1999 who-ish hypertension practice guidelines for primary care physicians

1999 WHO-ISHHypertension Practice Guidelines

for Primary Care Physicians

World Health OrganizationINTERNATIONAL SOCIETY OF HYPERTENSION

21999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

Working Group: Practice Guidelines

John Chalmers (Australia, Chairman)

Paul Chusid (USA)

Jay N Cohn (USA)

Lars H Lindholm (Sweden, Writing Coordinator)

Ingrid Martin (WHO, Switzerland)

Karl-Heinz Rahn (ISH, Germany)

Peter Sleight (WHL, UK)


WHO-ISH HypertensionGuidelines Subcommittee

Michael Alderman (USA)Kikuo Arakawa (Japan)Lawrie Beilin (Australia)John Chalmers

(Australia, Chairman)Serap Erdine (Turkey)Masatoshi Fujishima (Japan)Pavel Hamet (Canada)Lennart Hansson (Sweden)Lewis Landsberg (USA)Frans Leenen (Canada)Lars H Lindholm (Sweden)

Liu Lisheng (China)AFB Mabadeje (Nigeria)Stephen MacMahon (Australia)Giuseppe Mancia (Italy)Ingrid Martin (Switzerland)Albert Mimran (France)Karl-Heinz Rahn (Germany)Arturo Ribeiro (Brazil)Peter Sleight (UK)Judith Whitworth (Australia)Alberto Zanchetti (Italy)

The WHO-ISH Guidelines are written for a global audience from communities that vary widely in the nature of their health system and in the availability of resources.

The goal, however, remains universally the same, that is to lower BP and other risk factors in order to reduce the risk of CVD.


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GlobalGoal


What is the Goalof the Practice Guidelines?

To lower blood pressure (BP) and other risk factors in order to reduce the risk of cardiovascular disease (CVD)



Why is Hypertension Management Needed? (1)

• 600 million hypertensives in the world

• 3 million die annually as a direct result of hypertension


Why is Hypertension Management Needed? (2)

The Rule of Halves• Only 1/2 have been diagnosed

• Only 1/2 of those diagnosed have been treated

• Only 1/2 of those treated are adequately controlled

• Thus, only 12.5% overall are adequately controlled


What is New?1999 WHO-ISH 1993 WHO-ISH JNC-VI

Definition of > 140/90 >140/90 >140/90hypertension

Levels Grade 1,2,3 Mild, Moderate, Stage 1,2,3Severe

Decision Not based on BP BPto treat BP alone, but

assessment oftotal CV risk

Target BPs <130/85 <130/80 <140/90<140/90 (elderly) <140/90 (elderly)

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What is New?

1999 WHO-ISH 1993 WHO-ISH JNC-VI

Suitable first-line 6 drug 5 drug 2-3 drugdrug therapy classes classes classes

Combination Low dose Low dosetherapy combinations combinations

recommended if may be used tomonotherapy initiate therapyinadequate



Why BP <130/85 mm Hgand Not <140/90 mm Hg? (1)

• The relationship between CV risk and BP is continuous

• Today, more than 50% of all hypertensives have BP >160/90 mm Hg and 75% have BP >140/90

• The major determinant of the risk reduction conferred by antihypertensive therapy is the BP level attained


Why BP <130/85 mm Hgand Not <140/90 mm Hg? (2)

• In diabetics, there is a clear benefit of lowering BP <85 mm Hg

• The HOT Study showed that lowering BP < 85 mm Hg did not increase CV risk

• The goal should be to attain normal BP (<130/85 mm Hg)

Questions to be Answered (1)• What is high blood pressure?

• Clinical evaluation - what should be done?

• Which factors influence prognosis?

• Do patients benefit from antihypertensive treatment?

• How should hypertension be managed?


Questions to be Answered (2)• Which drug treatments should be used?

• What treatment goal should be set and how should patients be followed up?

