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Management of Hypertension
(3rd Edition)

Quick Reference for Health Care Providers

Ministry of Health Malaysia

Academy of Medicine of Malaysia

Malaysian Society of Hypertension

3rd Edition (2008).moh. Only 26% of treated patients achieve target BP.6% among those aged ≥30 years. choice of first line monotherapy includes ACEIs.Layout 1/14/10 3:50 PM Page 2 MANAGEMENT OF HYPERTENSION (3rd Edition) • QUICK REFERENCE FOR HEALTH CARE PROVIDERS KEY MESSAGES 1. prevalence of HPT in Malaysia was 42. CCBs and Diuretics.msh. cerebrovascular and renal morbidity and mortality. Details of the evidence supporting these recommendations can be found in the above CPG. 5.org.my : http://www. 9. Malaysia Academy of Medicine Malaysian Society of Hypertension 2 : http://www. Beta-blockers are no longer recommended as first line monotherapy. In 2006. Untreated or sub-optimally controlled HPT leads to increased cardiovascular. In patients with newly diagnosed uncomplicated HPT who have no compelling indications. 6. 3.org.02. 2. A SBP of 120–139 and/or DBP of 80–89mm Hg is defined as pre-HPT and should be treated in certain high risk groups.acadmed. 8. Therapeutic lifestyle changes should be recommended for all individuals with HPT and pre-HPT. ARBs.my : http://www. Therefore. Hypertension (HPT) is defined as persistent elevation of SBP of ≥140mm Hg and/or DBP of ≥90mm Hg. 7. Decision to commence pharmacological treatment should be based on global cardiovascular risks and not on the level of blood pressure (BP) per se. HPT is a silent disease. 10. Combination therapy is often required to achieve target and may be instituted early.gov. BP should be measured at every chance encounter.my . available on the following websites: Ministry of Health. 64% of cases remain undiagnosed. 4. This Quick Reference provides key messages and a summary of the main recommendations in the Clinical Practice Guidelines (CPG) Management of Hypertension.

physical examination and relevant investigations. To exclude secondary causes of hypertension 2.02. taken at two or more visits to the health care providers EVALUATION OF NEWLY DIAGNOSED HYPERTENSIVE PATIENTS Evaluation should include thorough history. To ascertain the presence of target organ damage (TOD) 3. Three main objectives: 1.Layout 1/14/10 3:50 PM Page 3 MANAGEMENT OF HYPERTENSION (3rd Edition) • QUICK REFERENCE FOR HEALTH CARE PROVIDERS CLASSIFICATION OF BLOOD PRESSURE (adults ≥18 years) Category Optimal Prehypertension Stage 1 HPT Stage 2 HPT Stage 3 HPT Systolic (mmHg) <120 120–139 140–159 160–179 ≥180 and and/or and/or and/or and/or Diastolic (mmHg) <80 80–89 90–99 100–109 ≥110 Diagnosis of hypertension is made based on the average of two or more readings. To assess lifestyle and identify other cardiovascular risk factors and/or concomitant disorders that may affect treatment and prognosis ALGORITHM FOR THE MANAGEMENT OF HYPERTENSION BLOOD PRESURE (Repeated readings) SBP = 120–159mm Hg AND/OR DBP = 80–99mm Hg SBP ≥160mm Hg AND/OR DBP ≥100mm Hg Assess global cardiovascular risks Medium/High/ Very High Drug treatment Low 3-6 monthly follow-up with advice on therapeutic lifestyle changes SBP <140mm Hg AND/OR DBP <90mm Hg SBP 140–149 mm Hg AND/OR DBP 90–94mm Hg SBP ≥150mm Hg AND/OR DBP ≥95mm Hg 6-monthly follow up 3-6 monthly follow-up and assessment Drug treatment 3 .

