INTRODUCTION AND

OVERVIEW
 PRESENTATION OUTLINE
● Epidemiology of Hypertension

● Definition

● Measurement of Blood Pressure

● Diagnosis & Classification

● Evaluation & Assessment

● Management Algorithm

● Cardiovascular Risks Stratification

● Therapeutic Lifestyle Modification

● Pharmacological Agents

● The Wagner Chronic Care Model

● Key messages
GLOBAL BURDEN OF HYPERTENSION

An estimated 1.4 billion individuals worldwide suffer from

hypertension in the year 2019

Egan BM et al. Global burden of hypertension. J Hypertens 2019; 37(6):1148-1153

 Hypertension is the leading cause
of death worldwide

Ezzati et al. N Engl J Med. 2013;369:954-964.

 Deaths attributable to risk factors in Malaysia

Poor Water & Sanitation 0.1% 0.1%

Underweight 0.2% 0.2%

Alcohol 2.3% 0.3%

Physical Inactivity 5.0% 7.1%

High BMI 7.0% 8.2%

High Cholesterol 7.3% 8.1%

Diabetes Mellitus 8.5% 9.1%

Tobacco 15.7% 1.2%

High BP 19.4% 22.8%

25% 20% 15% 10% 5% 0% 5% 10% 15% 20% 25%

Burden of Disease Study Malaysia 2008, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health
Male Female
 How are we doing ?-
National Health Morbidity Surveys
( NUR LIANA AB. Majid JHH 2018 )

1996 2006 2011 2015

Prevalence 34.6% 33.6% 35.3%

( >18 years )

Prevalence 32.9% 44.6% 43.8% 44.7%

( > 30 years )

Aware 33% 35.6% 40.7% 37.5%

 How are we doing ?-
National Health Morbidity Surveys
( NUR LIANA AB. Majid JHH 2018 )

1996 2006 2011 2015

Prevalence 34.6% 33.6% 35.3%

( >18 years )

Prevalence 32.9% 44.6% 43.8% 44.7%

( > 30 years )

Aware 33% 35.6% 40.7% 37.5%

Treated 64.1 % 78.9% 77.5% 83.2%

Control 26.1% 27.5% 34.3% 37.4%

 DEFINITION Remain unchanged
Hypertension is defined as
persistent elevation of systolic BP
of 140 mmHg or greater and/or
diastolic BP of 90 mmHg or
greater, taken at least twice on
two separate occasions
DIAGNOSIS & CLASSIFICATION
EVALUATION
INITIAL ASSESSMENT
 Measurement of Blood Pressure
1. Electronic devices

● If electronic BP set is used, it must be

Only models
confirmed by mercury sphygmomanometer
validated by
in patients with cardiac illness, professional
bodies
atherosclerosis, renal disease and in (www.bhsoc.org,
children. www.aami.org)
should
2. Automated ambulatory BP devices be used.
3. Aneroid sphygmomanometer

4. Mercury column sphygmomanometer

● Gold standard but largely replaced by electronic devices due to environmental and health concerns
 MEDICAL HISTORY
• duration and level of elevated BP if known
• symptoms of secondary causes of hypertension
• symptoms of target organ complications, e.g. renal impairment and heart failure
• symptoms of cardiovascular disease e.g CHD and cerebrovascular disease
• symptoms of concomitant disease that will affect prognosis or treatment, e.g.
diabetes mellitus, heart failure renal disease and gout
• family history of hypertension, CHD, stroke, diabetes, renal disease or
dyslipidaemia
• dietary history including salt, fat, caffeine and alcohol intake
• drug history of either prescribed or over-the-counter medication (NSAIDS, nasal
decongestants,OCP/HRT )
• exposure to traditional or complementary medicine
• lifestyle and environmental factors that will affect treatment and outcome, e.g.
smoking, physical inactivity, substance abuse; recreational and doping, psychosocial
stressors and excessive weight gain
• presence of snoring and/or day time somnolence which may indicate sleep
apnoea
 PHYSICAL EXAMINATIONS
• general examination: height, weight and waist circumference
• two or more BP measurements separated by at least 1 minute,
with sitting and standing BP for the elderly
• fundoscopy
• look for carotid bruit, abdominal bruit, presence of peripheral
pulses and radio-femoral delay
• cardiac examination
• chest examination for evidence of cardiac failure
• abdominal examination for renal masses/ bruit and aortic
aneurysm
• neurological examination to look for evidence of stroke
• signs of endocrine disorders, e.g. Cushing syndrome,
acromegaly and thyroid disease
MINIMUM INITIAL INVESTIGATIONS

