Southern African Hypertension Society HYPERTENSION GUIDELINE 2005

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Southern African Hypertension Society HYPERTENSION GUIDELINE 2005 Powered By Docstoc
					HYPERTENSION GUIDELINE
        2005 REVISION
         Progress report
This is not a final statement on
     the guideline content.
      Dr Vicki Pinkney-Atkinson
         Executive Director
       SAHS Guideline History
•   1989 One of the first national guidelines
•   2001
•   2003 Update selected sections
•   2005 Development
•   2006 publication and rollout


        IMPLEMENTATION
                       Progress Report
                      not the final story


Don’t shoot the messenger
Please note that this is only a progress report
One hypertension guideline for SA
    Evidence-based comprehensive care
One hypertension guideline for SA


• Department of Health /SAHS alliance
  – EDL




  alliance with European Society Cardiology
  does not include the hypertension guideline
Guideline development process
• Early 2004 comment on sections that needed
  revision requested.
• June 2004
  – Decision to revise the whole guideline
  – Agreement with Department of Health
• March 2005
  – Guideline meeting with SAHS Exco, local
    stakeholders e.g. SEMDSA, LASSA, SASSO
  – Agreement on direction of change
Guideline development process continued
 • July 2005
    – Small working group DOH & SAHS changes as
      recommended
 • August 2005
    – Revision circulated for comment to DOH, SAHS
      and other stakeholder groups
    – Available on website
 • October 2005 - stakeholder meeting to discuss
   revision
 • November 2005 final draft circulated
 • December 2005 submitted for publication
 • January 2006 publication web and print
National Guideline Working Party
•   Prof YK Seedat chairperson
•   Prof Brian Rayner
•   Prof Lionel Opie
•   Prof John Milne
•   Ms Anne Croasdale (DOH)
•   Ms Nosipho Mdondolo (DOH)
•   Dr Vicki Pinkney-Atkinson
Cumulative % of all CVD deaths 2000-2030, occurring in males
and females aged 35-64 in study and 2 comparator countries


           45
           40
           35
           30
           25
         %
           20
           15
           10
            5
            0
                    S Africa


                               India


                                       Brazil


                                                China


                                                        Russia


                                                                 US


                                                                      Portugal
  Source: Race Against Time
   Total years of life lost due to CVD among populations aged
35-64 for the 5 study and 2 comparator countries 2000 and 2030
 and the loss rates per 100,000 (assuming current CVD rates).

                                                                         2000       2030

                6000
                5000
 Rate/100,000




                4000
                3000
                2000
                1000
                  0
                       Brazil


                                S Africa


                                           Russia


                                                    China


                                                            India


                                                                    US


                                                                         Portugal
Source: Race Against Time
            Policy Briefs
        operationalisation
• LVH Diagnosis
• Microalbuminuria (in progress)
• ABPM (education programme)
            Lifestyle
    (deathstyle) modification
     Cornerstone of management
                Expanded
•   Smoking to non-smoking
•   Sozzling to moderation
•   Slothing to activity
•   Stuffing to healthy eating
                   Changes
•   Not really making any major changes
•   Updating most sections
•   Stroke
•   Pregnancy
•   New
    – Childhood as linked to obesity
    – Elderly
                        BP
GOALS SIMPLIFIED        BP MEASUREMENT
• 140/90 mmHg           • automatic devices
• 130/80 mmHg for         increasingly used
  certain conditions    • Must be validated by
• ISH                     organisations
• BP control within 6   www.dableducational.com
  months
  Hypertension is not a stand
       alone condition!