• How should hypertension during pregnancy be handled?

• How should hypertension in Type-2 diabetics be handled?



What is High Blood Pressure?

• BP levels are continuously related to the risk of CVD

• Definition of hypertension or raised BP is arbitrary

• Even within the normotensive range, people with the lowest BP levels have the lowest rates of CVD

Relative Risk of CHD and Stroke in Relation to Patient’s Usual Diastolic BP



New (1999) WHO-ISH Definitionsand Classification of BP Levels

Category Systolic BP Diastolic BP(mm Hg) (mm Hg)

Optimal BP <120 <80Normal BP <130 <85High-Normal 130-139 85-89

Grade 1 Hypertension (mild) 140-159 90-99 Subgroup: Borderline 140-149 90-94Grade 2 Hypertension (moderate) 160-179 100-109Grade 3 Hypertension (severe) >180 >110

Isolated Systolic Hypertension >140 <90 Subgroup: Borderline 140-149 <90


Clinical Evaluation - What Should Be Done?

• Confirm elevation of BP

• Exclude or identify secondary causes of hypertension

• Determine presence of target organ damage and quantify extent

• Search for other CV risk factors and clinical conditions that may influence prognosis and treatment

How to Record BP (1)

Measure BP several times on separate occasions with the patient in sitting position

Use a mercury sphygmomanometer or other non-invasive device


How to Record BP (2)Measure BP several times on several occasionsAllow the patient to sit for several minutes before measuring BP

Use a cuff with a bladder that is 12-13 cm X 35 cm, larger for fat arms

Use phase 5 Korotkoff sounds (disappearance) to measure diastolic BP

Measure BP in both arms at first visit

Measure BP in standing position in elderly subjects and diabetic patients

Place sphygmomanometer cuff at heart level, whatever the position of the patient



Multiple BP Measurements Recommended

Because BP is characterized by large spontaneous variations, diagnosis should be based on multiple BP measurements taken on several separate occasions

21


Minimum RoutineInvestigations

Clinical and family history

Full physical examination as described in medical textbooks

Laboratory investigations, including:– urinalyses for blood, protein, and glucose– microscopic examination of the urine– blood chemistry for potassium, creatinine, fasting glucose,

and total cholesterol

Electrocardiography (ECG)

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“Isolated” Office Hypertension

In some patients office BP is persistently elevated whereas daytime BP outside clinic environment is not. Continuing debate whether “isolated” office hypertension (“white coat hypertension”) is an innocent phenomenon or carries an increased risk of CVD

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Ambulatory BP Monitorings Should be Considered, if:

Unusual variability of BP over the same or different visits

“Isolated” office (“white coat”) hypertension in subjects with low CV risk

Symptoms suggesting hypotensive episodes

Hypertension resistant to drug treatment

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Ambulatory BP Monitoring

BP values obtained by home measurement or ambulatory monitoring are several mm Hg lower than office measurement

Average 24 hour or home BP values around 125/80 mm Hg = office BP 140/90 mm Hg

Reliable information about long-term prognostic value of ambulatory and home monitoring is awaited


Which Factors Influence Prognosis? (1)

Decisions should not be made on BP alone, but also on presence of other risk factors, target organ damage, and

concomitant diseases, as well as on other aspects of patients’ personal, medical, social, economic, ethnic, and

cultural characteristics


• Risk factors of CVD

I. Used for risk stratificationII. Other factors adversely influencing

prognosis

• Target organ damage (TOD)

• Associated clinical conditions (ACC)27




I. Used for risk stratification• Levels of systolic and diastolic blood

pressure (Grades 1-3)• Men >55 years• Women >65 years• Smoking• Total cholesterol >6.5 mmol/L (250 mg/dl)• Diabetes• Family history of premature

cardiovascular disease

Risk factors for CVD



II.Other factors adversely influencing prognosis• Reduced HDL cholesterol• Raised LDL cholesterol• Microalbuminuria in diabetes• Impared glucose tolerance• Obesity• Sedentary lifestyle• Raised fibrinogen• High risk socioeconomic group• High risk ethnic group• High risk geographic region

