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Hong Kong ReferenceHong Kong Reference Framework for Hypertension care for Adults in the Primary Care Settings

MANAGEMENT OFMANAGEMENT OF HYPERTENSION USING THE REFERENCE FRAMEWORK

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Demographics of HT in HK

Population Health Survey in 2003-20041

O ll l f h t i 27% Overall prevalence of hypertension 27%. Among them, 56% were unaware by patients For those known HT, 73% had taken anti-HT

prescribed by doctors while 16% reported to have taken over-the-counter medications.

1. Population Health Survey 2003‐2004. Collaborative project of DN and the Department of Community Medicine of HKU

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Management of hypertension byprivate doctors in Hong KongHong Kong Med J 2006;12:115-8

Only 24% of the private doctors measured blood pressure in all new patients aged above 18 years.

30% of the hypertensive patients were diagnosed by opportunistic BP screening.

Management of hypertension in Hong Kong

1 A significant proportion of HT patients were1. A significant proportion of HT patients were undiagnosed.

2. A significant proportion of HT patients were not properly managed.

3. Primary care providers have an important role in the management of hypertensionin the management of hypertension.

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Core Document (Table of Content)Chapter

1 Epidemiology

2 Population based Intervention and Life Course2 Population-based Intervention and Life Course approach

3 Role of Primary Care in the Management of HT

4 Patient Education

5 Aim of the Framework

6 Prevention of Hypertension6 Prevention of Hypertension

7 Early identification of People with Hypertension

8 Clinical Care of Adults with Hypertension

9 Patient Empowerment

10 Future Direction to Promote the Use of the Framework

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ModulesModule

1 Framework for population approach in the prevention and control of hypertension across the life course

2 Blood pressure measurement

3 Secondary hypertension

4 Evaluation for all newly diagnosed hypertensive patientspatients

5 Dietary intervention

6 Exercise recommendations to people with HT

7 Drug treatment for people with HT

8 Annual assessment

Recommendations from Reference Framework

Prevention and early identification of HT

1. Opportunistic blood pressure measurement in all adults from 18 years of age at least every 2 years

2. Advise individuals at increased risk of

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developing HT and patients with HT to maintain optimal body weight, restrict dietary salt intake, abstain from smoking and practise healthy lifestyles

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BPclassification

Initial BP(mmHg)

RecommendedMinimum Review Period

Action

SBP DBP

Pre-hypertension

120-139 80-89 Recheck <1 year Lifestyle modificationhypertension

Stage I HT 140-159 90-99 Confirm < 2 months Lifestyle modification

Stage II HT 160-179 100-109 Evaluate < 1 month Treat < 1 monthLifestyle modifications

>180 >110 Evaluate < 1 week Drug treatmentRefer if malignant HT

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Refer if malignant HT

The classification is based on the average of 3 or more properly measured seated BP readings, at least 1 week apart on office visits

Relationship between Blood Pressure and Cardiovascular Risk

1 The association between BP and CVS risk is1. The association between BP and CVS risk is continuous at all levels, starting as low as 115/70 mmHg, without a threshold.

2. The higher the BP, the greater is the chance of stroke, IHD, heart failure and other vascular causesF i di id l 40 70 f h3. For individuals 40–70 years of age, each increment of 20 mmHg in SBP or 10 mmHg in DBP doubles the risk of CVD across the entire BP range from 115/75 to 185/115 mmHg

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CV Mortality Risk Doubles withEach 20/10 mm Hg BP Increment*

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CVmortality

risk

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3

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*Individuals aged 40-69 years, starting at BP 115/75 mm Hg.CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressureLewington S, et al. Lancet. 2002; 60:1903-1913.JNC VII. JAMA. 2003.