• Unchanged
• Emphasised more strongly
      RISK FACTORS                                                             stroke

         Age, gender                                                    M     Angina
         Smoking                                                        I
                                                                               LVH
         LDL-cholesterol                                                      Heart
         Hypertension                                                         failure

                                                                               Renal
                                                                               failur
    Endothelial
    dysfunction
                                Vascular                                       e
                                disease
                                                                            Peripheral
      Diabetes                                                               arterial
      “diabetic without an MI                                                disease
      is similar to non-diabetic with an MI”
Modified from Luscher Eur Heart J Supplements, Vol 2 Suppl D May 2000
      Risk factor evaluation
• Retaining the qualitative approach
• Using the ESC risk chart
• Slightly more complicated
   STRATIFICATION OF RISK TO QUANTIFY
     PROGNOSIS(ESH/ECC) GUIDELINES)

                                     Blood pressure (mm Hg)
Other risk       Normal        High normal     Grade 1         Grade 2         Grade 3
factors and     SBP 120 –     SBP 130-139        (mild        (moderate         (severe
disease            129             or        hypertension)   hypertension)   hypertension)
history        Or DBP 80 -     DBP 85-89     SBP 140-159     SBP 160-179     SBP > 180 or
                    84                            or              or          DBP> 110
                                              DBP 90-99      DBP 100-109
No other       Average risk    Average       Low added       Moderate        High added
risk factors                     risk           risk         added risk         risk
1-2 risk        Low added     Low added      Moderate        Moderate        Very high
factors            risk          risk        added risk      added risk      added risk
3 or more                                                                    Very high
risk factors   Moderate       High added     High added      High added      added risk
or TOD or      added risk        risk           risk            risk
diabetes
ACC            High added     Very high      Very high       Very high       Very high
                  risk        added risk     added risk      added risk      added risk

                                                       J Hypertension 2003; 21: 1011-1053.
WHO CVD-RISK MANAGEMENT PACKAGE FOR
   LOW-MEDIUM RESOURCE SETTINGS
                                            STRATIFY RISK

                                                                                HIGH/VERY
                    LOW                                 MEDIUM
                                                                                   HIGH

                       LIFESTYLE MODIFICATION AS APPROPRIATE

              Monitor BP and                           Monitor BP and
          Other RF for 6-12 months                 Other RF for 3-6 months



       SBP > 150           SBP < 150         SBP < 140             SBP > 140
      Or DBP > 95         Or DBP < 95       Or DBP < 90           Or DBP > 90




                                     Continue to
                                       monitor

                                                                                BEGIN DRUG
                                                                                TREATMENT



WHO, Geneva 2002
       Metabolic syndrome
• More important new section
• Using the proposed new International
  Diabetes Federation guideline.
• www.idf.org
• In collaboration with LASSA and
  SEMDSA
 Lipids and Diabetes Mellitus
• Both are important comorbid conditions
  which significantly increase risk
• New control levels included in
  collaboration with
             Drug therapy
• Still using step approach
• Still start with thiazide or thiazide-like
• Restricted use
  – Hydralazine
  – Reserpine
• Beta blockers moved from second line
  – Restricted to compelling indications
            Drug therapy
• Combination therapy
• As many drugs as it takes to control the
  BP without side effects
        Compelling indications
• Remain largely unchanged
• ACE / ARB debate
  –   Important clinically significant drugs
  –   Increased number of indications
  –   which recommended first???
  –   Side effects have to be taken into account
• Beta blockers remain for certain
  specific indications
            Routine tests
Defined for:
  – Newly diagnosed
  – Uncomplicated controlled
  – Certain conditions
      Special investigations
     resistant hypertension
Should be performed by a hypertension
 “specialist” or in collaboration with such
 a person and dependant on the type of
 clinical problem
                Return visits
•       Defining number required for:
    –    Newly diagnosed
    –    Uncontrolled
    –    Resistant HT
           CONCLUSION
• Invitation for MAG to participate in the
  process by giving input
  – Omissions that would make your job easier
  – Content that might need altering
  – Suggested restructuring
   Southern African
  Hypertension Society
   Website: www.hypertension.org.za
     Membership free by visiting the
website or sending in application form
    sahs@hypertension.org.za