Proteinuria TOC: Heart Failure. Haemorrhages or exudates.73m2. stroke) MI: Mycardial Infarction 4 . microalbuminuria (2 out of 3 positive tests over a period of 4-6 months). coronary heart disease (CHD). GFR <60ml/min /1. Renal Failure Risk Factors (RF): additional RF (smoking. Transient ischaemic attack (TIA). heart failure. Retinopathy. family history of premature vascular disease) Clinical atherosclerosis (CHD. No TOC TOD or RF (≥3) or Clinical atherosclerosis High Previous MI or Previous Stroke or Diabetes Mellitus (DM) Very High SBP 120 – 139 and/or DBP 80 – 89 SBP 140 – 159 and/or DBP 90 – 99 SBP 160 – 179 and/or DBP 100 – 109 SBP 180 – 209 and/or DBP 110 – 119 Low Medium Low Medium High Very High Medium High Very High Very High High High Very High Very High SBP ≥210 and/or DBP ≥120 Risk level Low Medium High Very High Very High Very High Very High Management Lifestyle changes Very High Risk of major CV event in 10 years <10% 10–20% 20–30% >30% Drug treatment and lifestyle changes Drug treatment and lifestyle changes Drug treatment and lifestyle changes TOD: LVH. TIA. TC>6. carotid stenosis. proteinuria (≥1+). with or without papilloedema. Absence of one or more major pulses in extremities (except dorsalis pedis) with or without intermittent claudication. peripheral vascular disease.02.Layout 1/14/10 3:50 PM Page 4 MANAGEMENT OF HYPERTENSION (3rd Edition) • QUICK REFERENCE FOR HEALTH CARE PROVIDERS BASELINE INVESTIGATIONS • Full blood count • Urinalysis • Urine albumin excretion or albumin/creatinine ratio • Renal profile and serum uric acid • • • • Fasting blood sugar Fasting lipid profile Electrocardiogram (ECG) Chest X-ray (if clinically indicated) Note : Should be repeated 6-12 monthly thereafter (except for Chest X-Ray) MANIFESTATIONS OF TOD/TARGET ORGAN COMPLICATION (TOC) Organ system Cardiac Cerebrovascular Peripheral vasculature Renal Retinopathy Manifestations Left ventricular hypertrophy (LVH). stroke.5mmol/L. CARDIOVASCULAR RISK STRATIFICATION Co-existing Condition BP Levels (mmHg) No RF No TOD No TOC TOD or RF (1-2).

follow-up at 3-6 month interval is appropriate. Initiate drug treatment immediately. 5 . Look for symptoms and signs of hypertensive urgency or emergency. Appropriate for concurrent dyslipidaemias and diabetes mellitus. Recheck within 3-6 months. RECOMMENDATIONS FOR FOLLOW-UP BASED ON INITIAL BLOOD PRESSURE MEASUREMENTS FOR ADULTS Initial BP (mmHg) Systolic Diastolic <130 and <85 130–139 and 85–89 140–159 and/or 90–99 160–179 and/or 100–109 180–209 and/or 110–119 ≥210 and/or ≥120 Follow-up recommended to confirm diagnosis and/or review response to treatment. may increase the risk of new onset diabetes. However. Recheck in one year. EFFECTIVE ANTIHYPERTENSIVE COMBINATION Effective combination Beta-blockers + diuretics Beta-blockers + CCBs CCBs + ACEIs/ARBs ACEIs + diuretics ARBs + diuretics Comments Benefits proven in the elderly. cost-effective.02. appropriate for concurrent CHD. evaluate within one week and treat when confirmed. if pharmacotherapy is clinically indicated Continue treatment and 3-6 monthly follow-up BP well controlled Review after 4-6 weeks BP uncontrolled (3 options) Increase the dose of initial drug Substitute with another class of drug Add another class of drug If BP is still >140/90 mmHg with the combination of three drugs at near maximal doses. Evaluate within one month and treat when confirmed. Confirm within two months and treat if medium. diabetes mellitus and stroke. If asymptomatic. BLOOD PRESSURE TREATMENT TARGETS Category Uncomplicated hypertension Hypertension in high risk groups: DM. consider resistant HPT Pharmacological management of Stage 2 hypertension Initiating therapy with the right combination of at least 2 drugs is recommended. Appropriate for concurrent heart failure and diabetes mellitus.Layout 1/14/10 3:50 PM Page 5 MANAGEMENT OF HYPERTENSION (3rd Edition) • QUICK REFERENCE FOR HEALTH CARE PROVIDERS PHARMACOLOGICAL MANAGEMENT OF STAGE 1 HYPERTENSION Start with a single drug at low dose. Relatively cheap. Appropriate for concurrent heart failure. History of CVD Diabetics with proteinuria of >1g/24 hours Target blood pressure (mmHg) <140/90 <130/80 <125/75 Once target BP is achieved. high or very high risks.

