Magnitude of the Problem

·            Hypertension is a major health problem in Egypt with a prevalence rate of 26.3%
            among the adult population (> 25 years)¹. Its prevalence increases with aging,
            approximately 50% of Egyptians above the age of 60 years suffer from hypertension.
            About seven million Egyptians had high blood pressure in the year 1993.

·            Risks of hypertension include cardiovascular complications (heart failure, myocardial
            infarction, atrial fibrillation, aneurysms, dissection), renal (azotemia) and
            cerebrovascular (stroke, transient ischemic attacks "TIA", dementia), resulting in
            disability and premature death. These risks can be reversed by treatment and
            control of hypertension.

·            Hypertension is poorly managed in Egyptians. The rates of awareness, treatment and
            control are low. Only 8% of hypertensive Egyptians have their blood pressure
            controlled¹.

National Guidelines for Developing Countries

·            Hypertension guidelines from rich industrial countries may not be applicable in
            developing and economically disadvantaged communities.

·            Poverty, high illiteracy rate, inadequate health care system with limited access
            to medical insurance will limit hypertensive patient's care to the minimal acceptable
            level rather than the ideal or optimal western care recommended in international
            guidelines.

·            Racial, genetic, life style and environmental differences between white Caucasian
            and black, dark or Asian populations will influence the hypertension mechanisms²,
            humoral profile^3,4, type and extent of complications^5,6 (renal failure and stroke
            more common in blacks). Also, response to dietary therapy^7,8 (low salt, rich fruit
            and vegetable diet), and antihypertensive drugs (less control with ACE-inhibitors
            and beta adrenergic blockers in blacks)^9,10 varies.

·            Risk factors for hypertension and atherosclerotic cardiovascular disease such as
            obesity, excess dietary salt intake, diabetes and cigarette smoking are particularly
            prevalent among Egyptians¹¹.

·            Compared to developed countries, hypertensive population in the developing
            world includes a large proportion of young and middle aged individuals because
            of the younger mean age¹.

Minimal versus Optimal Care

·            Resources more than science dictate the type of care that can be provided. Limited
            resources and economic factors will influence the level of management.

·            Guidelines have to make a compromise between what is possible (minimal care) and
            what is ideal (optimal care), see tables 1, 2. This will have an impact on evaluation
            (getting the required information with the least expensive methods- relying more on
            detailed history and  physical examination) and on the initiation and type of therapy
            (stressing dietary therapy, life style, use of less expensive drugs, and initiating
            therapy at higher thresholds of blood pressure).

·            Even a small reduction in blood pressure is worthwhile if absolute targets prove
            difficult to achieve.

Table 1. Evaluation of Hypertensive Patients

	Minimal Care	Optimal Care
Detailed History- Physical Exam.	+++	++
Urine dipstick	+	+
Blood Sugar	+	+
ECG	+	+
Blood tests: urea, creatinine, lipid profile, K+	-	+
Optic Fundus	-	+

+++: strongly recommended.            +: recommended.                               - : not done

+: done if facilities are available.

Table 2. Therapy

	Minimal Care	Optimal Care
Duration of blood pressure monitoring before starting drug therapy	Weeks to months	Weeks to months
Life style and diet therapy	+++	++
Threshold Blood Pressure       Low risk group       Intermediate risk group       High risk group
	160/100	160/100
	150/90	140/90
	140/85	135/85
Drug of first choice	Small dose thiazide	Individualize
Target Blood Pressure       Low & intermediate risk groups       High risk group	< 140/90 < 135/85	< 140/90 < 135/85

Definition and Classification

·            Levels of blood pressure 140 mmHg or more systolic and 90 mmHg or more
            diastolic represent the cut points for the current definition of hypertension.

·            The following WHO/ISH classification of the levels of blood pressure (table 3) is
            recommended¹².

Table 3. Classification of Blood Pressure Levels

Category	Systolic	Diastolic
Optimal	<120	< 80
Normal	<130	<85
High-normal	130-139	85-89
Grade 1 (Mild Hypertension)	140-159	90-99
Grade 2 (Moderate Hypertension)	160-179	100-109
Grade 3 (Severe Hypertension)	> 180	> 110
Isolated Systolic Hypertension	> 140	<90

Diagnosis of Hypertension

·            Persistent elevation of systolic blood pressure above 140 mmHg and/or diastolic
            blood pressure above 90 mmHg on at least five repeated blood pressure
            measurements in five office visits over a period varying from days to months is
            required to make a diagnosis of hypertension. The frequency of visits and period
            of blood pressure monitoring will be dictated by the severity of hypertension
            and cardiovascular risk profile. Three visits are enough if the blood pressure
            is persistently above 160/100 mmHg or if target organ damage (TOD) is present.

