Ministry of Health

Sultanate of Oman

Brief Guidelines for

THE MANAGEMENT OF HYPERTENSION
In Primary Health Care

November 2007
Department of Non-Communicable Disease Surveillance and Control
Directorate General of Health Affairs
In collaboration with
Department of Cardiology, Royal Hospital
 ABBREVIATIONS

ACEI : Angiotensin converting enzyme inhibitor

Aldo : Aldosterone antagonist

ARB : Angiotensin receptor blocker

BB : Beta blocker

BP : Blood pressure

CCB : Calcium channel blocker

CKD : Chronic kidney disease

CNS : Central nervous system

DBP : Diastolic blood pressure

Diu : Diuretic

GFR : Glomerular filtration rate

HDL : High density lipoprotein

ICU : Intensive care unit

IHD : Ischaemic heart disease

LDL : Low density lipoprotein

SBP : Systolic blood pressure

What is hypertension
Hypertension is defined as: a systolic blood pressure of ≥ 140 mm Hg and/or a diastolic
pressure of ≥ 90 mm Hg in people who are not on anti-hypertensive medications.

Table 1: Classification of blood pressure for adults

BP Classification SBP (mmHg) DBP (mmHg)
Normal <120 and <80
Prehypertension 120-139 and/or 80-89
Stage 1 Hypertension 140-159 and/or 90-99
Stage 2 Hypertension ≥160 and/or ≥100

Diagnostic criteria and cut points

The diagnosis should be made based on the higher of two or more properly
measured seated BP readings on each of two or more visits to the physician
and has to be ≥140 mm Hg systolic and / or ≥90 mm Hg.

Lower cut points have been suggested for hypertension with diabetes or hypertension
with coronary heart disease (see table 2)

Figure 1: Recommendations for follow-up based on initial blood pressure

measurements for adults without acute end organ damage

Initial blood pressure*

Normal Stage 1 Stage 2

Prehypertension
(<120 and hypertension hypertension
(120-139 or
<80 mmHg) (140-159 or (≥160 or
80-89 mmHg)
90-99 mmHg) ≥100 mmHg)

Recheck in Recheck in Confirm within - Evaluate and manage as per

3 years✝ 1 year**✝ 2 months**✝ guidelines.
- For those with >180/110
mmHg evaluate and treat
immediately.

* If systolic and diastolic categories are different, follow recommendations for

shorter time follow up (e.g. 160/86mm Hg should be evaluated or referred to
secondary hospital within 1 month.
† Modify the scheduling of follow up according to reliable information about past BP
measurements, other cardiovascular risk factors or target organ disease.
** Provide advice about lifestyle modification.

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Treatment of hypertension

}
Table 2: Therapy targets
Patient Target
Hypertensives <140/90 mmHg
Hypertensive with diabetes
Hypertensive with renal disease <130/80 mmHg
Hypertensive with IHD
Hypertensive with diabetic nephropathy <125/75 mmHg

Figure 2: Treatment algorithm for hypertension

Is patient hypertensive No Recheck
- annually if SBP= 130-139 or
DBP= 85-89mmHg and
Advice lifestyle modification
Yes - every 3 years if SBP<130 and
DBP<85mmHg.

Lifestyle modifications
(3 months for stage 1 hypertension. For stage 2 hypertension and those with compelling
indications, start on drug treatment immediately along with lifestyle modifications).

Not at goal blood pressure (<140/90mmHg)

(<130/80mmHg for patients with diabetes, IHD or CKD)

Initial drug choices

Stage 1 hypertension Stage 2 hypertension

Without compelling With compelling Without compelling With compelling

indications indications indications indications

Other Other
Thiazide- type Two- drug combination
anti-hypertensive anti-hypertensive
diuretics for most. for most (usually
drugs (diuretics, drugs (diuretics,
May consider ACEI, thiazide-type diuretic
ACEI, ARB, BB ACEI, ARB, BB
ARB, BB, CCB or and ACEI or ARB
and CCB) as and CCB) as
combination or BB or CCB)*
needed needed

Not at goal blood pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider
consultation with hyertension specialist

Compelling indications are : Heart failure, post myocardial infarction, high coronary disease
risk, diabetes, CKD, recurrent stroke prevention.

* It is recommended to start with one drug, maximize the dose and then add on the next one if required.

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Table 3: Cardiovascular risk factors
Major risk factors
Hypertension
Cigarette smoking
❏

Obesity (body mass index) ≥ 30kg/m2

❏

Physical inactivity
❏

Dyslipidaemia
❏

Diabetes mellitus
❏

Microalbuminuria or estimated GFR <60ml per minute

❏

Age (older than 55 years for men and 65 for women)

❏

Family history of premature cardiovascular disease (men under age 55 and women
❏

under age 65)

❏

Low HDL ( < 0.9 mmol / L in male, < 1.1 mmol / L in female )
High LDL ( ≥ 3.4 mmol / L )
❏

Impaired glucose tolerance

❏

Target Organ Damage

❏

Left ventricular hypertrophy

❏

Angina or prior myocardial infarction

}
❏

Prior coronary revascularization Heart as target organ damage

❏

Heart failure
❏
❏

❏
❏
❏
❏
Stroke or transient ischaemic attack
CKD
Peripheral arterial disease
Retinopathy
} Brain as target organ damage

Table 4: Alternative medications used in patients with hypertension with

compelling indications.
Compelling indication Recommended drugs
Diu BB ACEI ARB CCB Aldo
Heart failure
* * (††) * * *
Post myocardial infarction * * *
High coronary disease risk-
(presence of 3 or more risk factors †) * * * * *
Diabetes ** * * * * *
CKD (creatinine clearance <30ml/min * *
Recurrent stroke prevention * *
† see table 3. ** Diu and BB should not be combined.
In chronic real failure: ACEI and ARB should not be used, vasodilators may be used
†† selected BB; with caution.