Risk factors for CVD



Target organ damage (TOD)

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• Left ventricular hypertrophy (electrocardiogram, echocardiogram, or radiogram)

• Proteinuria and/or slight elevation of plasma creatinine concentration 106-177 mmol/L (1.2-2.0 mg/dl)

• Ultrasound or radiological evidence of atherosclerotic plaque (carotid, iliac, and femoral arteries, aorta)

• Generalised or focal narrowing of the retinal arteries



Associated clinical conditions (ACC)

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Cerebrovascular disease• Ischaemic stroke• Cerebral haemorrhage• Transient ischaemic attack (TIA)

Heart disease• Myocardial infarction• Angina pectoris• Coronary revascularisation• Congestive heart failure



Associated clinical conditions (ACC)

32

Renal disease• Diabetic nephropathy• Renal failure, plasma creatinine concentration

>177 mmol/L (>2.0 mg/dl)Vascular disease

• Dissecting aneurysm• Symptomatic arterial disease

Advanced hypertensive retinopathy• Haemorrhages or exudates• Papilloedema



Which FactorsInfluence Prognosis? (8)

Low risk = <15 percent

Medium risk = 15-20 percent

High risk = 20-30 percent

Very high risk = 30 percent or higher

Typical 10 year risk of strokeor myocardial infarction

33



Example 1:

65-year old man with diabetes, TIAs, and BP of 145/90 mm Hg will have annual risk of major CVD event 20 times greater than 40-year old man with same BP but without diabetes or history of CVD

34



Example 2:

40-year old man with BP of 170/105 mm Hg will have risk of major CV event 2-3 times greater than man of same age with BP of 145/90 mm Hg and similar other risk factors

35

Stratifying Risk - Quantifying Prognosis



Do Patients Benefit from Antihypertensive Treatment? (1)

Yes, the randomized trials conducted to date have shown

clear evidence of a lower incidence of major CVD events after high BP was treated with

anti-hypertensive drugs. 371999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS


Do Patients Benefit from Antihypertensive Treatment? (2)

There is as yet no evidence that the main benefit of treating

hypertension is due to a particular drug property rather

than to lowering BP per se.


Effects of Antihypertensive Treatment in Randomised Controlled Trials



Absolute Effects of Antihypertensive Treatment

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10/5 mm Hg 20/10 mm Hg

Low risk patients <5 <9

Medium risk patients 5-7 8-11

High risk patients 7-10 11-17

Very high risk patients >10 >17

Patient Group Absolute treatment effects (CVDevents prevented per 1000 patients years)


Larger Risk Reductions?

• The estimates of antihypertensive benefits shown were reported from trials of about 5 years duration.

• It is possible that long-term treatment over decades might produce larger risk reductions.


Initiate lifestyle measures wherever appropriate in all patients, including those

who require drug treatment

• Smoking cessation

• Weight reduction

• Moderation of alcohol consumption

• Reduction of salt intake

• Increased physical activity42

Management Strategy (1)



Management Strategy (2)

Is patient at:

Very High Risk

High Risk

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Medium Risk

Low Risk


Management Strategy (3)Stratify Risk

Very High

High

Begin drugtreatment

Begin drugtreatment


Management Strategy (4)Stratify risk

Medium

Monitor BP & otherrisk factors for 3-6 months

SBP >140or DBP >90

Begin drugtreatment

SBP <140or DBP <90

Continue tomonitor

Low

Monitor BP & otherrisk factors for 6-12 months

SBP >150or DBP >95

Begin drugtreatment

SBP <150or DBP <95

Continueto monitor


Principles of Drug Treatment (1)

• Use a low dose of one drug to initiate therapy

• If good response and tolerability but inadequate control increase the dose of the first drug

• If little response or poor tolerability change to another drug class



• It is often preferrable to add a small dose of a second drug rather than increase the dose of the first drug

• Use long-acting drugs providing 24-hour efficacy on a once daily basis. Improves adherence to therapy and minimizes BP variability.




