Blood pressure control

in primary health care

WORKSHOP

Jurate KlumbieneKaunas University of Medicine, Kaunas,

Lithuania

Workshop agenda

• Presentation of a patient case in which the patient has

hypertension

• Identification of the patient’s problems and CVD risk

(individual exercise and plenary discussion)

• Designing a treatment plan (group work):

– Non-pharmacological measures

– Treatment goals, pharmacological therapy

– Measures to ensure compliance

• Presentation of the plans and discussion (plenary

presentation)

CASE: Alexander is a 56-year-old driver who schedules a visit as part of

a regular health examination. History:

– no significant past medical history, no medicine prescriptions

– a regular smoker (20cig/day since 25 years old)

– drinks a couple bottles of beer a night and "a bit more on the weekend”

– no family history of CVD

• Physical examination:

• Blood pressure (BP) 146/94 (repeated BP – 144/92, 148/98)

• Pulse rate 76, regular

• Weight - 102 kg, height – 178 cm

• Waist circumference – 110 cm

• The remainder of the physical examination was unremarkable

Laboratory investigations No abnormalities

Task for each participant

• Identify the patient’s problems and assess

CVD risk.

• Use ESH/ESC categorical stratification of

cardiovascular risk.

Plenary discussion

• The patient’s problems and CVD

risk

Tasks for group work

1) Non-pharmacological treatment

2) Treatment goals and pharmacological therapy

3) The measures to ensure compliance

CLASSIFICATION OF BP LEVELS(European Society of Hypertension and Cardiology, 2007)

CATEGORIES Systolic BP Diastolic BP

Optimal BP < 120 and/or <80

Normal BP 120-129 and/or 80-84

High-normal BP 130-139 and/or 85-89

Grade1 hypertension (mild) 140-159 and/or 90-99

Grade2 hypertension (moderate) 160-179 and/or 100-109

Grade3 hypertension (severe) >180 and/or >110

Isolate systolic hypertension >140 and <90

Stratification of CVD Risk (2007 Guidelines for the management of arterial hypertension, ESH and ESC)

BP: blood pressure; CVD: cardiovascular; HT: hypertension. Low, moderate, high, very high risk refers to 10 year risk of a CVD fatal or non-fatal event. The term “added” indicates that in all categories risk is greater than average. OD: subclinical organ damage; MS: metabolic syndrome.

Other risk factors, OD or disease

Normal BP High normal

BPGrade 1 HT Grade 2 HT Grade 3 HT

No other risk factors

Average

risk

Average

risk

Low

added riskModerate added risk

High added risk

1-2 risk factors

Low

added risk

Low

added riskModerate added risk

Moderate added risk

Very high added risk

3 or more risk factors, MS, OD or diabetes

Moderate added risk

High added risk

High added risk

High added risk

Very high added risk

Established CVD or renal disease

Very high added risk

Very high added risk

Very high added risk

Very high added risk

Very high added risk

Presentation of the treatment plans and discussion

Summary

• Blood pressure control

TREATMENT GOALS

To achieve a maximum reduction in the long-term total risk of cardiovascular morbidity and mortality (the treatment of all reversible risk factors identified, including smoking, dyslipidaemia or diabetes and the appropriate management of associated clinical conditions, as well as treatment of high blood pressure per se).

Blood pressure, both systolic and diastolic, should be lowered in all hypertensive patients:

At least below 140/90 mmHg.

It may prudent to recommend lowering blood pressure to values within the range 130-139/80-85 mm Hg (Reappraisal of European guidelines on hypertension management, 2009).

TREATMENT STRATEGIES

Lifestyle measures (non-pharmacological treatment) should be instituted whenever appropriate in all patients, including subjects with high normal blood pressure and patients who require drug treatment.

The purpose of non-pharmacological treatment is to lower blood pressure, to control other risk factors and clinical conditions and to reduce the number and doses of antihypertensive drugs which might be subsequently used.

Initiation of antihypertensive treatment (ESH/ESC, 2007)

Other risk factors, OD or disease

Normal BP High normal BP Grade 1 HT Grade 2 HT Grade 3 HT

No other risk factors

No BP intervention

No BP intervention

Lifestyle changes for several months then drug treatment if BP uncontrolled

Lifestyle changes for several weeks then drug treatment if BP uncontrolled

Lifestyle changes + immediate drug treatment

1-2 risk factors

Lifestyle changesLifestyle changes

Lifestyle changes for several weeks then drug treatment if BP uncontrolled

Lifestyle changes for several weeks then drug treatment if BP uncontrolled

Lifestyle changes + immediate drug treatment

3 or more risk factors, MS, OD or diabetes

Lifestyle changes

Lifestyle changes and consider drug treatment Lifestyle changes

+ drug treatmentLifestyle changes + drug treatment

Lifestyle changes + immediate drug treatmentDiabetes Lifestyle changes

Lifestyle changes + drug treatment

Established CVD or renal disease

Lifestyle changes + immediate drug treatment

Lifestyle changes + immediate drug treatment

Lifestyle changes + immediate drug treatment

Lifestyle changes + immediate drug treatment

Lifestyle changes + immediate drug treatment