manage this patient?
Slide 11
SEVERE HYPERTENSION

Severe hypertension is defined as BP > 180/110 mmHg


(persistent elevation after 30 minutes bed rest)

Possible clinical scenarios

Asymptomatic severe Hypertensive Hypertensive


HPT urgencies emergencies
• Incidental findings • Presents with grade III • Presents with
• Non-specific or IV retinal changes, symptoms and signs
symptoms like or proteinuria ≥ 2+, but of TOC e.g. acute
headache, dizziness, no overt organ failure heart failure,
lethargy subarachnoid
Management haemorrhage, acute
Management • Initial treatment coronary syndromes
• Most can be managed should aim for 25%
as outpatient reduction in BP over Management

DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION


• Review existing drug 24 hours but not • All patient should be
regime and lower than 160/90mm admitted
compliance Hg • Aim to reduce BP by
• For newly-diagnosed, • Combination therapy 25% over 3-12 hours
consider admission is often necessary but not lower than
for evaluation (see table below) 160/90 mmHg
• For established HPT, • Admit patient if BP • Best achieved with

INTERACTIVE CASE DISCUSSION 4


admit if compliance remain > 180/110mm parenteral drugs
remains a problem Hg

Slide 12
MANIFESTATIONS OF TOD/TARGET ORGAN COMPLICATION (TOC)

TRAINING MODULE FOR HEALTH CARE PROVIDERS


Organ System Manifestations MANAGEMENT OF HYPERTENSION (3rd Edition)

Left ventricular hypertrophy (LVH), coronary heart disease (CHD),


Cardiac
heart failure.

Cerebrovascular Transient ischaemic attack (TIA), stroke.

Peripheral Absence of one or more major pulses in extremities (except


vasculature dorsalis pedis) with or without intermittent claudication.

GFR < 60ml/min/1.73m2, proteinuria (≥1+), microalbuminuria (2 out


Renal
of 3 positive tests over a period of 4-6 months).

Retinopathy Haemorrhages or exudates, with or without papilloedema.

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Slide 13
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

CARDIOVASCULAR RISK STRATIFICATION

Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)

SBP 120-139
and/or Low Medium High Very High
DBP 80-89

SBP 140-159
and/or Low Medium High Very High
DBP 90-99

SBP 160-179
and/or Medium High Very High Very High
DBP 100-109
INTERACTIVE CASE DISCUSSION 4
DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION

SBP 180-209
and/or High High Very High Very High
DBP 100-119

SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120

Legend: Green Yellow Orange Red

Slide 14
TREATMENT OPTIONS FOR HYPERTENSIVE URGENSIES (ORAL)

Drug Dose Onset of action (hr) Duration (hr) Frequency (hr)

Captopril 25 mg 0.5 6 1-2 hrs

Nifedipine 10-20 mg 0.5 3-5 1-2 hrs

Labetalol 200-400 mg 2.0 6 4 hrs

Slide 15
Rapid reduction of BP (within minutes to hours) in asymptomatic severe HPT or hypertensive
urgencies is best avoided as it may precipitate ischaemic events.
Slide 16
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MRS. ZBL

• Explain to her that she has Stage 3 HPT (Hypertensive Urgencies) with very high CV
risk
• Explain the significance of the diagnosis and the importance to stabilize her blood
pressure
• Give nifedipine 10mg tablet orally as a stat dose (BP measured again after 30
minutes bed rest : 186/100 mmHg)
• Explain to her that she needs to be admitted to the nearest hospital as her BP
remains high

Slide 17
VISIT 2: BP REVIEW

DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION


• Mdm. ZBL came back to the clinic 1 week after being discharged from the hospital.
• Feeling well generally
• She brought along a discharge summary from the hospital which contains the
following informations:
Medications: - Amlodipine 10 mg daily
- Perindopril 8 mg daily

INTERACTIVE CASE DISCUSSION 4


- Simvastatin 40 mg nocte
Investigations: - FBS 5.8 mmol/l, Renal Profile normal.
- TC 6.7, TG 2.6, HDL 1.3, LDL 3.4 (all in mmol/litres).
- Liver Function Test normal
- Urine Microalbumin positive
- Awaiting ECHO appointment
• BP examination done in the clinic – 156/90 mmHg

Slide 18
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

DISCUSSION POINT 3

• Summarise her current problems.


• How would you manage this lady now?
• What is her target blood pressure?

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Slide 19
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

THERAPEUTIC LIFESTYLE MODIFICATION

Therapeutic lifestyle modification is the first line treatment in all patients with Hypertension

Weight Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a
reduction weight loss as little as 4.5 kg significantly reduces BP

An intake of < 100 mmol of sodium or 6g of sodium chloride a


Salt
intake day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or
3 teaspoonfuls of monosodium glutamate)

Standard advice is to restrict intake to no more than 21 units for


Alcohol
intake men and 14 units for women per week (1 unit equivalent to 1/2 a
pint of beer or 100ml of wine or 20ml of proof whisky)

Physical General advice on cardiovascular health would be for “milder”


INTERACTIVE CASE DISCUSSION 4
DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION

activity exercise, such as brisk walking 30 mins daily

A diet rich in fruits, vegetables and dairy products with reduced


Diet saturated and total fat can substantially lower BP (11/6 mmHg in
hypertensive patients and 4/2 mmHg in patients with high normal BP)

Smoking Cessation of smoking is important in the overall management of


cessation the patients with hypertension in reducing cardiovascular risk

Slide 20
BLOOD PRESSURE TREATMENT TARGETS

Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
Hypertension in high risk groups < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.
Slide 21
SUMMARY OF MDM. ZBL’S PROBLEMS:

1. Uncontrolled hypertension (Target BP < 130/80)


2. Very high CV risk with multiple TODs (LVH, proteinuria and Grade III Hypertensive Retinopathy
3. Overweight
4. Sedentary lifestyle
5. Smoker
6. Unhealthy dietary habit

Slide 22
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MDM. ZBL

• Educate regarding the state of her BP control - treatment target < 130/80 mmHg

DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION


• Re-emphasize therapeutic lifestyle modification
• Influence behaviour change through motivational interviewing techniques
• Add another type of antihypertensive agent e.g. thiazide diuretics
• Review monthly until target BP is achieved
• Review 3-monthly once target BP is achieved
• Consider resistant HPT if BP remains uncontrolled with 3 agents (including diuretics at

INTERACTIVE CASE DISCUSSION 4


maximum dose)
• Assess CV risks annually

Slide 23
DISCUSSION POINT 4

• What is the commonest cause of severe HPT?

TRAINING MODULE FOR HEALTH CARE PROVIDERS


• How would you maximize her concordance to the treatment plan? MANAGEMENT OF HYPERTENSION (3rd Edition)

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Slide 24
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

COMMON CAUSES OF SEVERE HYPERTENSION


The most common cause of severe hypertension is still long standing poorly controlled
essential hypertension

Cause Example
Renal parenchymal disease • Chronic pyelonephritis • Primary glomerulonephritis
• Tubulointerstitial nephritis

Systematic disorders with • Systemic lupus • Systemic sclerosis


renal involvement erythematosus • Vasculitides

Renovascular • Atherosclerotic disease • Polyarteritis nodosa


• Fibromuscular dysplasia

Endocrine • Pheochromocytoma • Conn Syndrome (primary


• Cushing syndrome hyperaldosteronism)

Drug • Cocaine • Cyclosporin


INTERACTIVE CASE DISCUSSION 4
DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION

• Amphetamines • Clodine withdrawal

Coarctation of Aorta -

Pre-eclampsia/eclampsia -

Slide 25
WAYS TO ACHIEVE TREATMENT CONCORDANCE

• Develop rapport with patients • Influence behaviour change through


• Regard patients as partners in managing motivational interviewing techniques
their conditions • Check on drug adverse effects regularly
• Educate patient regarding their conditions • Adhere to CPG recommendations

Slide 26
KEY LEARNING POINTS

• Stage 3 HPT is defined as SBP > 180 and/or DBP 110 mmHg, based on > 2 BP readings
at > 2 clinic visits
• Rapid reduction of BP (within minutes to hours) in asymptomatic severe hypertension or
hypertensive urgencies is best avoided as it may precipitate ischaemic events
• Emphasis on the therapeutic lifestyle intervention must be done at every clinic visit
• Combination therapy is recommended in patients presenting with stage 2 hypertension or
beyond
• If BP is still > 140/90 mmHg with 3 drugs (including diuretics at maximum doses),
patients by definition have resistant HPT
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Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Mr. LM • Married with 4 girls


• 51-year-old • Lorry driver for a
paint factory

VISIT 1

• Referred by a GP to the health clinic for insulin


initiation Case 5
• c/o tiredness & blurring of vision for 2 weeks
• Diabetes since 2005, on Metformin 1 g BD, Gliclazide
80mg BD & Simvastatin 40 mg ON
• Poor adherence to low sugar diet & exercise
• Non-smoker & non-alcoholic

Slide 2
INTERACTIVE CASE DISCUSSION 5
HYPERTENSION AND DIABETES

VISIT 1: PHYSICAL EXAMINATIONS

• Blood pressure 140/90 mmHg (average of 2 readings)


• Weight 74 kg & Height 170 cm, BMI 25.6kg/m2
• Bilateral cataracts
• Peripheral neuropathy of both lower limbs

Slide 3
VISIT 1: INVESTIGATION RESULTS FROM THE GP

• HbA1c 11.5%
• FBS 10.8 mmol/L
• LDL-C 3.6 mmol/L
• TG 1.75 mmol/L
• Urine albumin 2+, repeat in the clinic 1+
• Renal function normal
• Liver function normal
• ECG stat in the clinic normal

Slide 4
DISCUSSION POINT 1

• What are his problems?


• How would you tell him?
Slide 5
SUMMARY OF MR. LM’S CLINICAL PROBLEMS

• Uncontrolled diabetes with


- Nephropathy
- Cataract? retinopathy
- Peripheral neuropathy
• Unhealthy diet and low physical activity
• Dyslipidemia
• Hypertension

Slide 6
HOW COMMON IS HYPERTENSION IN PATIENTS WITH DIABETES MELLITUS?

• The Hypertension in Diabetes Study Group reported a 39% prevalence of hypertension


among newly diagnosed diabetic patients
• In half of the diabetes patients, the elevated BP presents before the onset of
microalbuminuria
• Strongly associated with obesity
• Hypertension is frequently present as a component of the metabolic syndrome

INTERACTIVE CASE DISCUSSION 5


HYPERTENSION AND DIABETES
Slide 7
DIAGNOSIS

Hypertension should be detected and treated early in the course of diabetes mellitus to
• prevent cardiovascular disease and
• delay the progression of renal disease and

TRAINING MODULE FOR HEALTH CARE PROVIDERS


• delay diabetic retinopathy MANAGEMENT OF HYPERTENSION (3rd Edition)

Slide 8
VISIT 1: FURTHER HISTORY

• Eat at the factory cafeteria 4 times per day (breakfast, morning snack, lunch &
afternoon snack) with teh tarik 3 times per day
• Unable to drive company lorry due to vision problem (loss of income)
• No time to do exercise
• Compliant to his medication
• No home sugar or BP monitoring
• Wife has recently been diagnosed to have breast cancer
• Mother had hypertension & diabetes, died of stroke (aged 60)

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Slide 9
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

DISCUSSION POINT 2

• How do you manage Mr. LM?


• What is your next step of action?

Slide 10
CARDIOVASCULAR RISK STRATIFICATION

Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)
INTERACTIVE CASE DISCUSSION 5
HYPERTENSION AND DIABETES

SBP 120-139
and/or Low Medium High Very High
DBP 80-89

SBP 140-159
and/or Low Medium High Very High
DBP 90-99

SBP 160-179
and/or Medium High Very High Very High
DBP 100-109

SBP 180-209
and/or High High Very High Very High
DBP 100-119

SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120

Risk Level Risk of major CV event in 10 years Management

Low < 10% Lifestyle changes

Drug treatment and lifestyle


Medium 10-20%
changes

Drug treatment and lifestyle


High 20-30%
changes

Drug treatment and lifestyle


Very High > 30%
changes
TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal Failure
Risk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinical
atherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke)
MI: Mycardial Infarction

Legend: Green Yellow Orange Red


Slide 11
THERAPEUTICS LIFESTYLE MODIFICATION-DIETARY COUNSELING

• Dietary counseling should be targeted to:


- Achieve an optimal body weight
- Achieve an agreed glycaemic control
- Manage concomitant dyslipidaemia
• Moderate dietary sodium restriction to enhance the effects of BP lowering drugs
especially ACEIs and ARBs
• Further sodium restriction, with or without a diuretic, may be necessary in the presence
of nephropathy or when the BP is difficult to control

Slide 12
THERAPEUTICS LIFESTYLE MODIFICATION-REGULAR PHYSICAL EXERCISE

• General advice on cardiovascular health would be for “milder” exercise, such as brisk
walking for 30 – 60 minutes at least 3 times a week

INTERACTIVE CASE DISCUSSION 5


Slide 13

HYPERTENSION AND DIABETES


DISCUSSION POINT 3

• Would you commence antihypertensive agent?


