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Brief on Reference Framework Brief on Reference Framework for Hypertension care in Adults

in Primary Care Settings

16 July 20111

Demographics of HT in HKThe Rule of Halves

27% of the population aged 15 or above had high blood pressure in the Population Health Survey in 2003‐20041pressure in the Population Health Survey in 2003 2004– 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.

In 2 other surveys in 2008 and 2009 the prevalence ofIn 2 other surveys in 2008 and 2009, the prevalence of Hypertension in HK was 10.0% and 10.3% respectively.2,3

1. Population Health Survey 2003‐2004. Collaborative project of DH and the Department of Community Medicine of HKU2. Thematic Household Survey Report No. 45 in Dec 2010. Census and Statistics Department, HKSAR3. Patient morbidity and management patterns of community‐based primary health care services in Hong Kong.  

Hong Kong Med J 2011;17(Suppl 3):S33‐7

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Management of hypertension byprivate doctors in Hong Kong

Hong Kong Med J 2006;12:115‐8

• Only 24% of the private doctors measured blood• 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. 

• The choice of anti‐HT drugs based mainly on drug efficacy.

Drug efficacy 56 9%– Drug efficacy  56.9%– Habit  22.9%– Simple regimen  19.7%– Drug safety  19.1%– Clinical guidelines  18.4%

Service Gaps

1. A significant proportion of HT patients were di dundiagnosed.

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

3. A significant proportion of HT patients were not adequately treatednot adequately treated. 

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Aims of the reference framework

1. Promote health, prevent disease and tackle major health risks in the populationhealth risks in the population

2. Recommend interventions which are evidence‐based and appropriate to primary care settings

3. Use as common reference for co‐ordinating different healthcare disciplines across Hong Kong

4 E i d h i4. Empower patients and their carers

CORE DOCUMENT

Chapter – table of contents

1 Epidemiology

2 Population-based Intervention and Life Course approach

3 Role of Primary Care in the Management of Hypertension

4 Patient Education

5 Aim of the Framework

6 Prevention of Hypertension

7 Early identification of People with y pHypertension

8 Clinical Care of Adults with Hypertension

9 Patient Empowerment

10 Future Direction to Promote the Use of the Framework

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Recommendations from Reference Framework

Prevention and early identification of HTy

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

Advise individuals at increased risk of developing HT to:

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- maintain optimal body weight, - restrict dietary salt intake, - abstain from smoking and - practise healthy lifestyles

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BPclassification

Initial BP(mmHg)

RecommendedMinimum

Action

Recommendations from Reference Framework

classification (mmHg) Minimum Review PeriodSBP DBP

Pre-hypertension

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

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

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

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

>180 >110 Evaluate < 1 week Drug treatment onceconfirmed.

Refer if malignant HT

Relationship between Blood Pressure and Cardiovascular Risk

1. The association between BP and CVS risk is continuous at all levels, starting as low as 115/70continuous 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 causes

3. 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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CVD Mortality Risk Doubles withEach 20/10 mm Hg BP Increment*

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CVDmortality

risk

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2

3

4

5

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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

Evaluation for Newly Diagnosed Hypertensive Patients (Module 4)

1. to assess lifestyle and identify cardiovascular i k f t th t ff t i drisk factors that may affect prognosis and guide treatment, 

2. to reveal identifiable causes of high blood pressure, and 

3 to assess the presence or absence of target3. to assess the presence or absence of target organ damage and CVS disease. 

(FBS, RFT, Lipid profile, ECG, urine analysis)

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Recommendations from Reference Framework

Treatment of HT – Lifestyle modifications (Module 5, 6)

1. Encourage overweight and obese patients to lose weigh

2. Increase level of physical activity and take regular exercise

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

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

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

6. Encourage all hypertensive patients to stop smoking

Lifestyle Modifications

Modification Recommendation Approximate SBP

Reduction (range)

Weight 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 reduction 3,4,5

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 mmHgys ca ac y gage egu a ae ob c p ys ca ac ysuch as brisk walking (at least 30 min per day, most days of the week).

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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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What are the benefits of BP control in reducing complications?

• Meta‐analysis of 61 prospective, observational studies which involve 1 million adultswhich 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

Individual vs population

• For individual patient, a few mmHg less may not be that significant to that person’s overallnot be that significant to that person s overall CVS risk . 

• However, these small differences in individual risk when multiplied by thousands produce significant reductions in CVS endpoints when these are counted at the population levelthese are counted at the population level.