SBP/DBP (mmHg)

115/75 135/85 155/95 175/105

Framework for Population Approach in The Prevention and Control of Diabetes Across the Life Course (MODULE 1)

Age Group Lifestyle advice Risk  Screening Disease  Monitor g p yassess‐ment

gmanage‐ment

complications

Antenatal  •Balanced diet•Physically active

•Monitor wt gain

•Watch out for HT and pre‐eclampsia

•BP control  •Monitor fetal growth•Obstetric Cx

Infancy •Breast feeding•Avoid obesity

•Monitor wt gain•Avoid obesity wt gain

Children •Abstain from smoking•Regular exercise•Health eating

•Monitor BMI

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Age Gp Lifestyle advice

Risk assessment

Screening Disease manage‐ment

Monitor compli‐cations

Rehabi‐litation care

Adult & Elderly

•Abstain from smoking•Healthy eating

•monitor  BMI•Monitor abdominal circumference

•Measure BP for all individuals aged >=

•BP and lipid control•Monitor

•Malig‐nant HT•TOD

•Help patients to cope with HTeating

•Limit Na intake•Regular exercise•Limit alcohol consumption

circumference•Family history

aged >= 18 every 2 yrs•Measure BP  for at risk people every 12 mths  or 

•Monitor drug adverse effects•Self care•Carer education

with HT and its Cx•Multidis‐ciplinary approach for stroke and renal failure

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mths orless

Blood Pressure Measurement (MODULE 2)

Mercury sphygmomanometer

most reliable most reliable

checking are needed: e.g. column position, mercury level, blockages and leakages

Electronic devices

can also be used

finger and wrist monitors should be avoided

routine checks and calibration

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Precautions about BP measurement (1)

Seated for at least 5 minutes

Remove constrictive clothing form the arm Remove constrictive clothing form the arm

Use an appropriate sized BP cuff

Support arm with antecubital fossa at heart level

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Precautions about BP measurement (2)

BP measurement not recommended during exercise or after exerciseexercise or after exercise

Avoid measure BP <1/2hr after eating

Smoking and caffeine should be avoided within 1-2 hours prior to BP recording

Emotional factors may affect BP: consider 24 hr b l t BP it i d lf BPambulatory BP monitoring and self BP

monitoring at home

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Secondary Hypertension (MODULE 3)

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Causes of secondary HT Obstructive sleep

apnea Side effects of drugs

Unhealthy dietp

Hyperaldosteronism

Renal parenchymal disease

Renovascular disease

Excess

Unhealthy diet

Erythropoietin side effect

Phaeochromocytoma

Hypothyroidism

H th idi Excess catecholamines

Coarctation of aorta

Cushing's syndrome

Hyperthyroidism

Hyperparathyroidism

Acromegaly18

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Evaluation of Newly Diagnosed Hypertensive Patients (MODULE 4)

Aims:

to assess lifestyle and identify cardiovascular risk factors that may affect prognosis and guide treatment,

to reveal identifiable causes of high blood pressure, and

to assess the presence or absence of target organ damage (TOD) and cardiovascular diseases

Target organ damages

Heart: LVH, IHD

Renal: Hypertensive nephropathyRenal: Hypertensive nephropathy

Vessel: atherosclerotic plague on big arteries (carotid, iliac,

femoral or aorta)

Angina

Heart failureHeart failure

Brain: stroke, dementia

Peripheral arterial disease

Hypertensive retinopathy, papilloedema

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Evaluation for Newly Diagnosed Hypertensive Patients

HistoryHistory

Physical examination

Laboratory investigationUrine analysis

RFTRFT

FBS

Lipid profile

12-lead ECG

What are the benefits of BP control in reducing complications? Meta-analysis of 61 prospective, observational

studies which involve 1 million adultsstudies which involve 1 million adults

Blood Pressure reduction of 2 mmHg decreases the risk of cardiovascular events by 7–10%

2 mmHg decrease in

7% reduction in risk of ischaemic heart disease mortality

decrease in mean SBP 10% reduction in

risk of stroke mortality

Lewington et al. Lancet 2002;360:1903–13

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Lifestyle Modifications

1. Encourage overweight and obese hypertensive patients to lose weighlose weigh

2. Increase fruits & vegetables to 5 portions/day and reduce total fat & saturated fat consumption

3. Reduce salt intake to less than 5grams/day (~a teaspoon) and not to use added salt

4 Increase level of physical activity and take regular exercise4. Increase level of physical activity and take regular exercise

5. Reduce alcohol intake in hypertensive patients to no more than 2 drinks/day for men and 1 drink/day for women

6. Encourage all hypertensive patients to stop smoking

Drug treatment and goal of therapy

Goals of treatment

Consider to start drug treatment in patients with sustained SBP ≧ 140mmHg or DBP ≧ 90mmHg despite lifestyle modification for 6 months or if target organ damage is present