• Which antihypertensive agent would you choose and why?
• What is his target blood pressure?
• How soon would you see him again?

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)

Slide 14
PHARMACOLOGICAL MANAGEMENT

• Pharmacological treatment should be initiated when:


1. The BP is persistently > 130/80 mmHg
or
2. There is a presence of microalbuminuria or overt proteinuria even if the BP is not
elevated

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Slide 15
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

CHOICE OF ANTIHYPERTENSIVES

• Certain classes of antihypertensive drugs may compromise diabetic control & aggravate
its complications

Drugs Adverse

Diuretics 1. High doses will decrease insulin responsiveness


2. Dyslipidaemia

ß-blockers 1. Masking of early symptoms of hypoglycaemia


2. Slowing of recovery from hypoglycaemia
3. Aggravation of symptoms of peripheral vascular disease
4. Dyslipidaemia

Peripheral β-blockers / 1. Worsening of orthostatic hypertension


Centrally acting drugs
INTERACTIVE CASE DISCUSSION 5
HYPERTENSION AND DIABETES

Slide 16
ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs)

1. Drugs of choice based on extensive data attesting to their cardiovascular and renal
protective effects in diabetic patients
2. In addition they do not have adverse effects on lipid and carbohydrate metabolism
3. If an ACEI is not tolerated, an ARB should be considered

Slide 17
ANGIOTENSION RECEPTOR BLOCKERS (ARBs)

1. Reported to be superior to conventional non-ACEI antihypertensive drugs in slowing the


progress of diabetic nephropathy at both the
i. microalbuminuric stage and
ii. overt nephropathy stage
2. They have been shown to be of similar efficacy as ACEIs but better tolerated
3. There have been no reports of adverse effects on carbohydrate and lipid metabolism
Slide 18
DIURETICS

1. Can be added on when monotherapy is inadequate


2. The lowest possible dose should be used to minimise adverse metabolic effects
3. Adverse metabolic effects from higher doses have been reportedly reduced when used
in combination with an ACEI or an ARB

Slide 19
CALCIUM CHANNEL BLOCKERS (CCBs)

1. Can be added on when monotherapy is inadequate


2. Do not have significant adverse metabolic effects or compromise diabetic control
3. Nondihydropyridine CCBs may be more superior to dihydropyridine CCBs in reducing
proteinuria in diabetic nephropathy

Slide 20

INTERACTIVE CASE DISCUSSION 5


β-BLOCKERS & PERIPHERAL α-BLOCKERS

HYPERTENSION AND DIABETES


1. ß-blockers may be used when ACEIs, ARBs or CCBs cannot be used or when there
are concomitant compelling indications
2. Peripheral α-blockers do not have adverse effects on carbohydrate or lipid metabolism
but orthostatic hypotension due to autonomic neuropathy may be aggravated

Slide 21
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

TARGET BLOOD PRESSURE

• Tight BP control should take precedence over the class of antihypertensive drug used
• The BP should be targeted to < 130/80 mmHg
• There are suggestions that a lower target BP may be necessary to maximally protect
against the development and progression of cardiovascular and renal disease
• The BP should be lowered even further to < 125/75 mmHg in the presence of
proteinuria of > 1 g/24 hours

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Slide 22
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

RECOMMENDATIONS

1. ACEIs are the agents of choice for patients with diabetes without proteinuria
2. ACEIs or ARBs are the agents of choice for patients with diabetes and proteinuria
3. ß-blockers, diuretics or CCBs may be considered if either of the above cannot be used

Slide 23
BLOOD PRESSURE TREATMENT TARGETS

Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
INTERACTIVE CASE DISCUSSION 5
HYPERTENSION AND DIABETES

Hypertension in high risk groups < 130/80


Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.

Slide 24
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MR. LM’S HYPERTENSION

1. Explain regarding the diagnosis of hypertension, its contribution of risk to diabetic complications
2. Educate regarding the need of BP treatment, target of < 130/80 mmHg, choice of
medication, potential heart & kidneys protection vs. side effects
3. Empower patient to self-manage through diet and exercise, home monitoring of sugar & BP
4. Commence ACEI as single antihypertensive agent
5. Arrange renal profile to be done within 2 weeks
6. Review after 1 month

Slide 25
VISIT 2: FOLLOW UP AT 1 MONTH LATER

• Feeling very well generally, no new complaint


• No side effect of ACEI or insulin
• Had visited the ophthalmologist, reply letter stated he has immature cataract and
moderate to severe non-proliferative diabetic retinopathy in both eyes, laser therapy
done, and follow-up in 3 months
• Still taking 4 meals in the factory cafetaria but able to keep ONE teh tarik a day, and
reduced some oily & salty food as he claimed he cannot control the menu
• Started to walk 20 to 30 minutes around his neighborhood every weekend
Slide 26
VISIT 2: FURTHER INFORMATION

• Home glucose monitoring 5 – 8 mmol/L


• Home BP monitoring 120 - 130/80 - 90 mmHg
• BMI and WC – no change
• BP in the clinic 130/80 mmHg
• Renal profile was normal
• Fasting blood sugar 6 mmol/L
• Urine protein 1+

Slide 27
DISCUSSION POINT 4

• What is the state of his BP control?


• How would you manage Mr. LM at this stage?
• What is your next step of action?

INTERACTIVE CASE DISCUSSION 5


Slide 28

HYPERTENSION AND DIABETES


VISIT 2: FURTHER MANAGEMENT FOR MR. LM

• Inform him that his treatment target < 130/80 mmHg is still not achieved
• Set personalized treatment goals with him
– Increase walking to 30 min three times a week
– Reduce outside food to 2 times per day to control oil & salt intake
– BP monitoring at least twice per week targeting < 130/80
• Emphasize on low salt diet & praise him for walking every weekend

TRAINING MODULE FOR HEALTH CARE PROVIDERS


• Increase the dose of ACEI or add a low dose diuretics MANAGEMENT OF HYPERTENSION (3rd Edition)

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Slide 29
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

VISIT 2: FURTHER MANAGEMENT FOR MR. LM

• Plan to review after 1 month


– If well-controlled – continue treatment, review 3-6 monthly
– If uncontrolled – check adherence, change/adjust medications 2 to 4 weekly till
target achieved
• Inform & emphasize needs for long-term follow up
• Educate importance of
– CV risks assessment annually
– Complication assessment 6-monthly

Slide 30
INTERACTIVE CASE DISCUSSION 5
HYPERTENSION AND DIABETES

KEY LEARNING POINTS

• About 2 in 5 people with recently diagnosed diabetes will have hypertension


• About 1 in 2 patients will have hypertension before the diagnosis of microalbuminuria
• Antihypertensive should be initiated when the BP is persistently > 130/80 mmHg or there
is microalbuminuria / proteinuria
• ACEIs / ARBs are the agents of choice for patients with diabetes
• The BP should be targeted to < 130/80 mmHg or to < 125/75 mmHg if the proteinuria
> 1 g/24 hours
74

Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Mr. AH • Married with 4


• 50 years old children
• Male • Food hawker

REVIEW VISIT 1

• Came to the clinic for routine review of blood


pressure Case 6
• On ß-blocker and thiazide diuretic
• Smoker – 20 cigarettes a day
• Otherwise well, no significant past medical history
• BMI 30 kg/m2, Waist Circumference (WC) 98 cm
• BP 152/90 mmHg, other examinations – normal
• FBS 5.8 mmol/l, Renal Profile normal
• TC 6.7, TG 2.6, HDL 1.3, LDL 3.4 (all in mmol/litres)
INTERACTIVE CASE DISCUSSION 6
HYPERTENSION AND METABOLIC SYNDROME

Slide 2
DISCUSSION POINT 1

• What is the diagnosis?


• What is the target blood pressure?
• Comment on his current medication.
• How do you manage this patient?
• How do you explain your plan to the patient?

Slide 3
METABOLIC SYNDROME DIAGNOSIS
Slide 4
BLOOD PRESSURE TREATMENT TARGETS

Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
Hypertension in high risk groups < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.

Slide 5
CHOICE OF PHARMACOTHERAPY

ß-blockers and thiazide diuretics have the potential to increase the incidence of new
onset diabetes, and this should be taken into consideration when choosing drugs for
patients diagnosed with Metabolic Syndrome.

HYPERTENSION AND METABOLIC SYNDROME


INTERACTIVE CASE DISCUSSION 6
Slide 6
REVIEW VISIT 1: SUMMARY OF MANAGEMENT PLAN

• Explain to him that he has Metabolic syndrome and the significance of the diagnosis in
relation to CV risks. Explain that his BP is still not controlled (target < 130/80 mmHg)
• Discuss lifestyle modifications e.g. exercise, diet and weight reduction
• Discuss about his medication and explain that it is unsuitable for his condition. Discuss
changing his medication to ACE Inhibitor or CCB
• Commence him on statin

TRAINING MODULE FOR HEALTH CARE PROVIDERS


• Arrange for Renal Profile (RP), FSL, LFT, ECG and urinalysis MANAGEMENT OF HYPERTENSION (3rd Edition)
• Arrange for a follow up in 3 months

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Slide 7
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

REVIEW VISIT 2

• Mr. AH came for follow up after 3 months


• Tried to do more walking
• Still smoking – not ready to stop
• Tried to cut down on salt and fried food but finding it difficult because he works as a
food hawker
• Mother aged 75 has Hypertension and Diabetes Mellitus. Father died at 65 with MI
• Has been taking Perindopril 8mg once daily and Simvastatin 40 mg once daily as
prescribed in the last visit – there is no side effect
• BP 142/86 mmHg, BMI 30 kg/m2, WC 97cm
• TC 5.2, TG 1.6, HDL 1.3, LDL 2.4 (all in mmol/litres)
• RP, LFT, ECG and urinalysis normal

Slide 8
INTERACTIVE CASE DISCUSSION 6
HYPERTENSION AND METABOLIC SYNDROME

DISCUSSION POINT 2

• How do you manage this patient at this stage?

Slide 9
REVIEW VISIT 2: SUMMARY OF MANAGEMENT PLAN

• Re-emphasize the significance of having Metabolic Syndrome in relation to his CV and


DM risk factors
• Educate regarding BP control – target still not achieved
• Educate regarding FSL reading – target now achieved
• Re-emphasize self-management through lifestyle modification (no change in BMI or WC
after 3 months)
• Consider adding Calcium Channel Blocker (CCB)
• Continue statin
• Discuss referral to a dietician
• Arrange follow up in 3 months
Slide 10
THERAPEUTIC LIFESTYLE MODIFICATION

As far as possible aim for an ideal Body Mass Index [Weight


Weight (kg)/Height2 (m)] – for Asians, the normal range has been proposed
reduction to be 18.5 to 23.5 kg/m2. However a weight loss as little as 4.5 kg
significantly reduces BP

An intake of < 100 mmol of sodium or 6g of sodium chloride a


Salt
intake day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or
3 teaspoonfuls of monosodium glutamate)

Standard advice is to restrict intake to no more than 21 units for


Alcohol
intake men and 14 units for women per week (1 unit equivalent to 1/2 a
pint of beer or 100 ml of wine or 20 ml of proof whisky)

General advice on cardiovascular health would be for “milder”


Physical
activity exercise, such as brisk walking for 30 – 60 minutes at least 3
times a week

A diet rich in fruits, vegetables and dairy products with reduced


Diet saturated and total fat can substantially lower BP (11/6 mmHg in

HYPERTENSION AND METABOLIC SYNDROME


hypertensive patients and 4/2 mmHg in patients with high normal BP)

Smoking Cessation of smoking is important in the overall management of

INTERACTIVE CASE DISCUSSION 6


cessation the patients with hypertension in reducing cardiovascular risk

Slide 11
DISCUSSION POINT 3

• Discuss the factors which may prevent this patient from achieving targets (weight/ BP)

TRAINING MODULE FOR HEALTH CARE PROVIDERS


• Discuss the factors which may motivate the patient to change MANAGEMENT OF HYPERTENSION (3rd Edition)
• What else can we do to help the patient?

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Slide 12
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

REVIEW VISIT 3

• Mr. AH brings along his wife who wants to help him. She is afraid of losing him
• Has been doing more exercise at home by walking to the local shops to get the newspaper
• His wife is trying to cook healthier meals
• Now smokes 15/day
• No side effect with ACE Inhibitor, CCB or Statin
• BP checked 130/80 mmHg
• Lost 2 kg since last appointment
• He’s happy with his progress
• Still waiting for his appointment with dietician

Slide 13
INTERACTIVE CASE DISCUSSION 6
HYPERTENSION AND METABOLIC SYNDROME

REVIEW VISIT 3: SUMMARY OF MANAGEMENT PLAN

• Continue to give encouragement and motivation for his positive lifestyle changes
• Get his wife involved in giving him encouragement and support
• Chase up his dietician appointment
• If BP remain controlled, continue with 3-6 monthly follow up
• Review his CV and DM risks annually

Slide 14
SUMMARY OF EVIDENCE

Metabolic Syndrome is a cluster of risk factors predisposing to CV disease and Diabetes.