• Full blood count

• Blood Glucose
• Renal Function Test
• Lipid Profile
• Uric Acid
• Urinalysis
• ECG
Coexisting Cardiovascular Risk Factors for
Risk Stratification

• Diabetes Mellitus
• Dyslipidaemia (TC > 6.5mmol/L)
• Smoking status
• Microalbuminuria
• Estimated GFR < 60mL/min/m2 (CKD)
• Family history of premature CV disease
(Male < 55 y/o; Female < 65 y/o)
Secondary Causes of Hypertension
• Parenchymal kidney disease
• Renovascular disease
• Sleep apnoea
• Primary aldosteronism
• Drug induced or drug - related
• Cushing syndrome
• Phaeochromocytoma
• Acromegaly
• Thyroid disease
• Parathyroid disease
• Coarctation of the aorta
• Takayasu Arteritis
TARGET ORGAN DAMAGE &
COMPLICATIONS
Risk Stratification
Algorithm for the Management of Hypertension
Healthy Living
Healthy Living
CHOICE OF FIRST LINE MONOTHERAPY

Choose monotherapy in patients with

stage 1 hypertension and with no
compelling indications from one of the 5
classes of drugs ( ACEIs, ARBs, Beta
Blockers , CCBs or Diuretics ) based on
patients' individual clinical profile
Antihypertensive agents
Antihypertensive agents
 Blood Pressure Targets
CATEGORY BLOOD
PRESSURE
TARGETS
For all < 140/90 mmHg

Diabetic < 140/80 mmHg

High/ very High Risk diabetic, < 130/80 mmHg

Lacunar stroke,
LVH, CKD with Proteinuria > 1g/
day
Choice of Anti- Hypertensive Drugs in Patients
with Concomitant Conditions
Effective Combination Therapy
Effective Combination Therapy Used in
Outcome Trials
 RESISTANT HYPERTENSION
If BP is still >140/90 mmHg with combination of 3 drugs (including a diuretic at near
maximal doses) it is by definition Resistant Hypertension

Before labeling a patient as having resistant hypertension exclude

● Inappropriately measured BP

● Non- adherence to medication

● Office Resistant hypertension

● Inappropriate combination and doses of drugs prescribed

● Intake of any substances which may antagonise the hypertensive effects of drugs taken ( eg NSAIDS,
sympathomimetics, liquorice, oral contraceptives, corticosteroids )
RESISTANT HYPERTENSION
Once Resistant Hypertension has been established

● exclude secondary hypertension ( Commonest OSA )

● re emphasise on non pharmacological approaches
● add spironolactone as the 4th drug ( provided renal function is
intact )
● add a 5th drug if is still not controlled on 4 drugs
( Choice of 5th drug include a beta blocker, an alpha

blocker or a centrally acting drug )

 REFRACTORY HYPERTENSION

Patients whose BP are not controlled after taking > 5 anti

hypertensives are by definition having

Refractory Hypertension

Both resistant and refractory

hypertensives , are candidates for device-
based intervention
* Hypertensive urgency - If patient has vague symptoms,
grade III / IV retinopathy and proteinuria

* Asymptomatic severe hypertension - If patient has no

symptoms, no TOD (proteinuria, retinopathy): can treat as
outpatient, start combination treatment, TCA one week
 Management of Hypertensive Urgency
( Severe hypertension with non-specific symptoms )
 Management of Hypertensive Emergency
( Severe hypertension with acute target organ damage )
KEY LEARNING POINTS