• More evidence of beneficial CVD effects with older drugs (e.g., diuretics and beta-blockers)

• Evidence of benefit with newer drugs (e.g., ACE inhibitors and calcium antagonists) is accumulating.



There are six maindrug classes used worldwide - diuretics, beta-blockers, ACE

inhibitors, calcium antagonists, alpha blockers, and angiotensin

II antagonists.



All 6 classes are suitable for the initiation and maintenance of BP lowering therapy, but the choice

of drugs will be influenced by cost and by many factors for special groups

of patients. In some parts of the world, reserpine and methyldopa are

also used frequently.


Indications

Compelling PossibleHeart failure Diabetes

Elderly patients

Systolic hypertension

Diu

reti

cs

Contraindications

Compelling PossibleGout Dyslipidaemia

Sexually active

males511999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

IndicationsCompelling Possible

Angina Heart failure

After myocardial infarct Pregnancy

Tachyarrhythmias DiabetesContraindications

Compelling Possible

Asthma and Dyslipidaemia

Chronic obstructive Athletes and

Pulmonary disease Physically active

Heart block (AV 2,3) Patients

Peripheral

vascular disease

Beta

-Blo

ckers


IndicationsCompelling PossibleAngina Peripheral

Elderly patients Vascular disease

Systolic hypertension

Calc

ium

Anta

gonis

ts

Contraindications

Compelling PossibleHeart block (AV 2,3) Heart failure*

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* verapimil or diltiazem


IndicationsCompelling Possible

Heart failure

Left ventricular dysfunct

After myocardial infarct

Diabetic nephropathy

ContraindicationsCompelling Possible

Pregnancy

Bilateral renal

artery stenosis

Hyperkalaemia

AC

E Inhib

itors


Indications

Compelling Possible

Prostatic Hypertrophy Glucose intolerance

Dyslipidaemia

Contraindications

Compelling Possible

Orthostatic

hypotension

Alp

ha-B

lock

ers


Indications

Compelling Possible

ACE-I cough Heart failure

ContraindicationsCompelling Possible

Pregnancy

Bilateral renal

Artery stenosis

Hyperkalaemia

Ang

iote

nsi

n II

Anta

gonis

ts


Combination Therapy (1)

In most patients, appropriate combination therapy produces BP

reductions that are twice as great as those obtained with monotherapy, for

example, 12-22 mm Hg systolic BP and 7-14 mm Hg diastolic BP for patients

with initial BP of >160/95 mm Hg


Combination Therapy (2)Effective drug combinations to treat hypertension are:

• diuretic and beta-blocker• diuretic and ACE inhibitor (or

Angiotensin II antagonist)• calcium antagonist (dihydropyridine) and

beta-blocker• calcium antagonist and ACE inhibitor• alpha-blocker and beta-blocker



Other Drugs to Consider in Hypertension

• Aspirin

• Cholesterol lowering therapy

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Treatment Goal (1)

Requires treatment of all reversible risk factors, such as smoking, raised cholesterol, or diabetes, and the management of associated clinical conditions, as well as treatment of raised BP

60

Reduce total CVD risk

Treatment Goal (2)

The goal of antihypertensive treatment should be to achieve “optimal” or “normal” BP in young, middle-aged, or diabetic subjects (below 130/85 mm Hg), and at least “high-

normal” BP in elderly patients (below 140/90 mm Hg)


Follow-Up (1)

• Follow-up during evaluation and stabilisation of treatment should be frequent to monitor BP and other risk factors

• Follow-up is important to establish good relations with the patient and to educate the patient, so that he/she takes responsibility for the life-long control


• Good communication between physician and patient is essential because treatment of hypertension is for life

• Adequate information about BP and high BP, about risks and prognosis, about expected benefits of treatment, and about risks and side effects of treatment are essential for satisfactory life-long control of hypertension which is poor in many countries today

63

Follow-up (2)



How Should HypertensionDuring Pregnancy be Diagnosed?