A person with Metabolic syndrome is twice likely to develop heart disease and five times
more likely to develop DM. Various components of Metabolic Syndrome should be treated
separately.

Slide 15
KEY LEARNING POINTS

• Metabolic syndrome is a cluster of risk factors predisposing to CV disease and DM


• Hypertension in Metabolic Syndrome must be treated aggressively to lower the risk.
Target BP < 130/80 mmHg
• Thiazide diuretics and β-blockers are found to increase incidence of developing DM in
Metabolic Syndrome
• Therapeutic lifestyle changes is key to patient management and achieving targets
• It is important to treat all of the variables in Metabolic Syndrome independently
80

Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Mr. M
• 53-year-old
• Male

VISIT 1

• Was referred back to you from hospital with the


following diagnoses:
- Hypertensive heart disease Case 7
- Left ventricular hypertrophy
- Hypercholesterolaemia

Slide 2
INTERACTIVE CASE DISCUSSION 7
HYPERTENSION AND CARDIOVASCULAR DISEASE

VISIT 1

• These were the list of medications he was discharged with:


- Losartan 50 mg OM
- Simvastatin 40 mg ON
- HCT 12.5 mg OM
- Atenolol 50 mg OM
• The letter stated that: “kindly follow up and do the needful”
• The patient expected you to prescribe the medication for him.

Slide 3
DISCUSSION POINT 1

• What would be your aims in this consultation in relation to hypertension management?


• How would you tell him?

Slide 4
TIPS FOR DISCUSSION POINT 1

• Try to have an outline for your points and be clear of the reasons for your points
• Write down your answer, you don’t have to write down your name. Discuss you answer
with the person you are comfortable with.
• Tell us your answer once you are ready
(10 minutes)
Slide 5
WHAT WOULD BE YOUR AIMS IN THIS CONSULTATION IN RELATION TO
HYPERTENSION MANAGEMENT?

1. Assess any other target organ damage


The referral letter stated that he has hypertensive heart disease. Hence it is likely that he
may suffer from various vascular related diseases like:

Ischaemic heart disease Stroke

Left ventricular hypertrophy Peripheral vascular disease


Heart failure Renal disease, secondary renal artery stenosis

Hypertensive vascular disease is a multi-organ disease.


Many systems could be affected by HPT.

Slide 6
WHAT WOULD BE YOUR AIMS IN THIS CONSULTATION IN RELATION TO

HYPERTENSION AND CARDIOVASCULAR DISEASE


HYPERTENSION MANAGEMENT?

2. Check for target control: BP < 130/80 mmHg, and other CVD risk factors

INTERACTIVE CASE DISCUSSION 7


Risk factors Targets
Smoking Abstinence
Wt BMI chart ideally < 23 kg/m2
Waist circumference Male < 90 cm, Female < 80 cm
Diet Low salt and possibly low cholesterol diet
Exercise 30 minutes 3-5 times/day
Cholesterol/DM See relevant CPG

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)

Slide 7
WHAT WOULD BE YOUR AIMS IN THIS CONSULTATION IN RELATION TO
HYPERTENSION MANAGEMENT?

3. Assess for suitability/adherence of medications


Essentially covers:
i. Side-effects
ii. Co-morbidities
iii. Psycho-social issues related to treatment of HPT

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Slide 8
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

WHAT WOULD BE YOUR AIMS IN THIS CONSULTATION IN RELATION TO


HYPERTENSION MANAGEMENT?

1. Assess any other target organ damage


2. Check for target control
3. Assess for suitability/adherence of medications
4. Self-management plan and holistic care (will not be discussed in details)

Slide 9
DISCUSSION POINT 2

• For each of these aims below (or your own aims), what are your actions?
INTERACTIVE CASE DISCUSSION 7
HYPERTENSION AND CARDIOVASCULAR DISEASE

1. Target organ damage assessment


2. Target BP control assessment
3. Assessment of optimal medication/adherence
• What is your next step of action?

Slide 10
HISTORY TAKING: ASK FOR

1. Symptoms of IHD, heart failure: NYHA class, claudication, history of stroke and
admission
2. Any consultation with specialist care and what care has he been receiving?
3. How has he been with the control of HPT, is he aware of his blood pressure and any
form of home blood pressure monitoring?
4. Any side effects from the medication, any problems (including personal preferences,
disruption of daily routine) in taking the medication?

Slide 11
PHYSICAL EXAMINATIONS

1. Observe: gait (remember the neurological complication)


2. Body mass index, waist circumference
3. BP, pulse (including peripheral pulses: remember to check this to detect underlying PVD;
ß-blocker effect)
4. Signs of end-organ damage: e.g. heart failure etc
Slide 12
INVESTIGATIONS

1. ECG: to look for features of LVH, IHD


2. Urine protein, KIV quantification of urine protein
3. Blood: renal profile, cholesterol, fasting blood sugar level
4. CXR (if it is not done)
5. Further referral to cardiologist for assessment

Slide 13
VISIT 1: FURTHER HISTORY

• Mr. M had been having HPT for 15 years


• He had not been regular with his medication apparently because of frequent traveling as
a businessman
• He ended up in the hospital because of minor cuts he sustained while doing some
carpentry work at home and was subsequently noted to have uncontrolled blood pressure

HYPERTENSION AND CARDIOVASCULAR DISEASE


• His effort tolerance had been good
• Quick dietary assessment did not reveal any significant issue. He exercised regularly

INTERACTIVE CASE DISCUSSION 7


Slide 14
VISIT 1: PHYSICAL EXAMINATIONS

• BMI = 26 kg/m2 WC = 105 cm


• BP 142/94 mmHg
• PR 56 bpm
• Right dorsalis pedis pulse was difficult to palpate

TRAINING MODULE FOR HEALTH CARE PROVIDERS


• No sign of heart failure/cardiomegaly MANAGEMENT OF HYPERTENSION (3rd Edition)
• You had a good look at the ankle (Do you know
the reason for examining the ankle?)

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Slide 15
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

VISIT 1: INVESTIGATIONS

• The levels of blood urea and serum creatinine were normal, K+ = 4.8 mmol/L
• Fasting blood sugar = 5.3 mmol/L
• Urine dipstix: normal reading for protein, no cell/cast was noted
• Cholesterol profile:
• TC 5.7 mmol/L HDL-C 0.9 mmol/L
• TG 1.8 mmol/L LDL-C 3.6 mmol/L
• ECG (next slide)

Slide 16
INTERACTIVE CASE DISCUSSION 7
HYPERTENSION AND CARDIOVASCULAR DISEASE

Slide 17
HE WAS OBVIOUSLY NOT TREATED TO TARGET

• What are his target?

Parameters Targets
BP < 130/80 mmHg
LDL-C (as the primary target) 3.4 mmol/L
BMI < 23.0 kg/m2
WC < 90 cm
Slide 18
DISCUSSION POINT 3

• What is your diagnosis for him now?


• Would you alter his medication or continue the same regime? Give reason.

Slide 19
WHAT IS YOUR DIAGNOSIS FOR HIM NOW?

• HPT: suboptimal control


• Left ventricular hypertrophy
• Hypercholesterolaemia
• Possibility of peripheral vascular disease
• Problems with adherence

HYPERTENSION AND CARDIOVASCULAR DISEASE


Slide 20

INTERACTIVE CASE DISCUSSION 7


WOULD YOU ALTER HIS MEDICATION OR CONTINUE THE SAME
REGIME? GIVE REASON

• He was given these medications from the hospital:


1. Losartan 50 mg OM
2. Simvastatin 40 mg ON
3. Hydrochlorothiazide (HCT) 12.5 mg OM
4. Atenolol 50 mg OM
• You were stuck and not sure which is the best. Suddenly, you thought of referring to the
CPG on HPT.

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)

Slide 21
RECOMMENDATIONS

• Hypertensive patients with LVH should receive an ARB as the first line treatment
• In CHD, β-blockers, ACEIs and long acting CCBs are the drugs of choice
• β-blockers, ACEIs, and aldosterone antagonists should be considered in patients
with CHD especially in post myocardial infarction and when associated with LV
dysfunction
• β-blockers need to be cautiously used in patients with peripheral vascular disease.
• They are contraindicated in patients with severe PVD
• Diuretics, ACEIs, β-blockers, ARBs, and aldosterone antagonists are drugs of choice
for heart failure.
• ARB is indeed the correct choice
• β-blockers may not be a suitable choice for him!
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Slide 22
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

PHARMACOLOGICAL MANAGEMENT

Choice of Hypertensive drugs in patients with concomitants conditions

β-blockers Peripheral
Concomitant disease Diuretics ACEIs CCBs α-blockers ARBs

Coronary heart disease + +++ +++ ++ + ++


Heart failure +++ +++ #
+++ +@
+ +++
Asthma + - + + + +
Peripheral vascular disease + +/- + + + +

• Diuretic is also the correct choice

Slide 23
INTERACTIVE CASE DISCUSSION 7
HYPERTENSION AND CARDIOVASCULAR DISEASE

DISCUSSION POINT 4

• What will be the best choice then?

Slide 24
WHAT WILL BE THE BEST CHOICE THEN?

• Perindopril (ACE-I) 2 mg (has to re-start the regime as he has not been taking Losartan)
• HCT 12.5 mg OM
• Simvastatin 80 mg ON
• Felodipine 5 mg OM (explore the option of fixed dose combinatio therapy)

Slide 25
KEY LEARNING POINTS

• The cardiovascular complications of HPT signify a long standing hypertension and


possibly have other target organ damage
• There are a wide range of choices for anti-hypertensives
• Appropriate choice of anti-hypertensive medication depends in co-morbidities and
complications, taking into consideration patient’s perspective
• Cost and side-effect can be a significant determinants
88

Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Mr. AK • Married with 5


• 58 years old grand children
• Male • Retired teacher Case 8

VISIT 1

• Brought to the clinic by his son on a wheel chair


• Developed right sided weakness and slurred
speech since 5 am today

Slide 2
INTERACTIVE CASE DISCUSSION 8
HYPERTENSION AND STROKE

VISIT 1: FURTHER INFORMATION

• No vomiting, headache, fever, blurred vision, fits, incontinence


• No history of injury
• Known to have hypertension for 10 years
• Defaulted treatment since the last 5 years and is currently not on any medication
• Smokes 20 cigarettes a day
• BP 210/100 mmHg, slurred speech, orientated to time, place and person
• Right side UL/LL: Power 3+/5, tone normal, reflexes normal
• Plantar equivocal
• Cardiovascular and chest examinations – unremarkable

Slide 3
DISCUSSION POINT 1

• What is the diagnosis?


Slide 4
SEVERE HYPERTENSION

Severe hypertension is defined as BP > 180/110mm Hg


(persistent elevation after 30 minutes bed rest)

Possible clinical scenarios

Asymptomatic severe Hypertensive Hypertensive


HPT urgencies emergencies
• Incidental findings • Presents with grade III • Presents with
• Non-specific or IV retinal changes, symptoms and signs
symptoms like or proteinuria ≥ 2+, but of TOC e.g. acute
headache, dizziness, no overt organ failure heart failure,
lethargy subarachnoid
Management haemorrhage, acute
Management • Initial treatment coronary syndromes
• Most can be managed should aim for 25%
as outpatient reduction in BP over Management
• Review existing drug 24 hours but not • All patient should be
regime and lower than 160/90mm admitted
compliance Hg • Aim to reduce BP by
• For newly-diagnosed, • Combination therapy 25% over 3-12 hours
consider admission is often necessary but not lower than
for evaluation (see table below) 160/90 mmHg
• For established HPT, • Admit patient if BP • Best achieved with

INTERACTIVE CASE DISCUSSION 8


admit if compliance remain > 180/110mm parenteral drugs

HYPERTENSION AND STROKE


remains a problem Hg

Slide 5
MANIFESTATIONS OF TOD/TARGET ORGAN COMPLICATION (TOC)

TRAINING MODULE FOR HEALTH CARE PROVIDERS


Organ System Manifestations MANAGEMENT OF HYPERTENSION (3rd Edition)

Left ventricular hypertrophy (LVH), coronary heart disease (CHD),


Cardiac
heart failure

Cerebrovascular Transient ischaemic attack (TIA), stroke

Peripheral Absence of one or more major pulses in extremities (except


vasculature dorsalis pedis) with or without intermittent claudication

GFR < 60ml/min/1.73m2, proteinuria (≥1+), microalbuminuria (2 out


Renal
of 3 positive tests over a period of 4-6 months)

Retinopathy Haemorrhages or exudates, with or without papilloedema

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Slide 6
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

COMMON CAUSES OF SEVERE HYPERTENSION*


INTERACTIVE CASE DISCUSSION 8
HYPERTENSION AND STROKE

Slide 7
HYPERTENSION AND STROKE

Blood pressure is the most consistent and powerful predictor of stroke and high blood
pressure is the most important modifiable cause of stroke. BP levels are continously
associated with the risk for stroke. Although both SBP and DBP are associated with stroke,
SBP is more predictive. In the Asia Pacific region, up to 66% of stroke can be attributed to
hypertension.