The goal of therapy for simple hypertensive patients is bl d b l 140/ 90 Hblood pressure below 140/ 90 mm HgTarget blood pressure for patients with diabetes and chronic kidney diseases is below 130/80 mmHg

Control of all cardiovascular risk factors

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LifestyleLifestyle

Control Control of blood of blood

Lifestyle Lifestyle modificationsmodifications Drug treatmentDrug treatment

pressurepressure

Lifestyle ModificationsEvidences from studies

Modification Recommendation Approximate SBP

Reduction (range)

W i ht d ti 1 2 M i t i l b d i ht 5 20 H / 10kWeight reduction1,2 Maintain normal body weight 5-20 mmHg/ 10kg

weight reduction

Adopt DASH eating plan

Diet rich in fruits, vegetables, high K and low fat dairy products with a reduced content of saturated and total fat.

8-14 mmHg

Dietary sodium 3,4,5

reduction Reduce dietary sodium intake to no more than 6g per day

2-8 mmHg

Physical activity 6,7 Engage in regular aerobic physical activity 4-9 mmHgPhysical activity , Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week).

4-9 mmHg

Moderation of alcohol

consumption

Limit consumption to no more than 2 drinks per day in most men and to no more than 1 drink per day in women and lighter weight persons.

2-4 mmHg

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Dietary Intervention (MODULE 5)

DASH – Dietary Advice to Stop Hypertension:

Rich in fruits, vegetables Rich in potassium, magnesium and

calcium Low in cholesterol, saturated and total fatLow in sodiumLow in sweets and added sugars

DASH eating plan based on 2000 calories a day

Food GroupDailyServings  Examples of Serving Sizes

Grain and grain products

6‐8 1 slice bread1 cup ready to eat cerealproducts  1 cup  ready‐to‐eat cereal1/2 cup cooked rice, pasta, or cereal

Vegetables (dark green vegetables 

are good sources of K+ and Mg++)

4‐5 1 cup raw leafy vegetables1/2 cup cooked vegetables1/2 cup vegetable juice

Fruits( d f K )

4‐5 1 medium fruit1/4 d i d f it

1 cup = 240 ml

(good sources of K+) 1/4 cup dried fruit1/2 cup fresh, frozen, or canned fruit1//2 cup fruit juice

Low fat or fat free dairy products 

(good sources of Ca++)

2‐3 1 cup milk1 cup yoghurt1 1/2 ounce cheese

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Food GroupDailyServings  Examples of Serving Sizes

Lean meats, poultry, and fish

6 or less 1 ounce (28 grams) cooked lean meat, skinless poultry, or fish

d d k / /Nuts, seeds, and dry beans(good sources of Mg++ & Ca++)

4‐5 per week 1/3 cup or 1 1/2 ounces nuts1 tablespoon or 1/2 ounces seeds

Fats and oils 2‐3 1 teaspoon soft margarine1 tablespoon low‐fat mayonnaise2 tablespoons light salad dressingtab espoo s g t sa ad d ess g1 teaspoon vegetable oil

Sweets 5 or less per week

1 tablespoon sugar1 tablespoon jelly or jam1 cup lemonade

1 cup = 240 ml

Recommending Exercise to People with HT (adopted from Department of Health Exercise Prescription) (MODULE 6)

Physical RecommendationsyActivity Profile

Frequency • Perform aerobic exercise everyday• Perform resistance exercise 2 to 3 times per week

Intensity • Aerobic and resistance exercise should be at

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Intensity Aerobic and resistance exercise should be at least at moderate intensity

Time • 30 to 60 minutes per day of aerobic exercise

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Special precautions on prescribing exercise to people with HT Avoid intensive isometric exercise

If HT is poorly controlled should avoid heavy physical If HT is poorly controlled, should avoid heavy physical exercise until appropriate treatment has been given and BP lowered

For patients on β-blockers and diuretics

educate them about sign and symptoms of heat intolerance and hypoglycaemia

For patients on anti-hypertensive medications such as calcium channel blocker &vasodilators

extend and monitor the cool-down period.