Usually defined by absolute levelof BP (for example, 140/90 mm Hg or over)

or an increase in BP from pre-conception or first trimester (for example, SBP rise of >25

mm Hg and/or DBP rise of >15 mm Hg)

64


How Should HypertensionDuring Pregnancy be Defined?

Hypertension in pregnancy usually defined as:

pre-existing chronic hypertension de novo diagnosed, gestational hypertension or

pre-eclampsia pre-eclampsia superimposed on chronic

hypertension

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How Should HypertensionDuring Pregnancy be Handled?

• BP above 170/110 mm Hg should be lowered to protect mother from risk of stroke or eclampsia

• Opinion is divided on the need for drug treatment for BP below this level

66

Antihypertensive DrugsMost Widely Used Acutely

During Pregnancy

• Nifedipine

• Labetalol

• Hydralazine


• Beta-blockers:oxprenolol, pindolol, labetalol

atenolol, however, is associated with fetal growth retardation when used long-term throughout pregnancy

• Methyldopa

• Prazosin, hydralazine, nifedipine, and isradipine

68

Antihypertensive DrugsMost Widely Used Chronically

During Pregnancy


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Drugs Most WidelyAvoided During Pregnancy

• ACE inhibitors (associated with possible adverse fetal effects)

• Angiotensin ll antagonists (effects may be similar to ACE inhibitors)

• Diuretics used infrequently because of concerns of reducing already compromised plasma volume



Hypertensionin Type-2 Diabetics (1)

• Diabetes and hypertension are multiplicative risk factors for CVD

• Absence of hypertension in diabetes is associated with a better long-term survival

70



• Progressive decline in glomerular function can be slowed with antihypertensive treatment

• Similar lifestyle measures are recommended for hypertension and diabetes

71



Good evidence for reductionin CVD events in diabetic patients treated

with antihypertensivedrugs, including diuretics,

and more recently, beta-blockersand ACE inhibitors

72



The goal of antihypertensive treatment in Type-2 diabetics should be to achieve

“optimal” or “normal” BP (that is below 130/85 mm Hg)

73


What is the ImplementationPlan for Practice Guidelines? (1)

• Publication in as many national medical journals as possible

• Over 2 million brochures to be printed in English and several other languages

• Distribution worldwide with assistance of national hypertension and GP societies

74


What is the ImplementationPlan for Practice Guidelines? (2)

• Funding by multiple pharmaceutical companies with no-strings-attached unrestricted educational grants

• Presentations at symposia, congresses, medical meetings, hospitals, medical schools, etc.

75


Summary (1)

The goal of the 1999 WHO-ISH Hypertension Practice Guidelines is to

lower BP and other risk factors in order to reducethe risk of CVD

76


Summary (2)

The goal of the 1999 WHO-ISH Hypertension Practice Guidelines

is to lower BP and other risk factors in order to reduce the risk of CVD -- in

primary care settings outside the hospital

77

How to Get Additional Copiesof Practice Guidelines

Contact your nationalsociety/league of hypertension, or

Write to: World Health OrganizationCardiovascular Diseases ProgrammeCH-1211 Geneva 27, Switzerland


• Fax: +41 22 791 4151• E-mail: [email protected]

No-strings-attached UnrestrictedGrant Funding for Practice Guidelines

by Following CompaniesBayer

Bristol-Myers SquibbGlaxo Wellcome

Merck (MSD)Novartis

PfizerRocheSearleZeneca


1999 who-ish hypertension practice guidelines for primary care physicians

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