Slide 8
DISCUSSION POINT 2

• How would you manage the patient?


• How would you explain your plan to him and his son?
Slide 9
SEVERE HYPERTENSION

Severe hypertension is defined as BP > 180/110 mmHg


(persistent elevation after 30 minutes bed rest)

Possible clinical scenarios

Asymptomatic severe Hypertensive Hypertensive


HPT urgencies emergencies
• Incidental findings • Presents with grade III • Presents with
• Non-specific or IV retinal changes, symptoms and signs
symptoms like or proteinuria ≥ 2+, but of TOC e.g. acute
headache, dizziness, no overt organ failure heart failure,
lethargy subarachnoid
Management haemorrhage, acute
Management • Initial treatment coronary syndromes
• Most can be managed should aim for 25%
as outpatient reduction in BP over Management
• Review existing drug 24 hours but not • All patient should be
regime and lower than 160/90mm admitted
compliance Hg • Aim to reduce BP by
• For newly-diagnosed, • Combination therapy 25% over 3-12 hours
consider admission is often necessary but not lower than
for evaluation (see table below) 160/90 mmHg
• For established HPT, • Admit patient if BP • Best achieved with

INTERACTIVE CASE DISCUSSION 8


admit if compliance remain > 180/110 parenteral drugs

HYPERTENSION AND STROKE


remains a problem mmHg

Slide 10
TREATMENT OF HYPERTENSION IN ACUTE STROKE

TRAINING MODULE FOR HEALTH CARE PROVIDERS


Recommendations MANAGEMENT OF HYPERTENSION (3rd Edition)
• Lowering blood pressure is the key to both primary and secondary prevention of stroke
• In acute stroke, lowering BP is best avoided in the first few days unless hypertensive
emergencies co-exist
• In primary prevention, the benefits of BP lowering is seen in both normotensive and
hypertensive patients
• ACEI- or ARB- based treatment is preferred in secondary prevention

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Slide 11
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

TREATMENT OF HYPERTENSION IN ACUTE STROKE

Treatment of elevated BP in acute stroke is still controversial. In general, it is best to avoid


lowering BP in the first few days after a stroke unless there is evidence of accelerated
hypertension or patients presenting concurrently with hypertensive emergencies.

Recommendations
• Lowering blood pressure is the key to both primary and secondary prevention of stroke
• In acute stroke, lowering BP is best avoided in the first few days unless
hypertensive emergencies co-exist
• In primary prevention, the benefits of BP lowering is seen in both normotensive and
hypertensive patients
• ACEI- or ARB- based treatment is preferred in secondary prevention

Slide 12
INTERACTIVE CASE DISCUSSION 8
HYPERTENSION AND STROKE

TREATMENT OPTIONS FOR HYPERTENSIVE EMERGENCIES (PARENTERAL)

Slide 13
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MR. AK

• Explain the diagnosis to the patient and his son – Hypertensive Emergency presenting
with Stroke (Right Hemiparesis)
• Explain the importance of hospital admission and the importance of confirming the
type of stroke (haemorrhagic/Infarct)
• Arrange and prepare for hospital admission:
1. Secure intravenous line
2. Inform the receiving hospital
3. Send by ambulance, accompanied by paramedics
Slide 14
VISIT 2: BP REVIEW

• Mr. AK came back to the clinic 1 month after being discharged from the hospital
• Stable but no improvement of symptoms
• Still has residual weakness of right side of body and slurred speech
• Tolerating oral fluids and soft diet
• Using diapers due to mobility problems but no incontinence
• Appointment with physiotherapist: twice per week
• Appointment with neurologist: in 4 months

Slide 15
VISIT 2: BP REVIEW

• He brought along a discharged letter from the hospital which contains the
following informations:

Diagnosis: Left Cerebral Infarct


CT scan of brain: Left temporo-parietal hypodense lesion. No midline shift. Findings
consistent with Left Cerebral Infarct.
- Hydrochlorothiazide 25 mg daily

INTERACTIVE CASE DISCUSSION 8


Medications:
- Perindopril 4 mg daily

HYPERTENSION AND STROKE


- Simvastatin 40 mg nocte
- Aspirin 150 mg daily
Investigations: - FBS 5.5 mmol/l, Renal Profile normal.
- TC 6.5, TG 2.3, HDL 0.9, LDL 4.6 (all in mmol/litres).
- Liver Function Test normal
- Urine Microalbumin positive
- ECG: LVH - awaiting ECHO appointment

BP upon discharge – 150/90 mmHg

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
Please review his blood pressure

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Slide 16
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

VISIT 2: FURTHER HISTORY

• Taken care at home by his wife and youngest daughter


• Stopped smoking since incidence
• Eat home-cook meal
• Has been to Physiotherapy twice for mobilization exercise
• Adhering to the medication given by hospital
• Understand that Stroke is the complication of Hypertension
• No symptoms to suggest secondary causes of hypertension

Slide 17
VISIT 2: PHYSICAL EXAMINATION FINDINGS
INTERACTIVE CASE DISCUSSION 8
HYPERTENSION AND STROKE

• BMI: 26 kg/m2
• Waist circumference (WC): 88 cm
• BP: 140/90 mmHg
• Fundoscopy : normal
• Cardiovascular examinations - normal
• Chest examinations – normal
• Abdominal examinations – normal
• Neurological examinations – Right side UL/LL: Power 3+/5, hypertonia, reflexes brisk,
sensation: normal
• Plantar: up going

Slide 18
DISCUSSION POINT 3

• What is the level of his global CV risk stratification?


• How would you manage the patient?
• How do you educate the patient to prevent him from getting another stroke?
• What is his target BP and cholesterol level?
Slide 10
CARDIOVASCULAR RISK STRATIFICATION

Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)

SBP 120-139
and/or Low Medium High Very High
DBP 80-89

SBP 140-159
and/or Low Medium High Very High
DBP 90-99

SBP 160-179
and/or Medium High Very High Very High
DBP 100-109

SBP 180-209
and/or High High Very High Very High
DBP 100-119

SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120

INTERACTIVE CASE DISCUSSION 8


Risk Level Risk of major CV event in 10 years Management

HYPERTENSION AND STROKE


Low < 10% Lifestyle changes

Drug treatment and lifestyle


Medium 10-20%
changes

Drug treatment and lifestyle


High 20-30%
changes

Drug treatment and lifestyle


Very High > 30%
changes
TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal Failure

TRAINING MODULE FOR HEALTH CARE PROVIDERS


Risk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinical
MANAGEMENT OF HYPERTENSION (3rd Edition)
atherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke)
MI: Mycardial Infarction

CV Risk level is calculated based on his untreated BP


Legend: Green Yellow Orange Red

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Slide 20
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

TABLE 3. CARDIOVASCULAR RISK FACTORS

Major risk factors


√ Hypertension
Cigarette Smoking
Central obesity (waist circumference > 90 cm for men, > 80 cm for women)
√ Physical inactivity
√ Dyslipidaemia
Diabetes mellitus
√ Microalbuminuria
Estimated GFR* < 60 mL/min
√ Age (> 55 years for men, > 65 years for women)
Family history of premature cardiovascular disease (men < 55 years or women < 65 years)

Target Organ Damage


Heart Brain
√ • Left ventricular hypertrophy √ • Stroke or transient ischemic attack
INTERACTIVE CASE DISCUSSION 8
HYPERTENSION AND STROKE

• Angina or prior myocardial infarction Chronic kidney disease


• Prior coronary revascularisation Peripheral arterial disease
• Heart failure Retinopathy

*GFR, glomerular filtration rate

Slide 21
THERAPEUTIC LIFESTYLE MODIFICATION

Therapeutic lifestyle modification is the first line treatment in all patients with Hypertension

Weight Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a
reduction weight loss as little as 4.5 kg significantly reduces BP

An intake of < 100 mmol of sodium or 6 g of sodium chloride a


Salt
intake day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or
3 teaspoonfuls of monosodium glutamate)

Standard advice is to restrict intake to no more than 21 units for


Alcohol
intake men and 14 units for women per week (1 unit equivalent to 1/2 a
pint of beer or 100 ml of wine or 20 ml of proof whisky)

Physical General advice on cardiovascular health would be for “milder”


activity exercise, such as brisk walking 30 mins daily

A diet rich in fruits, vegetables and dairy products with reduced


Diet saturated and total fat can substantially lower BP (11/6 mmHg in
hypertensive patients and 4/2 mmHg in patients with high normal BP)

Smoking Cessation of smoking is important in the overall management of


cessation the patients with hypertension in reducing cardiovascular risk
Slide 22
SECONDARY PREVENTION OF STROKE

• BP lowering has been shown to reduce the risk of subsequent strokes


• “ACEI + diuretic” has been shown to reduce stroke recurrence
• ARBs lower the morbidity and mortality from further strokes

Slide 23
BLOOD PRESSURE TREATMENT TARGETS

Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
HPT in high risk groups: DM, History of CVD < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.

INTERACTIVE CASE DISCUSSION 8


Slide 24

HYPERTENSION AND STROKE


TARGET LDL- C LEVELS

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)

* Almost all individuals with 0-1 risk factor have a 10 year risk < 10%, thus 10 year risk
assessment in there individials with 0-1 risk factor is not necessary.
** These include individuals with multiple risk factors but a 10 year risk of CHD of < 20%
*** After 8-12 weeks of TLC

Stroke
Stroke is the 3rd leading cause of mortality in Malaysia. Evidence for the role of elevated
serum cholesterol in the pathogenesis of stroke is lacking. Fibrates and statins are safe and
should be considered in all patients presenting with strokes or transient ischaemic attacks.

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Slide 25
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. AK

• Educate him regarding the risk of recurrent stroke and the need to modify his very high CV risk
• Educate regarding BP treatment target < 130/80 mmHg, choice of medication –
potential benefits vs side effects
• Empower patient to self-manage through therapeutic lifestyle modification and self
home BP monitoring.
• Continue ACE Inhibitor and Diuretic
• Add another agent e.g. CCB – as his BP is still uncontrolled
• Continue statin and aspirin
• Monitor Renal Profile, Fasting Serum Lipid and LFT
• Review monthly until target BP is achieved
• Review 3 monthly once target BP is achieved
• Continue long-term follow up
• Assess CV risks annually
INTERACTIVE CASE DISCUSSION 8
HYPERTENSION AND STROKE

Slide 26
PRIMARY PREVENTION OF STROKE

• Trials have shown that a 10 mmHg reduction in SBP or a 5 mmHg reduction in DBP in
hypertensive patient can lead to a 34% reduction in the risk of stroke.
• ß-blockers, diuretics, CCBs, ACEIs and ARBs have been shown to reduce risk and
mortality of stroke.

Slide 27
SUMMARY OF EVIDENCE - HYPERTENSION AND STROKE

• Blood pressure is the most consistent and powerful predictor of stroke and high blood
pressure is the most important modifiable cause of stroke
• β-blockers, diuretics, CCBs, ACEIs, and ARBs have been shown to reduce the risk
and mortality of stroke
• Calcium channel blockers in particular, provided significantly better protection against
stroke compared with diuretics and/or β-blockers in Asian and Caucasian populations.
Combination of an ACEI and diuretics has been shown to reduce stroke recurrence in
both normotensive and hypertensive patients when treatment was started at least two
weeks after the stroke
• The morbidity and mortality from further strokes were also shown to be significantly
lower in patients receiveing ARBs compared to CCBs for the same level of BP control
• In haemorrhagic stroke, in general, it is best to avoid lowering BP in the first few days
after a stroke unless there is evidence of accelerated hypertension or patients presenting
concurrently with hypertensive emergencies
Slide 28
KEY LEARNING POINTS

• Therapeutics lifestyle changes should be recommended for all individuals with HPT and pre-HPT
• Blood pressure is the most consistent and powerful predictor of stroke and high blood
pressure is the most important modifiable cause of stroke
• Lowering blood pressure is the key to both primary and secondary prevention of stroke
• Rapid reduction of BP (within minutes to hours) in asymptomatic severe hypertension or
hypertensive urgencies is best avoided as it may precipitate ischaemic events
• In primary prevention, a CCB-based therapy is preferred in secondary prevention, the
benefits of BP lowering is seen in both normotensive and hypertensive patients ACEI- or
ARB- based treatment is preferred in secondary prevention

INTERACTIVE CASE DISCUSSION 8


HYPERTENSION AND STROKE TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

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INTERACTIVE CASE DISCUSSION 8 MANAGEMENT OF HYPERTENSION (3rd Edition)
HYPERTENSION AND STROKE

100
TRAINING MODULE FOR HEALTH CARE PROVIDERS
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Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Mr. MR • Married with 5


• 70 years old children
• Male • Retired teacher

REVIEW VISIT 1

• Known hypertensive since 2 years, came to the


clinic for follow-up Case 9
• Previous BP ranged from SBP 160-172 mmHg
and DBP 74-80 mmHg
• Also has osteoarthritis of knees and constipation
occasionally
• Current medication Nifedipine 10 mg tds, Diclofenac sodium 50 mg tds(prn), Ranitidine
150 mg od (prn), Lactulose syrup 15 ml ON (prn)
• On examination: alert, conscious and oriented
• PR 70/min, BP 170/76 mmHg on standing and sitting
INTERACTIVE CASE DISCUSSION 9
HYPERTENSION IN THE ELDERLY

• BMI 26 kg/m2
• Respiratory, Cardiovascular, GIT and CNS examinations–unremarkable

Slide 2
DISCUSSION POINT 1

• Describe the type of hypertension in this man


• Comment on his BP control status
• Comment on his medications
• How do you explain your management plan to the patient?