Layout 1/14/10 3:50 PM Page 6 MANAGEMENT OF HYPERTENSION (3rd Edition) • QUICK REFERENCE FOR HEALTH CARE PROVIDERS SEVERE HYPERTENSION Severe hypertension is defined as BP >180/110mm Hg (persistent elevation after 30 minutes bed rest) Possible clinical scenarios Asymptomatic severe HPT • Incidental findings • Non-specific symptoms like headache. subarachnoid haemorrhage. admit if compliance remains a problem Management • Initial treatment should aim for 25% reduction in BP over 24 hours but not lower than 160/90mm Hg • Combination therapy is often necessary (see table below) • Admit patient if BP remain >180/110mm Hg Management • All patient should be admitted • Aim to reduce BP by 25% over 3-12 hours but not lower than 160/90 mmHg • Best achieved with parenteral drugs Treatment options for hypertensive urgencies (oral) Drug Captopril Nifedipine Labetalol Dose 25mg 10–20mg 200–400mg Onset of action (hr) 0.5 0.g. lethargy Hypertensive urgencies • Pesents with grade III and IV retinal changes. repeating if necessary at 5 min intervals to a max of 200mg then 2mg/min IV) 5–100µg/min Onset of action (hr) Duration (hr) seconds ≤5 min 1 – 5 min 3 – 6 hrs Remarks Caution in renal failure Caution in heart failure Nitrates 2 – 5 min 3 – 5 min Preferred in acute coronary syndromes and acute pulmonary oedema Rapid reduction of BP (within minutes to hours) in asymptomatic severe HPT or hypertensive urgencies is best avoided as it may precipitate ischaemic events.0 Duration (hr) 6 3–5 6 Frequency (prn) 1 – 2 hrs 1 – 2 hrs 4 hrs Treatment options for hypertensive emergencies (parenteral) Drug Sodium nitroprusside Labetolol Dose 0. but no overt organ failure Hypertensive emergencies • Presents with symptoms and signs of TOC e. WHEN TO REFER • hypertensive urgency or emergency • suspected secondary hypertension • resistant hypertension • recent onset of TOC/TOD • pregnancy • children <18 years old 6 .02. acute heart failure. proteinuria ≥2+.5 2.25–10µg/kg/min IV bolus 50mg (over at least 1 min. acute coronary syndromes Management • Most can be managed as outpatient • Review existing drug regime and compliance • For newly-diagnosed. consider admission for evaluation • For established HPT. dizziness.