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Formula for estimated GFR
Creatinine clearance (male)= 140-age(years)Xweight in KgX1.23 ml/min
Plasma creatinine in micro mol/L
For females, multiply by 0.85

Measures to reduce cardiovascular risk

For hypertensives aged 50 years or more, who have satisfactory control over their
blood pressure give 75 mg aspirin once a day.
❏

Give both aspirin and statin when there is evidence of cardiovascular disease - angina,
myocardial infarction, stroke, transient ischaemic attack, peripheral vascular disease etc.
❏

Table 5: Lifestyle modifications

Modification Recommendation Approximate SBP Reduction

Weight reduction Maintain normal body weight 5-20 mmHg/10 kg

(body mass index 18.5-24.9 kg/m2). weight loss

Consume a diet rich in fruits,

Adopt healthy vegetables, and low fat dairy 8-14 mmHg
eating plan products with a reduced content
of saturated and total fat.

Reduce dietary sodium intake to

Dietary sodium no more than 100 mmol per day 2-8 mmHg
reduction (2.4 g sodium or 6 g sodium
chloride: about 1 teaspoon).

Engage in regular aerobic physical

Physical activity activity such as brisk walking 4-9 mmHg
(at least 30min per day, most days
of the week).
Abstinence is the best policy.
However in those who do consume
Abstinence / alcohol, limit consumption to no
Moderation of more than 2 drinks (1 oz or 30 ml 2-4 mmHg
alcohol ethanol; e.g., 24 oz beer, 10 oz wine,
consumption or 3 oz 80-proof whiskey) per day in
most men and to no more than 1
drink per day in women and lighter
weight persons.

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Tips on pharmacological treatment

Thiazide diuretics should be used as the first line of drug treatment in combination
with other drugs. Only if a diuretic cannot be used or a compelling indication is present,
❏

should therapy be initiated with another drug class.

More than 60% of hypertensive patients cannot be controlled with one drug and will
require 2 or more antihypertensive agents from different drug classes.
❏

Addition of a second drug from a another class should be initiated when use of a single
drug in adequate doses fails to achieve the goal.
❏

❏ In those with lower BP goals or with very high BP, 3 or more drugs may be required.

When you suspect any of the following

Effective drug combinations are:
complications or target organ diseases,
1. A diuretic with a ß-blocker
refer to the secondary hospital immediately
2. Diuretic with ACE inhibitor
3. A ß-blocker with a dihydropyridine
1. Heart failure
calcium antagonist
2. IHD
4. An ACE inhibitor with a calcium
3. Stroke
antagonist
4. Kidney disease
5. ß-blocker and an blocker
5. Accelerated or malignant hypertension

Hypertensive emergencies or urgencies

(A) Hypertensive emergencies

Sudden increase in systolic and diastolic BP associated with acute target-organ
damage (cardiovascular, renal, central nervous system) that require immediate
management in a hospital setting.

They are:
Hypertensive encephalopathy
Acute left ventricular failure with pulmonary edema
❏

Dissecting aortic aneurysm

❏

Acute myocardial ischemia

❏

Eclampsia
❏

Acute renal failure

❏

Symptomatic microangiopathic hemolytic anemia

❏
❏

(B) Hypertensive urgencies

Severe elevations in BP without acute target-organ (cardiovascular, renal, CNS)
dysfunction or damage.

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Table 6: Evaluation and management of hypertensive urgencies and
emergencies

Urgency Emergency

BP >180/110 Usually >220/140

Symptoms Severe headache or Shortness of breath

asymptomatic Chest pain
❏

Nocturia
❏

Dysarthria
❏

Weakness
❏

Altered conciousness
❏
❏

Examination Clinical cardiovascular Encephalopathy

disease present but stable Pulmonary edema
❏

(no evidence of acute Cerebrovascular

❏

or impending target organ accident

❏

dysfunction) Renal insufficiency

Cardiac ischemia
❏
❏

Therapy Observe 3-6 hours Baseline laboratory

Lower BP with tests
❏ ❏

short-acting oral agent* Intravenous line

❏

Adjust current therapy Monitor BP

❏
❏ ❏

Plan Arrange follow-up evaluation Immediate admission

in <24 hours to ICU
❏

* Captopril 25mg, repeat as needed; Clonidine 0.1-0.2 mg, repeat hourly as required to
a total dose of 0.6mg; Labetalol 200-400 mg, repeat every 2-3 hours; Prazocin 1-2 mg,
repeat every hour as needed

Hypertension in pregnancy

Refer immediately to the secondary hospital for management.