Slide 3
DEFINITION OF HYPERTENSION IN THE ELDERY IS THE SAME AS IN
THE GENERAL POPULATION

Category Systolic (mmHg) Diastolic (mmHg)

Optimal < 120 and < 80


Diagnosis of
Prehypertension 120-139 and/or 80-89 hypertension is
made based on the
Stage 1 HPT 140-159 and/or 90-99 average of two or
more readings,
Stage 2 HPT 160-179 and/or 100-109 taken at two or
more visits to the
Stage 3 HPT ≥ 180 and/or ≥ 110 health care
providers
Slide 4
BLOOD PRESSURE TREATMENT TARGETS

Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
HPT in high risk groups: DM, History of CVD < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.

Slide 5
CHOICE OF PHARMACOTHERAPY

• Five major classes of antihypertensive drugs (diuretics, β-blockers, CCBs, ACEIs


and ARBs) have been shown to reduce CV events in the elderly
• In older patients with isolated systolic hypertension, diuretics are preferred because
they significantly reduce multiple endpoints

INTERACTIVE CASE DISCUSSION 9


HYPERTENSION IN THE ELDERLY
Slide 6
REVIEW VISIT 1: SUMMARY OF MANAGEMENT PLAN

• Educate Mr. MR regarding his uncontrolled systolic BP (170/76 mmHg) and its impact
• Negotiate the management plan:
1. Advice on therapeutic lifestyle change – to lose weight by exercise and modest
salt reduction.
2. Change his medication - stop the nifedipine, change to hydrochlorothiazide 12.5 mg

TRAINING MODULE FOR HEALTH CARE PROVIDERS


once daily. MANAGEMENT OF HYPERTENSION (3rd Edition)
3. Arrange annual investigations to assess CV risks.
4. Arrange follow-up visit within 1 month.

Slide 7
REVIEW VISIT 2

• Mr. MR came back to the clinic after 1 month


• Feeling very well generally
• BP checked again in this visit – 160/72 mmHg on standing and sitting
• His FBS, FSL, Renal Profile, Urine Analysis and ECG were normal

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Slide 8
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

DISCUSSION POINT 2

• Describe the blood pressure control status


• Discuss the underlying reasons for his BP control status
• What is your next step of action?

Slide 9
REVIEW VISIT 2: SUMMARY OF MANAGEMENT PLAN

• Educate Mr. MR that his systolic BP is still uncontrolled


• Assess his adherence to treatment
• Add a long-acting CCB at the lowest dose e.g. Amlodipine 5 mg od
INTERACTIVE CASE DISCUSSION 9
HYPERTENSION IN THE ELDERLY

• Arrange follow up review in 1 month

Slide 10
REVIEW VISIT 3

• Mr. MR came back to the clinic after 1 month


• Feeling very well generally
• BP checked again in this visit – 140/68 mmHg

Slide 11
DISCUSSION POINT 3

• What is your next step of action?

Slide 12
REVIEW VISIT 3: SUMMARY OF MANAGEMENT PLAN

• Inform Mr. MR that his BP has achieved the control target


• Re-emphasize lifestyle intervention
• Emphasize the importance of adherence to treatment and long term follow-up
• Arrange follow up every 3 months
• Assess CV risks annually
Slide 13
SUMMARY OF EVIDENCE (1)

• HPT magnifies risk for CVD in the elderly compared with younger populations
• SBP is a better predictor of CV events than DBP especially in the elderly
• SBP increases linearly with age leading to an increase of isolated systolic hypertension
in the elderly
• In patients with marked SBP and not tolerating treatment well, reducing SBP to below
160 mmHg initially is acceptable. Subsequently attempts should be made to reduce BP
to target level

Slide 14
SUMMARY OF EVIDENCE (2)

• Several RCT have shown that treatment of hypertension in the elderly up to the age of
84 years reduces CV morbidity and mortality, particularly stroke
• For those > 85 years, benefit of treating hypertension prevents the fatal and debilitating
consequences of hypertension such as stroke, heart failure and dementia. (HYVET TRIAL
2008)

INTERACTIVE CASE DISCUSSION 9


HYPERTENSION IN THE ELDERLY
Slide 15
SUMMARY OF EVIDENCE (3)

• Salt restriction is especially effective in the elderly due to greater sensitivity to sodium
• Five major classes of antihypertensive drugs (diuretics, ß-blockers, CCBs, ACEIs and
ARBs) have been shown to reduce CV events in the elderly
• In older patients with isolated systolic hypertension, diuretics are preferred because

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
they significantly reduce multiple endpoints

Slide 16
SUMMARY OF EVIDENCE (4)

• Several trials using CCBs have shown benefits particularly in stroke reduction
• ACEi are the drugs of choice for those with concomitant left ventricular systolic
dysfunction, post MI or DM
• ARBs have also been shown to reduce fatal and non-fatal strokes in hypertensive
patients aged 65 years or older

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Slide 17
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

SUMMARY OF EVIDENCE (5)

• The starting dose of HPT medications in older patients should be at the lowest available
• In order to maximise adherence, the drug regime should be as simple as possible
• The elderly tend to be on polypharmacy – drug interactions should be taken into
account when considering antihypertensive treatment

Slide 18
KEY LEARNING POINTS

• The goals of treatment of hypertension in older patients should be the same as in


younger patients
INTERACTIVE CASE DISCUSSION 9
HYPERTENSION IN THE ELDERLY

• In those patients with marked SBP and not tolerating treatment well, reducing SBP to
below 160 mmHg initially is acceptable. Subsequently, attempts should be made to
reduce BP to target levels
• Weight loss and modest salt reduction are effective in the elderly because of their greater
sensitivity to sodium
• Five major classes of drugs have been shown to reduce CV events in the elderly
(diuretics, β-blockers, CCBs, ACEi and ARBs)
• ACEi are the drugs of choice for those with concomitant left ventricular systolic
dysfunction, post MI and DM
108

Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Mdm NH • G1P0
• 35 years old • Housewife

VISIT 1

• Came for antenatal booking.


• POA 21 weeks
• UPT positive done by private GP 3 months ago Case 10
• Booking BP 130/80 mmHg
• Otherwise well – no other symptoms
• Strong family history of hypertension
• BP 140/90 mmHg
• Normal physical examination
INTERACTIVE CASE DISCUSSION 10
HYPERTENSION IN PREGNANCY

Slide 2
DISCUSSION POINT 1

• How would you manage the patient?

Slide 3
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MDM. NH

• Explain to her that she has a raised BP (140/90 mmHg)


• Explain the significance of the reading and the importance of confirming the diagnosis
• Negotiate the management plan:
1. Arrange to see the nurse for E.O.D BP check for 1 week
2. Arrange baseline investigations
3. Advise on sign and symptoms of pre-eclampsia
4. Arrange follow-up visit within 1 week

Slide 4
VISIT 2: BP REVIEW

• Mdm. NH came back to the clinic after 1 week


• Feeling very well generally
• BP checked by nurse over a week
– 140/90, 145/95, 140/90 mmHg
• BP checked again in this visit – 140/90 mmHg
• Urine albumin - nil
Slide 5
DISCUSSION POINT 2

• What is the diagnosis?


• What is your next step of action?

Slide 6
HYPERTENSION IN PREGNANCY

Group of diseases in which hypertension is the chief clinical manifestation in pregnancy -


two distinct groups:
• Normotensive women who develop pre-eclampsia syndrome
• Women with chronic hypertension who are at the higher risk of developing
superimposed pre-eclampsia

Slide 7
DIAGNOSIS

INTERACTIVE CASE DISCUSSION 10


HYPERTENSION IN PREGNANCY
Mdm. NH’s BP taken ≥ 2 visits were ≥ 140/90 mmHg

Hypertension in Pregnancy is defined as a systolic blood pressure (BP) ≥ 140 mmHg


and/or a diastolic BP ≥ 90 mmHg.

An increase of 15 mmHg and 30 mmHg diastolic and systolic BP levels above baseline BP
is no longer recognized as hypertension if absolute values are below 140/90 mmHg.

Korotkoff V should now be used as the cut-off point for diastolic BP, and Korotkoff IV

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
utilized only when Korotkoff V is absent.

Slide 8
BASELINE INVESTIGATIONS

• Biochemical investigations:
– Platelet count, hematocrit
– Serum uric acid and creatinine
– Liver function test
– UFEME
– OGTT
– 24 hour urine protein
• Other relevant investigation TRO secondary causes

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Slide 9
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

VISIT 2: FURTHER HISTORY

• No significant past medical history


• Not on any regular medication
• Both parents hypertensive
• Father had heart attacks at aged 60 years
• No pre-eclamptic symptoms
• No symptoms to suggest secondary causes of hypertension
• Sedentary lifestyle
• Normal diet

Slide 10
INTERACTIVE CASE DISCUSSION 10
HYPERTENSION IN PREGNANCY

VISIT 2: PHYSICAL EXAMINATION FINDINGS

• BP 140/90 mmHg
• Normal weight gain
• Fundoscopy normal
• Cardiac & respiratory examinations – normal
• Symphysis fundal height – 21 cm
• Neurological examinations – normal

Slide 11
VISIT 2: BASELINE INVESTIGATION RESULTS

• Renal Profile: Urea 3.2 , Sodium 132, Potassium 3.5, Chloride 101 (all in mmol/L),
Creatinine 65 µmol/L
• Serum uric acid: 200 µmol/L
• Full Blood Count: Hb 11.5 g/dL, wbc 4500/mL, platelet 211,000/mL
• OGTT: 5.3/7.0 mmol/L
• Urinalysis - albumin negative

Slide 12
DISCUSSION POINT 3

• How do you classify hypertension in pregnancy?


• What do you think Madam NH has?
Slide 13
CLASSIFICATION OF HDP

HDP

Preeclampsia
Preeclamsia-
Gestational HPT Chronic HPT superimposed on
eclampsia
chronic HPT

Slide 14
CLASSIFICATION OF HDP

1. Preeclampsia-eclampsia: clinically diagnosed in the presence of de novo hypertension


after gestational week 20, and one or more of the following:
i. Significant proteinuria.
ii. Renal insufficiency: serum creatinine 90 µmol/l or oliguria.

INTERACTIVE CASE DISCUSSION 10


iii. Liver disease: raised transaminases and/or severe right upper quadrant or epigastric pain.

HYPERTENSION IN PREGNANCY
iv. Neurological problems: convulsions (eclampsia), hyperreflexia with clonus or severe
headaches, persistent visual disturbances (scotoma).
v. Haematological disturbances: thrombocytopenia, coagulopathy, haemolysis.
vi. Fetal growth restriction.

This is followed by normalisation of the BP by three months postpartum. Oedema is no


longer part of the definition of preeclampsia. Either excessive weight gain or failure to gain
weight in pregnancy may herald the onset of preeclampsia.

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 15
CLASSIFICATION OF HDP

2. Gestational hypertension: hypertension alone, detected for the first time after 20 weeks
pregnancy. The definition is changed to “transient” when pressure normalizes postpartum.
3. Chronic hypertension: hypertension diagnosed prior to gestational week 20; or presence
of hypertension preconception, or de novo hypertension.
4. Preeclampsia superimposed on chronic hypertension:
This can be diagnosed by the appearance of any of the following in a woman with
chronic hypertension:
i) De novo proteinuria after gestational week 20.
ii) A sudden increase in the severity of hypertension.
iii) Appearance of features of preeclampsia-eclampsia.
iv) A sudden increase in proteinuria in women who have preexisting proteinuria early in gestation.

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Slide 16
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

DISCUSSION POINT 4

• How do you manage Mdm NH?