5mg OD 1 tablet BD 500mg OD 200mg OD 4 tablet OD 1. • ACEIs should be stopped if rise in creatinine >30% from baseline.02. 7 .5mg OD 2.5mg OD 2.5mg OD 5mg OD 2mg OD 2. start Labetolol with 50mg BD.5mg BD 1mg OD 100mg BD 12.5mg OD 10mg OD 10mg TDS 30mg OD 80mg BD 200mg OD 10mg OD 60mg TDS 90mg BD 10mg OD 20mg OD 30mg TDS 120mg OD 240mg TDS 200mg BD • Verapamil may reduce heart rate and use with care with Beta Blockers. Miscellaneous Prazosin (Alpha Blocker) Doxazosin Labetalol Carvedilol Methyldopa 0.Layout 1/14/10 3:50 PM Page 7 MANAGEMENT OF HYPERTENSION (3rd Edition) • QUICK REFERENCE FOR HEALTH CARE PROVIDERS ANTIHYPERTENSIVE AGENTS Formulation Diuretics Chlorothiazide Hydrochlorothiazide Amiloride/hydrochlorothiazide 5mg/50mg Indapamide SR Indapamide Triamterene/hydrochlorothiazide 50mg/25mg 250mg OD 25mg OD 1 tablet OD 1. • Used with care in patient with gout. ACE Inhibitors (ACEIs) Captopril Enalapril Lisinopril Perindopril Ramipril Quinapril 25mg BD 2.5mg OD 2.5mg OD 125mg BD 10mg BD 16mg OD 800mg TDS 50mg OD 1gm BD • Doxazosin is useful in patient with benign prostatic hypertrophy.5mg OD 2 tablet BD • Potassium should be closely monitored. • Potassium sparing diuretics may cause hyperkalemia if given with ACEIs/ARBs/renal insufficiency. • In elderly. Angiotensin Receptor Blockers (ARBs) Candesartan Irbesartan Losartan Telmisartan Valsartan Olmesartan 8mg OD 150mg OD 50mg OD 20mg OD 80mg OD 20mg OD 16mg OD 300mg OD 100mg OD 80mg OD 160mg OD 40mg OD • Contraindicated in pregnancy and bilateral renal artery stenosis.5mg OD 50mg TDS 20mg BD 80mg OD 8mg OD 10mg OD 40mg BD • Contraindicated in pregnancy and bilateral renal artery stenosis. Minimum dose Maximum dose Remarks Beta Blockers Atenolol Bisoprolol Metoprolol Propanolol 50mg OD 5mg OD 50mg BD 40mg BD 100mg OD 10mg OD 200mg BD 320mg BD • Contraindicated in patient with COAD. • Check serum creatinine before initiation and repeat 2 weeks after initiation. severe Peripheral Vascular Disease and heart block. Calcium Channel Blockers (CCBs) Amlodipine Diltiazem Diltiazem SR Felodipine Lercanidipine Nifedipine Nifedine SR Verapamil Verapamil CR 5mg OD 30mg TDS 90mg BD 2.

Block E1.Layout CHOICE OF ANTIHYPERTENSIVE AGENTS IN PATIENTS WITH CONCOMITANT CONDITIONS Diuretics ACEIs +++ +++ + + +++ +++ + + +++ ++$ + ++ + +* + +++ + + +@ ++ + + + + + + + + +/+/+ + ++* +/+ +/++ +++ + + ++ +++ + + ++ ++$ + + CCBs + ++ +/+/+ +++ + + ++ + +++ +++ + + + + +/+++# +++ +/+ +/+/Betablockers ARBs Peripheral Alphablockers Concomitant disease Diabetes mellitus (without nephropathy) 1/14/10 Diabetes mellitus (with nephropathy) Gout Dyslipidaemia 3:50 PM Coronary heart disease CPG Secretariat Health Technology Assessment Unit Medical Development Division Ministry of Health Malaysia Level 4.Use with care Contraindicated * Only non-dihydropyridine CCB # Metoprolol. Parcel E. Federal Government Administrative Complex 62590 Putrajaya Heart failure Asthma Page 8 MANAGEMENT OF HYPERTENSION (3rd Edition) • QUICK REFERENCE FOR HEALTH CARE PROVIDERS 8 Peripheral vascular disease Non-diabetic renal impairment Renal artery stenosis Elderly with no co-morbid conditions Tel: 603-8883 1245/6 email: htamalaysia@moh.my Very elderly (>80 years old) with no co-morbid conditions The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice +/.02. carvedilol – dose needs to be gradually titrated @ Current evidence available for amlodipine and felodipine only $ Contraindicated in bilateral renal artery stenosis .gov. bisoprolol.

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