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First line anti‐HT recommended by evidence based guidelines

1. European Society of HT guidelines 2003 any drug (beta blocker ARBs ACE inhibitors CCBs‐ any drug (beta‐blocker, ARBs, ACE inhibitors, CCBs, 

diuretics) at the discretion of individual doctor

2. WHO International Society of HT guideline 2003‐ thiazide‐type diuretics

3. US JNC VII  in 2003‐ thiazide‐type diureticsyp

4. UK NICE in 2006‐ calcium‐channel blockers or thiazide‐type diuretics for 

most patients

‐ ACEI/ ARB for the younger HT  (Grade C recommendation)

Recommendations from Reference FrameworkChoice of anti‐hypertensive drugs (Module 7)

1. 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‐type diuretics are largely equivalent in efficacy and safety. 

3. It is noted that beta‐blockers were less effective than the comparator drug at reducing major CVS events, in particular stroke. An additional concern is the increased risk of developing diabetes, particular with the combination of thiazide‐type diuretic. 

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Treatment algorithm (Module 7)

Referral to specialist• Suspected secondary hypertension

• Patients aged 30 or below

• Patients with progressive complications e.g. target organ damage

• Pregnancyeg a cy

Immediate referral to hospital setting• Malignant hypertension

　 DBP > 130mmHg;  Heavy proteinuria; Papilloedema; Encephalopathy

• Accelerated hypertension: DBP > 130mmHg and retinal hemorrhage

• Persistent BP > 220/120mmHg despite rest or drug treatment/ g p g

• Pregnancy:

　 BP 140/90mmHg and > 20 weeks gestation

　 Signs and symptoms of pre‐eclampsia (headache, proteinuria, oedema)

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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 Receptor  ACE inhibitor intolerance Pregnancy,Blockers (ARB) Bilateral renal artery stenosis,

Hyperkalaemia

Alpha‐Blockers Benign prostatic hypertrophy 

Beta‐Blockers Angina,Post myocardial infarctionTachyarrhythmias

Asthma, chronic obstructive pulmonary disease,Heart block

CalciumChannel Blockers

Elderly patients,Isolated systolic hypertensionChannel lockers

(dihydropyridine)so a ed sys o c ype e s o

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

Angina  Heart block 

Thiazide/thiazide‐likeDiuretics

Heart failure,Elderly patients,Isolated systolic hypertension

Gout

Recommendations from Reference Framework

G l f t t t (M d l 7)Goals of treatment (Module 7)

The goal of therapy for simple hypertensive patients is blood 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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Multiple Antihypertensive Agents Are Often Needed to Achieve Target BP

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No. of Antihypertensive Agents

2 3 4

Target BP (mm Hg)

Trial1 2 3 4

MAP 92AASK5

DBP 80HOT4

MAP 92MDRD3

DBP 75ABCD2

DBP 85UKPDS1

(mm Hg)

SBP 140/DBP 90ALLHAT7

SBP 135/DBP 85IDNT6

DBP- diastolic blood pressure MAP - mean arterial pressure ; SBP- systolic blood pressure

1. UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713. 2. Estacio RO et al. Am J Cardiol. 1998;82:9R-14R.3. Lazarus JM et al. Hypertension. 1997;29:641-650. 4. Hansson L et al. Lancet. 1998;351:1755-1762.

5. Kusek JW et al. Control Clin Trials. 1996;16:40S-46S. 6. Lewis EJ et al. N Engl J Med. 2001;345:851-860. 7. ALLHAT. JAMA. 2002;288:2998-3007.

HOW TOHOW TO IMPLEMENT ?

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Chronic disease management program at GOPCRisk 

Stratification

Medium 

Low riskRisk factor 

modification to

Very high risk

Proactive multi‐disciplinary team management at 

GOPC

Improved control to 

risk

High risk

modification to prevent complications

Early intervention of complications

reduce hospital admissions for complications

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Less for More

Doctor DoctorDoctorDoctor

Nurse Allied health

Low to moderate risk group: lengthen interval of Doctor consultation, with Nurse/Allied   health assessment in between

High risk group: Close follow up by FM doctor till stable and satisfactory control

DoctorDoctor

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INITIATIVES1. Health promotional activities for patients will be

organized to enhance patient education and empowerment

2. To review and update the Reference Framework regularly based on latest medical development and research

3. CME programmes for doctors will be organised with professional organisations

4. Engage community partners in implementation of the recommended strategies.

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YOUR  SUPPORT WILL BE CRUCIALWILL BE CRUCIAL 

IN THE PROMOTION OF REFERENCE FRAMEWORKS!

THANK YOU!THANK YOU!30