• What is your next step of action?

Slide 17
MANAGEMENT

• Early diagnosis of Hypertension in Pregnancy is vital


• Recognition of Severity - mild
- severe
• Colour Coding
INTERACTIVE CASE DISCUSSION 10
HYPERTENSION IN PREGNANCY

Red Code - Mild pre eclampsia and more than 36 weeks gestation
- Severe pre eclampsia
- Eclampsia
Yellow Code - Mild pre eclampsia and less than 36 weeks gestation

Slide 18
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MDM. NH

• Educate regarding the diagnosis of Hypertension in pregnancy, and potential complications


• Educate regarding BP treatment target < 140/90 mmHg, choice of medication –
potential benefits vs side effects
• Regular fetal and maternal surveillance
• Monitor sign and symptom of impending pre-eclampsia
• Empower patient to self-manage through therapeutic lifestyle modification
• Address transportation problems if any
• Address adverse traditional beliefs and taboos
• Refer early to Obstetrician in nearest hospital for combine care

Slide 19
VISIT 3: FOLLOW UP

• Mdm. NH came for review after 2 weeks (POA 23 weeks)


• Her Renal Profile was normal
• Has headache and mild epigastric pain
• BP checked again in this visit – 150/100 mmHg
• Weight increasing
• Repeat urine protein 2+
Slide 20
DISCUSSION POINT 5

• How do you manage this lady at this stage?

Slide 21
VISIT 3: SUMMARY OF MANAGEMENT PLAN FOR MDM. NH

• Educate on her BP level – BP is high and she is symptomatic (severe pre-eclampsia)


• She needs to be admitted to the hospital for BP stabilization
• Perform appropriate resuscitation in the clinic before transfer

Slide 22
ANTIHYPERTENSIVE DRUGS COMMONLY USED IN PREGNANCY

INTERACTIVE CASE DISCUSSION 10


HYPERTENSION IN PREGNANCY TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

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Slide 23
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

SEVERE PREECLAMPSIA

Must be promptly identified so that the patient can be urgently admitted to hospital for close
observation and timely delivery. The Royal College of Obstetrician and Gynecology (RCOG)
defines severe pre eclampsia as follows:
1. Systolic BP 170 mmHg or diastolic BP 110 mmHg (acute hypertensive crisis in
pregnancy) on two occasions, with proteinuria of 1 g/day.
2. Diastolic BP 100 mmHg on two occasions, with significant proteinuria (1+ on dipstick),
with two or more signs or symptoms of imminent eclampsia:
a. severe headache h. abnormal liver enzymes (elevated ALT
b. visual disturbance or AST)
c. epigastric pain and/or vomiting i. HELLP syndrome (haemolysis,
d. clonus elevated liver enzymes, low platelets)
e. Papilloedema j. intrauterine growth restriction (IUGR)
f. liver tenderness k. pulmonary oedema and/or congestive
g. platelet count below 100,000/cmm cardiac failure
INTERACTIVE CASE DISCUSSION 10
HYPERTENSION IN PREGNANCY

Slide 24
ANTICONVULSANTS IN PREECLAMPSIA-ECLAMPSIA

Parenteral magnesium sulphate is currently the drug of choice for the prevention of eclampsia
and to abort an eclamptic fit. The alternative is intravenous diazepam (intravenous bolus 10
mg slowly over 10-15 minutes followed by infusion), bearing in mind that it is inferior in efficacy
compared to magnesium sulphate.

Slide 25
POSTPARTUM CARE

• Advised to have BP checked regularly at local clinics if there is a significant delay in their
scheduled hospital follow-up
• In these patients, the dose of antihypertensive should be tailed down gradually and not
stopped suddenly
• De novo onset of hypertension or aggravation of BP levels during the postpartum period,
can occur
• These patients should be promptly referred to hospital especially if there is significant
proteinuria. Eclampsia may occur in the postpartum period
• Chronic hypertension is diagnosed when the hypertension and/or proteinuria fails to
disappear within three months postpartum
Slide 26
KEY LEARNING POINTS

1. Preconception counseling and adjustment of treatment in women with chronic hypertension.


2. Recognition of women at high risk of preeclampsia and referral in early pregnancy for
screening and prophylaxis.
3. Nutritional supplementation for prevention of preeclampsia and/or its complications.
4. Prevention of eclampsia and other complications of preeclampsia
5. Primary care providers play an important role in preventing, detecting, monitoring
and managing preeclampsia and its complications

INTERACTIVE CASE DISCUSSION 10


HYPERTENSION IN PREGNANCY TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

115
INTERACTIVE CASE DISCUSSION 10 MANAGEMENT OF HYPERTENSION (3rd Edition)
HYPERTENSION IN PREGNANCY

116
TRAINING MODULE FOR HEALTH CARE PROVIDERS
118

Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Puan Rahmah • Last child birth 6/12


• 35 years old ago
• Para 4 • Accountant

VISIT 1

• Referred to you for BP 150/90 mmHg after 1/12


on Combine Oral Contraceptive (COC) Case 11
• Currently not breast-feeding her child
• Generally well- asymptomatic
• Strong family history of hypertension

Slide 2
INTERACTIVE CASE DISCUSSION 11
HYPERTENSION AND OCP

DISCUSSION POINT 1

• What further history would you like to elicit?


• What physical examinations would you perform?
• List the investigation you would do?

Slide 3
VISIT 1- FURTHER HISTORY

• Blood pressure before starting COC 130/80 mmHg


• History of pregnancy induce hypertension
• No symptoms of secondary causes of HPT & TOD
• Unhealthy diet & sedentary lifestyle
• Non smoker but husband is a chronic smoker
• Not on any other medication except COC
• Stressful at work and at home taking care of 4 children

Slide 4
VISIT 1- PHYSICAL EXAMINATIONS

• Repeat BP 152/90 mmHg


• BMI 23 kg/m2
• Urine albumin negative, RBS 5.5 mmol/L, ECG normal
Slide 5
DISCUSSION POINT 2

• Discuss the patient’s problems

Slide 6
VISIT 1

Problem List
• Stage 1 hypertension on COC
• Passive smoker, poor diet control, sedentary lifestyle
• Stressful at work and home

Slide 7
DISCUSSION POINT 3

INTERACTIVE CASE DISCUSSION 11


• What would you do now?
• How do you explain your plan to the patient?

HYPERTENSION AND OCP


• Discuss alternative methods of contraception for this patient

Slide 8
VISIT 1- FURTHER ACTIONS

TRAINING MODULE FOR HEALTH CARE PROVIDERS


• Explain that she needs to stop the COC in order to control her BP MANAGEMENT OF HYPERTENSION (3rd Edition)
• Advice and reinforce on therapeutic life-style change – diet, exercise, stress management
• Closer monitoring of BP and CVD risk factors
• Counsel on other methods of contraception e.g. IUCD, POP, injectable depots, implants
& barrier methods

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Slide 9
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

HYPERTENSION AND ORAL CONTRACEPTIVES

The incidence of hypertension is reported to be higher in women taking combined oral


contraceptives (COC), especially in obese and older women. The mechanism by which the
BP rises is unknown. A women who develops hypertension while using COC should be
advised to stop taking them and should be offered alternative forms of contraceptions.
Progesterone Only Pills and low dose COC are not known to raise BP nor increase the
risks of myocardial infarction. They are recommended alternatives for patients with
hypertension or those who develop hypertension and yet wish to continue oral
contraception. A prudent approach to the use of oral contraception would be to measure
baseline BP before initiating treatment. Blood pressure should be reviewed regularly, at least
every six month.

Slide 10
INTERACTIVE CASE DISCUSSION 11
HYPERTENSION AND OCP

SUMMARY OF EVIDENCE

• A woman who develops hypertension while using COC should be advised to stop taking
them and should be offered alternative forms of contraception
• Blood pressure should be reviewed regularly, at least every six months

Slide 11
KEY LEARNING POINTS

• The incidence of hypertension is reported to be higher in women taking COC, especially


in obese and older women
• Before started all woman on OCP the blood pressure must be check then monitored
regularly while she is on OCP
• Woman who develops hypertension while using COC should be advised to stop taking
them and should be offered alternative forms of contraception
• Progesterone Only Pills191 and low dose COC, recommended alternatives for patients
with hypertension or develop hypertension and wish to continue with OCP
122

Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

• Madam OKL • Married with 4


• 52 years old children
• Teacher

VISIT 1

• Came to the clinic for review


• Was commenced on hormone replacement Case 12
therapy (HRT) - Progyluton® 2 months ago
when she presented with worsening hot flushes
and vaginal dryness
• Last menstruation was about a year ago
• Last blood tests were done 6 months ago (confirmed her postmenopausal status)
• BP readings were between 140/90-150/94 mmHg for the past 6 months before she was
commenced on HRT
INTERACTIVE CASE DISCUSSION 12
HYPERTENSION AND HORMONE REPLACEMENT THERAPY

Slide 2
VISIT 1: FURTHER HISTORY

• No symptoms of CVD and TOD


• Practice a prudent diet
• Does regular walk every morning
• Non-smoker
• Taking mefenamic acid for her painful knee occasionally
• Children are healthy
• Parents died of ‘old age’ at 70+ years old
• Living with husband

Slide 3
VISIT 1: PHYSICAL EXAMINATIONS AND BASELINE INVESTIGATIONS

Result
BMI 22 kg/m2, WC= 75 cm
Neck - no goitre, no carotid bruit
Heart and lung - normal
Abdomen and pelvic - normal
Legs - normal
Other systems – normal
FBG 5.5 mmol/L, Fasting serum lipid normal
Urine microalbumin negative
ECG normal
Slide 4
DISCUSSION POINT 1

• What is the diagnosis?


• What is her global CV risk stratification level?

Slide 5
DIAGNOSIS & CLASSIFICATION OF HYPERTENSION

Category Systolic (mmHg) Diastolic (mmHg)

Optimal < 120 and < 80


Diagnosis of
Prehypertension 120-139 and/or 80-89 hypertension is
made based on the
and/or

HYPERTENSION AND HORMONE REPLACEMENT THERAPY


Stage 1 HPT 140-159 90-99 average of two or
more readings,
Stage 2 HPT 160-179 and/or 100-109 taken at two or
more visits to the
Stage 3 HPT ≥ 180 and/or ≥ 110 health care
providers

INTERACTIVE CASE DISCUSSION 12


Slide 6
CARDIOVASCULAR RISK STRATIFICATION

Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
Mellitus (DM)

TRAINING MODULE FOR HEALTH CARE PROVIDERS


(mmHg)
MANAGEMENT OF HYPERTENSION (3rd Edition)
SBP 120-139
and/or Low Medium High Very High
DBP 80-89

SBP 140-159
and/or Low Medium High Very High
DBP 90-99

SBP 160-179
and/or Medium High Very High Very High
DBP 100-109

SBP 180-209
and/or High High Very High Very High
DBP 100-119

SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120

Legend: Green Yellow Orange Red

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Slide 7
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

VISIT 1: FURTHER INFORMATION

• Her BP was checked again twice (15 minutes apart) on this visit: 160/100 mmHg

Slide 8
DISCUSSION POINT 2

• Summarise Mdm. OKL’s problems.


• How do you manage this lady?

Slide 9
INTERACTIVE CASE DISCUSSION 12
HYPERTENSION AND HORMONE REPLACEMENT THERAPY

VISIT 1: SUMMARY OF PROBLEMS

• Post-menopause with persistent vasomotor symptoms


• Underlying Stage 1 hypertension – worsening to Stage 2 (160/100 mmHg) since
commencing HRT
• No significant co-existing CV risk factor apart from HPT
Slide 10
ALGORITHM FOR THE MANAGEMENT OF HYPERTENSION

HYPERTENSION AND HORMONE REPLACEMENT THERAPY


INTERACTIVE CASE DISCUSSION 12
Slide 11
HYPERTENSION AND HOME REPLACEMENT THERAPY

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)
The presence of hypertension is not a contraindication to oestrogen-based hormonal
replacement therapy (HRT). It is recommended that all women treated with HRT should have
their BP monitored every six months. The decision to continue or discontinue HRT in these
patients should be individualised.

The Women’s Health Initiative (WHI) trial involving 98, 705 women aged 50-79 years,
concluded that the use of HRT increased cardiovascular events. Conjugated equine
estrogen (CEE), alone or in combination with medroxyprogesterone acetate, was used in the
study. In view of this, greater caution and closer monitoring is required for hypertensive
patients on CEE.

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Slide 12
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

CHOICE OF PHARMACOTHERAPY

Pharmalogical management of stage 2 hypertension


Initiating therapy with the right combination of at least 2 drugs is recommended

Effective Combination
β-blockers + diuretics
β-blockers + CCBs
CCBs + ACEIs/ARBs
ACEIs + diuretics
ARBs + diuretics

Slide 13
INTERACTIVE CASE DISCUSSION 12
HYPERTENSION AND HORMONE REPLACEMENT THERAPY

BLOOD PRESSURE TREATMENT TARGETS

Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
HPT in high risk groups: DM, History of CVD < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.

