HYPERTENSION MANAGEMENT

Step
1 Assess ALGORITHM Step BP TARGETS
8 • <140/90 mmHg
Major risk factors Step Measure Blood Pressure • <150/90 mmHg if >
according to SAHS guidelines* 80 years
•Levels of systolic and diastolic BP 2
Step
Consider home or 24 hour BP monitoring in patients
•Smoking
with stage 1 hypertension without
•Dyslipidaemia:
TOD/complications/risk factors
ototal cholesterol > 5.1 mmol/L, OR 7
oLDL > 3 mmol/L, OR
oHDL men < 1 and women < 1.2 mmol/L
Step
•Diabetes mellitus
•Men > 55 years
3 Lifestyle changes Routine Management
•Women > 65 years •Weight reduction Step 1:Choose any of the
•Family history of early onset of CVD: •Restrict salt, dietary sugars, and saturated
•Men aged <55 years fat
following:*
•Women aged <65 years •Limit alcohol consumption •Hydrochlorothiazide 12.5 -25 mg daily or
•Waist circumference- abdominal obesity: •Increase fruit and vegetables indapamide 1.25 – 2.5 mg daily
•Men ≥ 94 cm •Increase physical activity •CCB
•Women ≥ 80 cm •Stop all tobacco products •ACE-I or ARB
Step •If 20/10mmHg above goal proceed
Target Organ Damage 4
directly to step 2
Step 2
•LVH: based on ECG 1. Combine any 2 of the above
3 2. Combine all 3 of above
oSokolow-Lyons > 35 mv (S in V1 + R in
V5 or V6) 3. Maximize doses of individual agents
oCornell product > 2440 mm.ms (S in V3 Step 3
+ R in aVL + 6 in females) x QRS •Spironolactone 25mg daily (monitor K+
duration) and avoid if eGFR < 45 mls/min)
oR in aVL > 11 mv •β blocker,  blocker, minoxidil, centrally
•LVH on echocardiography acting drug, or hydralazine
•Micro-albuminuria: albumin creatine ratio •Consider furosemide 40mg b.d. in place
- 3-30 mg/mmol of thiazide if eGFR < 45mls/min
•Check adherence, secondary causes,
Complications home or 24 hour BP monitoring for white
coat or pseudoresistance, consider
•Coronary heart disease referral to specialist
•Heart failure
•Chronic kidney disease: * CCBs/diuretics preferred in
oalbuminuria > 30mg/mmol OR eGFR < Blacks/Elderly
60ml/min * 24 hour acting drugs and single pill
Is there a hypertensive
Step
•Stroke or TIA combinations preferred
•Peripheral arterial disease
•Advanced retinopathy: urgency or emergency?
5
ohaemorrhages OR BP > 180/110 mmHg
3 No
oexudates
opapilloedema
with symptoms and/or
accelerated TOD
No
Step Are there compelling
Abbreviations Yes
• LVH = left ventricular hypertrophy
6 indications/contraindications?
• eGFR = estimated glomerular filtration rate (see below)
• TOD = target organ damage Refer for
• TIA = transient ischaemic attack
• ACE-I = angiotensin converting enzyme inhibitor hospital
• ARB = angiotensin receptor blocker admission
• CCB = calcium channel blocker
• HF = heart failure
• ISH = isolated systolic hypertension

Routine Tests and Measurements Compelling indications and contraindications

TEST FREQUENCY COMMENT CLASS CONDITIONS CONTRAINDICATIONS
ANTHROPOMETRY FAVOURING THE USE COMPELLING POSSIBLE
 Body weight Every visit  HF
 Height First visit
DIURETICS  Elderly  Pregnancy
 BMI Every visit < 25 for men and women (thiazide;  ISH  Gout  β blockers (especially
 Hypertensives of African atenolol)
 Waist circumference Men <94 cm; Women <80 cm* thiazide-like)
Every visit origin.
URINE DIPSTICK ROUTINE DIURETICS  Renal insufficiency
 HF  Pregnancy
 Protein.  First visit (loop)
 Blood.  Yearly if ABNORMAL DIPSTICK DIURETIC
 Glucose normal Any one of the following:  HF
 Renal failure
 Repeat at next  Proteinuria ≥ 2+; (anti-  Post-myocardial infarction
 Hyperkalaemia
 Resistant hypertension
visit if  Haematuria ≥ 1+. aldosterone)
abnormal on Refer for further investigation  Elderly
first visit CCB  ISH
URINE ALBUMIN/  Performed on diagnosis of diabetes
LONG ACTING  Angina pectoris  Tachyarrhythmias
First visit then ONLY  Peripheral vascular disease  HF
CREATININE RATIO mellitus type 2 or 5 years after the
yearly (dihydropyridine)  Carotid atherosclerosis
-Diabetes mellitus only diagnosis type 1
 Pregnancy (nifedipine only)
BLOOD TESTS CCB non-  Angina pectoris
 Creatinine Use eGFR in ml/min/ 1.73m²  AV block (grade 2 or
 Sodium/Potassium
Yearly if normal dihydropyridine  Carotid atherosclerosis  Constipation
3)
 Uric acid
(except uric acid) (verapamil,  Supraventricular
 HF
(verapamil)
tachycardia
Fasting glucose Yearly if normal
GTT/HBA1C in patients with impaired diltiazem)
fasting glucose.  HF  Pregnancy;
Random total Measure fasting lipogram if cholesterol >  LV dysfunction  Hyperkalaemia;
Yearly if normal 5.1 mmol/L or in high risk groups  Post-myocardial infarction  Bilateral renal artery
cholesterol
 Non-diabetic nephropathy stenosis
Diabetics only ACE-I  Type 1 diabetic nephropathy  Angioneurotic oedema
HBA1C 6 monthly
 Prevention of diabetic (more common in
Yearly in high risk Refer to criteria for LVH, check for microalbuminuria blacks than in
ECG (RESTING)
patients signs of ischaemia  Proteinuria Caucasians)
This may include but not limited to  Type 2 diabetic nephropathy
ultrasound kidneys, CT scan/angiography  Type 2 diabetic with  Pregnancy;
and vascular studies, sleep studies or microalbuminuria  Hyperkalaemia
SECONDARY CAUSE
Referral endocrine tests as indicated by clinical ARB  Proteinuria  Bilateral renal artery
or COMPLICATIONS
suspicion  LVH stenosis.
 ACE-I cough or intolerance
 Peripheral vascular
disease
 Bradycardia
 Asthma
 Glucose intolerance
 Angina pectoris  Chronic obstructive
Suggested referral to specialist level  Post-myocardial infarction pulmonary disease
 Metabolic syndrome
β-BLOCKER  Athletes and
• Severe or resistant hypertension  HF (selected only)  AV block (grade 2 or
physically active
• Labile hypertension  Tachyarrhythmias 3)
patients
 Pregnancy (atenolol)
• Secondary causes suspected  Non dihydropyridine
CCB’s (verapamil,
• Progressive TOD, complications or multiple
diltiazem)
comorbidities
• Hypertensive urgency or emergency

*Cardiovasc J Afr 2014; 28: 288-94