Blood pressure control

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• Blood pressure control
• in primary health care
• WORKSHOP

Jurate Klumbiene Kaunas University of Medicine,
Kaunas, Lithuania
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Workshop agenda

• Presentation of a patient case in which the
  patient has hypertension
• Identification of the patients 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)

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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

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Task for each participant

• Identify the patients problems and assess CVD
  risk.
• Use ESH/ESC categorical stratification of
  cardiovascular risk.

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Plenary discussion

• The patients problems and CVD risk

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Tasks for group work

• Non-pharmacological treatment
• Treatment goals and pharmacological therapy
• The measures to ensure compliance

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CLASSIFICATION OF BP LEVELS(European Society of
Hypertension and Cardiology, 2007)
CATEGORIES Systolic BP Diastolic
BP Optimal BP lt 120 and/or
lt80 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) gt180
and/or gt110 Isolate systolic hypertension
gt140 and lt90
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Stratification of CVD Risk (2007 Guidelines for
the management of arterial hypertension, ESH and
ESC)
Other risk factors, OD or disease Normal BP High normal BP Grade 1 HT Grade 2 HT Grade 3 HT
No other risk factors Average risk Average risk Low added risk Moderate added risk High added risk
1-2 risk factors Low added risk Low added risk Moderate 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
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.
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Presentation of the treatment plans and discussion
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Summary

• Blood pressure control

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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).

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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.

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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 changes Lifestyle 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 treatment Lifestyle changes drug treatment Lifestyle changes immediate drug treatment
Diabetes Lifestyle changes Lifestyle changes drug treatment Lifestyle changes drug treatment Lifestyle changes drug treatment Lifestyle changes immediate 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