Slide 14
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MDM. OKL

• Explain to her that she has an underlying Stage 1 HPT which is now worsening.
• Initiate therapy with 2 drugs e.g. CCB + ACEi
• Discuss the option of continuing HRT and advise to have regular Pap smear and
mammogram
• Re-emphasize on therapeutic lifestyle modification
• Educate regarding potential complications, the need to start medication and her
treatment target
• Review monthly until target BP is achieved
• Review 3-monthly once target BP is achieved
• Re-assess CV risks annually
Slide 15
A NOTE ON HORMONE REPLACEMENT THERAPY-PROGYLUTON

• 11 white tab each containing Calendar pack of Oestradiol valerate 2 mg, 10 brown tab
each containing Norgestrel 500 mcg, Oestradiol Valerate 2 mg
• Before starting treatment, a thorough general medical (including blood pressure
measurement, urine test for sugar and, if necessary, special liver tests), and
gynaecological examination (including the breasts and a cytological smear) should be
carried out to detect any diseases requiring treatment or any risks and, above all, to rule
out pregnancy. Control examinations are recommended at about 6-monthly intervals
• Progyluton is not a contraceptive. Where applicable contraception should be practised
with non-hormonal methods

Slide 16
SUMMARY OF EVIDENCE

HYPERTENSION AND HORMONE REPLACEMENT THERAPY


• The presence of hypertension is not a contraindication to oestrogen based hormonal
replacement therapy (HRT)
• It is recommended that all women treated with HRT should have their BP monitored
every six months

INTERACTIVE CASE DISCUSSION 12


• The decision to continue or discontinue HRT in these patients should be individualized
• The Women's Health Initiative (WHI) trial involving 98, 705 women aged 50-79 years,
concluded that the use of HRT increased cardiovascular events. In view of this, greater
caution and closer monitoring is required for hypertensive patients on CEE

Slide 17
KEY LEARNING POINTS
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
• Stage 1 HPT is defined as SBP 140 and/or DBP 90 mmHg or greater, based on > 2 BP
readings at > 2 clinic visits
• HRT is safe in hypertensive women. The presence of hypertension is not a
contraindication to oestrogen based hormonal replacement therapy (HRT)
• Untreated or sub-optimally controlled hypertension leads to increased cardiovascular,
cerebrovascular and renal morbidity and mortality
• Decision to commence pharmacological treatment should be based om global
cardiovascular risks and not on the level of blood pressure (BP) per se
• All women treated with HRT should have their BP monitored every six months including
regular gynaecological examination, mammogram and cervical smear

127
INTERACTIVE CASE DISCUSSION 12 MANAGEMENT OF HYPERTENSION (3rd Edition)
HYPERTENSION AND HORMONE REPLACEMENT THERAPY

128
TRAINING MODULE FOR HEALTH CARE PROVIDERS
130

Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

GOLD STANDARD BP MEASUREMENT

• Invasive Measurement

Slide 2
WORKSHOP ON BP (BP MEASUREMENT TECHNIQUE & SKILLS)

MERCURY COLUMN SPHYGMOMANOMETER-GOLD STANDARD NON


INVASIVE METHOD

Slide 3
STEPS TO BP MEASUREMENT

Check the machine


1. The mercury meniscus – make sure it is at zero. If not, minus the baseline reading
2. Inflation – deflation device
a) after 3-5 seconds of rapid inflation the mercury column should touch 200 mmHg or
40 mmHg above estimated SBP
b) ability to deflate at a rate of 2-3 mmHg per second
3. Cuff – both length and width of the bladder must be correct. The length of the bladder
must at least be 80% of the circumference of the arm and the width at least 40% the
circumference of the arm
Slide 4
BLADDER LENGTHS

WORKSHOP ON BP (BP MEASUREMENT TECHNIQUE & SKILLS)


Slide 5
STEPS TO BP MEASUREMENT

• Rest the patient, back rested on the chair and arm supported at heart level, no coffee
or smoking 30 minutes before
• Wrap the cuff properly
• Palpate the brachial or radial artery
• Inflate the bladder until the pulse disappear and inflate another 30 mmHg
• Deflate the cuff slowly until the pulse is felt again (estimated SBP)
• Bladder inflated to 30 mmHg above the estimated SBP

Slide 6 MANAGEMENT OF HYPERTENSION (3rd Edition)


TRAINING MODULE FOR HEALTH CARE PROVIDERS

STEPS TO BP MEASUREMENT

• First repetitive appearance of clear tapping sound (Korotkoff 1) is SBP. Disappearance of


sound (Korotkoff V) is DBP.
• If Korotkof sound does not disappear, use Korotkof 1V (muffling)
• Measure on both arm at first visit. If > 20/10 mmHg is abnormal
• Measure lying and standing (after 1 minute) BP for the elderly and the diabetics

131
MANAGEMENT OF HYPERTENSION (3rd Edition)
WORKSHOP ON BP (BP MEASUREMENT TECHNIQUE & SKILLS)

132
TRAINING MODULE FOR HEALTH CARE PROVIDERS

Slide 9
Slide 8
Slide 7

Beware of defective machine


CLINICAL HYPERTENSION

THE SPHYGMOMANOMETER

AUTOMATED SPHYGMOMANOMETER
Slide 10
OTHER METHODS OF MEASUREMENT

• Aneroid sphygmomanometer
• Automated ambulatory BP devices
• Validated by either BHS or AAMI methods

Slide 11
AMBULATORY BP

Indicated in:
• suspected ‘white coat’ hypertension
• borderline hypertension
• labile hypertension

WORKSHOP ON BP (BP MEASUREMENT TECHNIQUE & SKILLS)


• resistant hypertension (not controlled on 3 drugs including a diuretics)
• ‘hypotensive symptoms’

Slide 12

TRAINING MODULE FOR HEALTH CARE PROVIDERS


MANAGEMENT OF HYPERTENSION (3rd Edition)

Slide 13
DETECTING POSTURAL HYPERTENSION

• BP taken both lying and at least 1 minute standing


• Significant drop: SBP ≥ 20 mmHg

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Slide 14
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)

MEASURING BILATERAL BP DIFFERENCES

• Difference of BP ≥ 20/10 mmHg


• Consider: - Atherosclerosis
- Congenital co-arctation of aorta
- Vasculitis: big vessels disease: Takayasu disease

Slide 15
AUSCULTATORY GAPS

• It is a normal phenomenon
seen in elderly
WORKSHOP ON BP (BP MEASUREMENT TECHNIQUE & SKILLS)

Slide 16
CHANGE IN BP WITH DAILY ACTIVITIES

Activities SBP DBP Activities SBP DBP


Meetings +20 +15 Eating +9 +10
Work +16 +13 Talking +7 +7
Transportation +14 +9 Desk work +6 +5
Walking +12 +6 Reading +2 +2
Dressing +12 +10 Television +0.3 +3.2
Chores +11 +7 Relaxing 0 0
Telephone +10 +7 Sleeping -10 -8

Slide 17
KEY LEARNING POINTS

• Proper steps in blood pressure measurement is important to avoid inaccurate readings.


• Optimal blood pressure measurement determines management strategies
136
TRAINING MODULE FOR HEALTH CARE PROVIDERS

PRE & POST TEST QUESTIONNAIRE


MANAGEMENT OF HYPERTENSION (3rd Edition)

MULTIPLE CHOICES QUESTIONS (MCQs) (TRUE/FALSE)

TOPIC 2: DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION

1. The following statement(s) is/are true regarding pre-hypertension:


A. If left untreated, almost two thirds will progress to develop stage 1 hypertension
B. Younger individuals are associated with a higher rate of progression
C. It tends to cluster with other cardiovascular risk factors
D. Almost a third of BP-related deaths from coronary heart disease occur in pre-hypertensive
individuals
E. Pre-hypertensive level of blood pressure itself is an independent cardiovascular risk factor

2. With regards to the management of pre-hypertension, the following statement(s) is/are true:
A. All patients should be managed with therapeutic lifestyle modification
B. Patients should be followed up at least once every 2 years
C. Decisions regarding pharmacological treatment should be based on the individual’s global
cardiovascular risk
D. Pharmacological treatment is indicated in pre-hypertensive patients at low cardiovascular risk
PRE-TEST AND POST-TEST QUESTIONNAIRE (MCQs)

E. In patients with diabetes mellitus and pre-hypertension, pharmacological treatment is


required if BP is > 130/80 mmHg

TOPIC 3: DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION

1. Madam Y has recently been diagnosed with stage 1 hypertension. She is a heavy smoker and her
total cholesterol is 6.8 mmol/L. The following statement(s) is/are true regarding her condition and
management:
A. She has a medium cardiovascular risk
B. Her target blood pressure is < 140/90 mmHg
C. Pharmacological treatment should commence with combination of 2 drugs at low dose
D. β-blocker is recommended for first line therapy for this patient
E. Thiazide diuretic is contraindicated in her case

2. The following statement(s) is/are true with regards to the management of stage 1 hypertension:
A. In patients without target organ damage, an observational period of 3-6 months on lifestyle
modification is recommended
B. Monotherapy can lower the blood pressure to < 140/90 mmHg in 40-60% of cases
C. Increasing the dose of the initial drug is an option if patient shows response but target BP is not
achieved
D. Monotherapy should be continued for at least 6 months before a second drug can be added
E. Substituting the drug with another class is recommended when the drug is not tolerated
TOPIC 4: DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION &
RESISTANT HYPERTENSION

1. For patients with stage 2 hypertension, the target blood pressure of < 140/90 mmHg is
recommended if they have:
A. History of tobacco smoking
B. Diabetes mellitus
C. Chronic kidney disease
D. Central obesity
E. Cardiovascular disease

2. Below is/are the recommended antihypertensive combination(s) for patients with stage 2
hypertension and heart failure:
A. β-blocker + ACEi
B. β-blocker + CCB
C. CCB + ACEi
D. ACEI + diuretic
E. ARB + diuretic

3. The following statement(s) is/are true with regards to resistant hypertension:


A. It is defined when a patient’s BP is > 140/90 mmHg on 3 antihypertensive agents including a
diuretic at near maximal dose
B. Non-compliance to medication must be excluded
C. The commonest cause is secondary hypertension

PRE-TEST AND POST-TEST QUESTIONNAIRE (MCQs)


D. Excessive salt intake is a contributing factor
E. Specialist referral is required in suspected cases of renal artery stenosis

TOPIC 5: DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION

1. A 48-year-old woman is evaluated for hypertension. Physical examination showed BP: 182/86
mmHg. She does not give history of headaches. Fundoscopy showed that she has Grade 3
Hypertensive retinopathy. Her home blood pressure measurements remain the same results as
above. Which of the following statement(s) is/are true :
A. She is having Hypertensive Urgencies
B. Patient can be reassured of her blood pressure readings
C. She needs to be referred to the nearest hospital for initiating antihypertensive agent
D. She can be managed as outpatient with just home blood pressure monitoring
E. She may need hospital admission if her blood pressure remains elevated after 30 minutes of rest

TRAINING MODULE FOR HEALTH CARE PROVIDERS


2. A 56-year-old man was diagnosed with essential hypertension 6 months ago. His blood MANAGEMENT OF HYPERTENSION (3rd Edition)
pressure remained elevated at average 174/110 mmHg. He was taking Tablet Amlodipine 5
mg daily. His blood pressure today in the clinic is 172/112 mmHg. He denied of having any
headache or blurring of vision. There were no hypertensive retinopathy changes in his eyes. Which
of the following statement(s) is/are most appropriate for the patient at the current situation?
A. He must be referred to the hospital today for further evaluation of his blood pressure readings
B. Advice him to continue to comply with his current medicine
C. He has Stage 3 Hypertension
D. We should ask for symptoms of limb weakness.
E. We would order Urine microalbumin test

3. The following statement(s) is/are correct regarding the management of Stage 3 Hypertension:
A. Patient’s blood pressure target is < 140/90 mmHg if there is no target organ complication
B. Non-adherence to therapy is an important cause of uncontrolled blood pressure
C. Monotherapy is sufficient to get the blood pressure to target
D. Fundoscopy and an ECG evaluation are needed for assessments of their target organ damage
or complication
E. There is no role of therapeutic lifestyle changes for these patients

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TRAINING MODULE FOR HEALTH CARE PROVIDERS

TOPIC 6: HYPERTENSION AND DIABETES


MANAGEMENT OF HYPERTENSION (3rd Edition)

1. A 54-year-old man with type 2 diabetes has had intermittent mild headaches for the past one
month. He is now euglycemic with oral hypoglycemic agents and lifestyle modifications. His older
sister has had hypertension and has been taking antihypertensive medications for several years.
Physical exam reveals an afebrile medium size man with a BP of 158/96 mm Hg (average of 2
readings), normal and regular peripheral pulses, hard exudates and narrowing of the arterioles on
fundoscopic exam, and no carotid bruits. Lungs are clear and neurologic exam is also normal. His
recent test result show the following: fasting plasma glucose, 5.8 mmol/L; HbA1c, 6.9%; normal
urinalysis; and normal electrocardiogram (ECG).