Patients should be informed about the cardiac prodromal symptoms

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Drug Treatment for Patient with Hypertension (MODULE 7)

1. Concluding evidence generated from existing trials1. Concluding evidence generated from existing trials indicate that the main benefits of antihypertensive therapy in CVS outcomes are due to lowering of blood pressure per se, rather than choice of drug class, except patients with compelling indications.

2 ACEI calcium channel blockers and thiazide-2. ACEI, calcium channel blockers and thiazidetype diuretics are largely equivalent in efficacy and safety.

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3. Beta-blockers is NOTrecommended as first line therapy:

h d t h d t i l h d th t th head-to head trials showed that they were less effective than the comparator drug at reducing major CVS events, in particular stroke

increased risk of developing diabetes, particular with the combination of thiazide-type diuretic.

4. Aldomet, alpha blockers No convincing evidence in reducing CVS

morbidity and mortality

Points to consider when prescribing anti-hypertensives (1)

1 Previous favourable or unfavourable1. Previous, favourable or unfavourable, experience of the individual patient with a given class of drugs.

2. Cost of drugs

3. Presence of TOD

l di DM th f th renal disease, DM or the presence of other coexisting CVD may either favour or limit the use of particular classes of antihypertensive drugs

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Points to consider when prescribing anti-hypertensives (2)

4 A significant number of patients require two or4. A significant number of patients require two or more anti-hypertensive drugs in order to achieve blood pressure control. The possibility of interactions with drugs used for other conditions present in the patient.

5. There is substantial inter-individual variation in5. There is substantial inter individual variation in response to single drugs

Class of Drug Compelling Indications Compelling Contraindications

ACE Inhibitors (ACEI) Heart failure,Left ventricular dysfunction,Post myocardial infarction,Diabetic nephropathy

Pregnancy,Bilateral renal artery stenosis,Hyperkalaemia

Angiotensin II ACE inhibitor intolerance PregnancyAngiotensin IIReceptor Blockers (ARB)

ACE inhibitor intolerance Pregnancy,Bilateral renal artery stenosis,Hyperkalaemia

Alpha-Blockers Benign prostatic hypertrophy

Beta-Blockers Angina,Post myocardial infarctionTachyarrhythmias

Asthma, chronic obstructive pulmonary disease,Heart block

Calcium Elderly patients,Channel Blockers(dihydropyridine)

y p ,Isolated systolic hypertension

CalciumChannel Blockers(rate limiting, e.g. verapamil, diltiazem)

Angina Heart block

Thiazide/thiazide-likeDiuretics

Heart failure,Elderly patients,Isolated systolic hypertension

Gout

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Annual Assessment (MODULE 8)

Aim:

to detect complications

to assess patient’s knowledge, attitude and compliance of HT and drug treatment

to advise on healthy lifestyle and cardiovascular risk factors

to ensure satisfactory BP control

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Annual assessment (1)

History •Angina, neurological symptomsS ki t t•Smoking status

•Alcohol intake•Exercise•Family history of premature coronary heart disease•Patients’ concerns

Physical •Measure BP

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Physical examination

•Measure BP•Check body mass index•Cardiovascular examination

Annual assessment (2)Laboratory investigation

General: urine for protein/albuminuric acid if on diuretic

R l f ti t t S di P t i URenal function test: Sodium, Potassium, Urea, Creatinine

Lipid Profiles: Total cholesterolTriglycerideHDL-CholesterolLDL-Cholesterol

Management •Review the risk factors and blood results

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•Assess side effects•Encourage lifestyle modification•Explore reasons for non-compliance•Ensure patients understand HT and benefits of follow up

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Summary

1. Early intervention and blood pressure control d di l bidit d t litreduce cardiovascular morbidity and mortality.

2. Lifestyle modifications and drug treatment are both important and should be individualized to maintain an optimal control of all clinical parameters.

3. Multidisciplinary team approach is needed to provide ongoing education to reduce risks, assess patients’ needs, monitor treatment responses and adherence.

Initiatives

Service gaps are being identified in the d ti f th f f kadoption of the reference frameworks

Patient education and empowerment are crucial. The patient’s version of the Reference Frameworks and other education materials are available at the website of the PCO.

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One page summary on HT and DM reference frameworkOne page summary on HT and DM reference framework

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