2. In 2015, prevalence of HPT in Malaysia

was 44.7% among those > 30 years years

3. HPT is a silent disease , 62.5%   of the cases

remained undiagnosed. Therefore  BP should be
measured at every chance encounter

5. A SBP of 130-139mmHg and/or  DBP of 85-89

mmHg is defined as ' At Risk BP' an should be treated
in certain risk groups
KEY LEARNING POINTS
6. Healthy Living should be recommended for
all individuals with HPT and At Risk BP

8. In patients with newly diagnosed

uncomplicated HPT who have no compelling
indications, choice of first line monotherapy
include ACEIs, ARBs, BBs, CCBs and
Diuretics
9. Only 37.4% of treated patients achieve
target BP

in Stage 2 and some risk category in Stage 1

 THE ROLE OF
CHRONIC CARE MODEL
IN HYPERTENSION MANAGEMENT
 THE CHRONIC CARE MODEL

6 1
4 2 3 5

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1. ORGANISATION OF HEALTH CARE
A system seeking to improve
chronic disease care must be
motivated and prepared for
change throughout the
organization from the micro,
meso and macro levels

Create policies and allocate resources with a clear focus to

improve delivery of care for patients with hypertension
 2. DELIVERY SYSTEM DESIGN
Utilising multidisciplinary
healthcare team to transform
a system that is essentially
reactive (responding mainly
when a person is sick) to one
that is proactive and focused
on keeping a person as
healthy as possible

Multi-disciplinary practice team with

clear division of labour - planned
management and follow-up
 3. DECISION SUPPORT

Promote clinical care that

is consistent with up-to-
date scientific evidence and
patient preferences

Translate evidence based clinical practice guideline

recommendation into daily clinical practice
4. SELF-MANAGEMENT SUPPORT
Emphasize on the patients’
central role as active
partners in managing their
health through
empowerment and
motivation

Empower patients with knowledge and skills to enhance confidence to

self-care. Build quality relationship through effective communication.
 5. CLINICAL INFORMATION SYSTEM

Organize patients and

population data to facilitate
efficient and effective chronic
disease care

Computerized system to remind &

prompt actions; support shared care
among multiple professionals, provide
feedback to healthcare personnel, track
progress and defaulters
 6. COMMUNITY RESOURCES

Mobilize community
resources to meet the needs
of patients

Patients & care providers need linkages with community

resources such as home care, exercise program and support
groups.
 Decision Support Tool Clinical Informed,
Information Empowered
System Patient

Prepared &
Proactive Productive Interactions
Doctor and
NCD Team

Self-
Management
Support Tool

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 EVIDENCE SUPPORTING THE
CHRONIC CARE MODEL
● CCM has been shown to improve quality of
care and outcomes for various chronic
conditions including hypertension
● Of the 77 papers which met the inclusion
criteria, 75 papers reported improvements to
healthcare practice or health outcomes for
people living with chronic disease.
● The most commonly used elements of the
CCM were self-management support and
delivery system design.

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CHRONIC CARE MODEL IN
MALAYSIA

49
A cross-sectional survey to assess the feasibility to implement the components of Chronic
Care Model (CCM) in the public primary care clinics
 Majority of the clinics were already equipped with core resources to implement the CCM

 Majority of the clinics have adequate multidisciplinary staff who were willing to be trained
and were committed to improve patient care

 Therefore, implementation of the essential components of the CCM was feasible, despite
various constraints
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CHRONIC CARE MODEL IN
MALAYSIA

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CHRONIC CARE MODEL IN
MALAYSIA

52
KEY PRACTICE POINTS
1. Produce a prepared, proactive health care
team to manage chronic conditions

2. Create effective clinical information

systems e.g. disease registry,
comprehensive medical records

3. Translate CPG recommendations into daily

clinical practice

4. Empower patients to self-manage their

conditions

5. Perform continuous quality improvement activities

e.g. Clinical Audit
THANK YOU