Which of the following(s) would you consider for treatment of this patient?
A. A thiazide-type diuretic
B. A combination of a β-blocker and thiazide-type diuretic
C. A combination of a β-blocker and an ACE inhibitor
D. A combination of a calcium channel blocker and an ACE inhibitor
E. A combination of a thiazide-type diuretic and a ARB

2. In the drug management of hypertension in diabetic patients,


A. amlodipine worsens peripheral neuropathy
B. atenolol causes hypoglycemia
PRE-TEST AND POST-TEST QUESTIONNAIRE (MCQs)

C. hydrochlorothiazide is contraindicated in the presence of proteinuria


D. perindopril prevents cardiovascular events
E. prazocin reduces glucose metabolism

3. Which of the following statements regarding management of hypertensive patient with type 2
diabetes mellitus is/are TRUE?
A. When the systolic blood pressure is > 20 mmHg above goal or diastolic blood pressure is > 10
mmHg above goal, monotherapy is recommended
B. Many patients require 3 or more antihypertensive medications to achieve blood pressure goal
C. All patients with diabetes and hypertension should be treated with calcium channel blocker
D. They need less stringent blood pressure goal
E. Pharmacotherapy is indicated in patients with microalbuminuria

TOPIC 7: HYPERTENSION AND METABOLIC SYNDROME

1. Which of the criterion/criteria below is/are TRUE for Metabolic Syndrome


A. Waist circumference of > 90 in men and > 80 in women
B. Raised Blood pressure > 130/85 mmHg
C. Fasting blood sugar of > 6.1 mmol/L
D. Raised Triglyceride and Low HDL
E. Raised Triglyceride and Raised LDL

2. In the drug management for patients with Hypertension and Metabolic Syndrome.
A. Thiazide Diuretics is recommended as first line agent
B. ß-blockers should be avoided
C. ACE Inhibitor is a recommended drug of choice
D. Calcium Channel Blocker should be avoided
E. Combination therapy is considered safe

3. Which of the statement(s) below regarding Metabolic Syndrome is/are TRUE


A. It is associated with increased risk of developing cardiovascular disease
B. It is associated with increased risk of developing diabetes insipidus
C. Lifestyle modification is not as important as drug management
D. It requires education for patients to achieve target BP of < 130/80 mmHg
E. Weight loss management is crucial in reversing risk of Metabolic Syndrome
TOPIC 8: HYPERTENSION AND CARDIOVASCULAR DISEASE

1. A 56-year-old man presented with intermittent left pain calf pain worsen on prolong walking. He has
no significant past medical history. His blood pressure was 140/90 mmHg. The left dorsalis pedis
pulse was weaker than the right side. Which of the following statement(s) is/are correct?
A. His risk of stroke is high
B. Electrocardiography is an optional investigation
C. He should be called back within a week to confirm his status of hypertension
D. Atenolol is an appropriate anti-hypertensive
E. His target blood pressure is < 140/90 mmHg

2. Which of the following scenario(s) is/are correctly paired with the optimal choice of anti-
hypertensives given?
A. A 60-year-old woman with congestive cardiac failure secondary to prolong uncontrolled
hypertensive: Atenolol
B. A 50-year-old man with primary stage II hypertension and left ventricular hypertrophy: Losartan
C. A 70-year-old man with primary hypertension and significant Q wave in his electrocardiogram at
the anterior chest leads: Amlodipine
D. A 45-year-old man with primary hypertension and recent myocardial infarct: Perindopril
E. A 66-year-old woman with uncontrolled hypertension and congestive heart failure NYHA classII
who are already on T. Perindopril 4 mg daily: Metoprolol

3. The following(s) is/are necessary in the assessment of patient presented with symptoms of heart
failure and prolong hypertension:

PRE-TEST AND POST-TEST QUESTIONNAIRE (MCQs)


A. Urine protein
B. Heamoglobin level
C. Chest X-ray
D. Doppler ultrasound of peripheral arteries in the lower limb
E. Serum potassium and sodium

TOPIC 9: HYPERTENSION AND STROKE

1. Ahmad, a 45-year-old businessman presented to the health clinic with left sided body weakness of
1 day duration. His vital signs are as below:
BP : 190/110 mmHg
PR : 90 beats/min
Temp : 36.5˚C
RR : 14 breaths/min
The following statement(s) is/are correct regarding Ahmad’s condition:

TRAINING MODULE FOR HEALTH CARE PROVIDERS


A. Ahmad is categorized under Hypertensive Urgencies MANAGEMENT OF HYPERTENSION (3rd Edition)
B. Oral Captopril can be given to lower Ahmad’s blood pressure
C. Aspirin is recommended
D. He can be treated as an out-patient
E. He needs oxygen supplementation for cerebral protection

2. The following statement(s) is/are correct regarding hypertension and stroke:


A. Dyslipidaemia is a better predictor of stroke compared to blood pressure
B. Drug treatment is recommended in previous history of Transient Ischaemic Attack (TIA)
C. In haemorrhagic stroke presented with BP > 180/110 mmHg, immediate reduction of BP is best
avoided
D. Diastolic blood pressure (DBP) is more predictive for stroke
E. ß-blockers have been shown to reduce risk and mortality of stroke

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TRAINING MODULE FOR HEALTH CARE PROVIDERS

3. Mr. Tan a 58-year-old pensioner had history of ischaemic stroke 5 years ago. His current medications
MANAGEMENT OF HYPERTENSION (3rd Edition)

are Aspirin 150 mg OD and Hydrochlorothiazide 25mg OD. The following statement(s) is/are correct:
A. CCB provides better protection than Thiazide Diuretic regarding secondary prevention
B. It is recommended to withhold his Hydrochlorothiazide if his blood pressure ranges from
110-120/70-80 mmHg
C. Perindopril is the preferred choice
D. His target LDL level is < 3.4 mmol/L
E. His target blood pressure control is < 140/90 mmHg

4. The following statement(s) is/are correct regarding Stroke:


A. In Asia Pacific region, about 2/3 of strokes attributed to hypertension
B. Combination of an ACE-Inhibitor and diuretic has been shown to reduce recurrent stroke.
C. Treatment with aspirin alone is sufficient
D. In primary prevention, the risk of stroke is significantly reduced with 10 mmHg reduction of
systolic blood pressure
E. In severe hypertensive with acute stroke, blood pressure lowering to < 160/90 mmHg is
mandatory

TOPIC 10: HYPERTENSION IN THE ELDERLY


PRE-TEST AND POST-TEST QUESTIONNAIRE (MCQs)

1. Based on current evidence, the following class(es) of drugs has / have been shown to reduce
cardiovascular events in the elderly:
A. Calcium channel blockers
B. Ace inhibitors
C. β-blockers
D. Diuretics
E. α-blockers

2. When prescribing antihypertensive agents in the elderly, the following rule(s) is/are important:
A. Start with low dose
B. Go slow on increasing the dose
C. Combination preparation is encouraged
D. The target BP is below 130/80 mm Hg
E. In patients with marked systolic hypertension, reducing SBP below 160 mmHg is initially
acceptable

3. In patients with postural hypertension, the following BP should be used as a guide to treatment
decisions:
A. Standing BP
B. Sitting BP
C. Lying BP
D. Supine BP
E. Ambulatory BP

TOPIC 11: HYPERTENSION IN PREGNANCY

1. Which of the following(s) is/are the risk factor(s) for developing high blood pressure in pregnancy?
A. First pregnancy
B. Previous history of hypertension during pregnancy
C. Twin pregnancy
D. Diabetes Mellitus
E. Poor weight gain
2. What is/are the complication(s) of hypertension in pregnancy?
A. Fits
B. Stroke
C. Placenta accreta
D. Stillborn
E. Disseminated intravascular coagulopathy

3. Which of the following(s) is/are the sign(s) of pre-eclampsia?


A. Sudden increase in weight (> 1 kg per week)
B. Polyuria
C. Epigastric pain
D. Visual disturbance such as blurred vision
E. Nausea and vomiting

TOPIC 12: HYPERTENSION AND ORAL CONTRACEPTIVE PILLS

1. The following statement(s) is/are true regarding hypertension and oral contraceptives:
A. Baseline blood pressure is essential before initiating combined oral contraceptive (COC)
B. Progestrogene only pills (POP) are known to raise blood pressure
C. Incidence of hypertension is reported to be higher in woman taking COC
D. Women who develop hypertension while using COC are advisable to continue using COC
provided their blood pressure is monitored regularly
E. Low dose COC is a recommended alternative for patients with hypertension who wish to

PRE-TEST AND POST-TEST QUESTIONNAIRE (MCQs)


continue oral contraception

2. The following contraceptive method(s) is/are known to raise blood pressure:


A. Combined oral contraceptive (COC)
B. Intrauterine Devices (IUDs)
C. Progesterone only pills (POP)
D. Mirena
E. Low dose COC

TOPIC 13: HYPERTENSION AND HORMONE REPLACEMENT THERAPY

1. In the management of a hypertensive post-menopausal women on hormone replacement therapy:


A. The decision to continue or discontinue HRT in these patients should be individualised
B. Physician should be aware that the use of HRT increased the risk of recurrent cardiovascular
events

TRAINING MODULE FOR HEALTH CARE PROVIDERS


C. Monitoring of every three months is recommended if BP is uncontrolled MANAGEMENT OF HYPERTENSION (3rd Edition)
D. Cardiovascular risk stratification should be done annually
E. Pap smear should be done bi-annually up to 65 years of age

2. A hypertensive woman on hormone replacement therapy is at risk for:


A. Breast cancer
B. Colorectal cancer
C. Venous thromboembolism
D. Osteoporosis
E. Gall-bladder disease

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TRAINING MODULE FOR HEALTH CARE PROVIDERS

PRE & POST TEST QUESTIONNAIRE


MANAGEMENT OF HYPERTENSION (3rd Edition)

MULTIPLE CHOICES QUESTIONS (MCQs) (TRUE/FALSE)

ANSWER
TOPIC 2: DIAGNOSIS 2. A. F 3. A. T 2. A. T
AND MANAGEMENT B. F B. T B. T
OF PRE-HYPERTENSION C. T C. T C. F
D. T D. F D. T
1. A. T E. T E. T E. T
B. F
C. T TOPIC 6: TOPIC 9: 3. A. T
D. T HYPERTENSION AND HYPERTENSION AND B. F
E. T DIABETES STROKE C. T
D. T
2. A. T 1. A. F 1. A. F E. T
B. F B. F B. T
C. T C. F C. F TOPIC 12:
D. F D. T D. F HYPERTENSION AND
E. T E. T E. T OCP

TOPIC 3: DIAGNOSIS 2. A. F 2. A. F 1. A. T
AND MANAGEMENT B. F B. T B. F
OF STAGE 1 C. F C. T C. T
PRE-TEST AND POST-TEST QUESTIONNAIRE (MCQs)

HYPERTENSION D. T D. F D. F
E. F E. T E. T
1. A. T
B. T 3. A. F 3. A. T 2. A. T
C. F B. T B. F B. F
D. F C. F C. T C. F
E. F D. F D. F D. F
E. T E. F E. F
2. A. T
B. T TOPIC 7: 4. A. T
C. T HYPERTENSION AND B. T TOPIC 13:
D. F METABOLIC C. F HYPERTENSION AND
E. T SYNDROME D. T HORMONE
E. F REPLACEMENT
TOPIC 4: DIAGNOSIS 1. A. T THERAPY
AND MANAGEMENT B. T TOPIC 10:
OF STAGE 2 C. T HYPERTENSION IN 1. A. T
HYPERTENSION & D. T THE ELDERLY B. T
RESISTANT E. F C. F
HYPERTENSION 1. A. T D. T
2. A. F B. T E. F
1. A. T B. T C. T
B. F C. F D. T 2. A. T
C. T D. T E. F B. F
D. T E. T C. T
E. T 2. A. T D. F
3. A. T B. T E. F
2. A. T B. F C. F
B. F C. F D. F
C. F D. T E. T
D. T E. T
E. T 3. A. T
TOPIC 8: B. F
3. A. T HYPERTENSION AND C. F
B. T CARDIOVASCULAR D. T
C. F DISEASE E. F
D. T
E. T 1. A. T TOPIC 11:
B. F HYPERTENSION IN
TOPIC 5: DIAGNOSIS C. F PREGNANCY
AND MANAGEMENT D. F
OF STAGE 3 E. F 1. A. T
HYPERTENSION B. T
2. A. F C. T
1. A. T B. T D. T
B. F C. F E. F
C. F D. T
D. F E. F
E. T