·            Failure to measure blood pressure accurately using a standardized technique
            and failure to realize the variable nature of blood pressure and office induced
            hypertension (white coat effect) will misclassify individuals. Levels of blood
            pressure measured at home or during daytime ambulatory recording should
            be less than 135/85 mmHg.

Blood Pressure Measurement

·            Use a calibrated, well maintained machine (mercury or aneroid).

·            Examination done in a quiet room after five minutes rest in a relaxed position,
            avoiding talking, full bladder and withholding for  two hours tobacco, eating
            and coffee.

·            Use the appropriate cuff size, following a standardized measurement technique¹³,
            record the blood  pressure to the nearest 2 mmHg in at least two measurements,
            take the lower reading.Use phase V (disappearance of sounds) for diastolic
            blood pressure.

Evaluation

·            Assess cardiovascular risk and target organ damage (TOD) through a careful detailed
            history and physical examination with a detailed questioning about current medications.
            Body weight should be checked on each office visit.

·            Urine dipstick analysis should be done in all patients and if possible blood sugar,
            and a standard 12  lead ECG.

·            If blood testing facilities are available examine blood for urea, creatinine, potassium,
            hemoglobin, total cholesterol, HDL and LDL cholesterol and triglycerides.

·            Echocardiography is not a part of the routine evaluation.

·            An underlying cause (secondary hypertension) is suspected when hypertension is
            difficult to control (in spite of triple drug therapy), or if it is severe and of sudden
            onset particularly in a young subject or above the age of 60 years or if there is
            rapid deterioration in kidney function. Referral to specialized facilities is needed in 
            these conditions.

Risk Categorization

·            Prognosis in hypertensive patients is highly variable depending largely on factors other
            than blood pressure such as sex, age, other risk factors, TOD, or history of
            cardiovascular disease¹⁴. Cardiovascular risk can vary more than ten folds at a
            given blood pressure level¹⁵.

·            Hypertensive patients can be categorized according to their risk profile
            (adopted from JNC VI)¹⁶.

Group A (low risk): no TOD, no other risk factors and no associated

cardiovascular disease.

Group B (intermediate risk): one or more additional risk factors but not

diabetes or TOD (table 4).

Group C (high risk): diabetes, TOD and/or associated cardiovascular

disease (table 5).

Table 4. Cardiovascular Risk Factors

- Male gender.

- Age > 65 years.

- Current cigarette smoking.

- Diabetes.

- Total S- Cholesterol >240 mg/dl, HDL-C<40 mg/dl or LDL-C >160 mg/dl

-    Positive family history: atherosclerotic cardiovascular disease in first degree relative before the age of 40 years in males and 50 years in females.

Table 5. Target Organ Damage and Associated Atherosclerotic  Diseases  

- Left ventricular hypertrophy: by clinical, ECG, or echo.

- Heart failure: clinical manifestations.

- Coronary disease: angina, myocardial infarction, history of CABG or PCI.

- Renal disease: serum creatinine >1.8 mg/dl, proteinuria.

- Cerebrovascular disease: stroke, TIA, dementia.

- Peripheral arterial disease.

- Abdominal aortic aneurysm.

- More than grade 1 optic fundus retinopathy.

Life Style Modification

·            Recommended in all hypertensive patients and should be the initial therapeutic
            approach in mild hypertension.

·            Limit calorie intake in overweight individuals (BMI > 25 kg/m²) aiming at a
            weight reduction of 5 Kg.

·            Limit salt (sodium chloride) intake to less than 6 gm/day.

·            Encourage fruits and vegetables consumption (6-8 portions/day).

·            Limit intake of total and saturated fats, encourage fish and fat free dairy products.

·            Increase physical activity by regular exercise e.g. 30 minutes brisk walk/day.

·            Combined diet, exercise and weight control may limit the need to drug therapy,
            allow step down or even discontinuation¹⁷.

·            Limit alcohol intake and stop cigarette smoking.

Initiation and Monitoring of Drug Therapy

·            Unless there is an emergency or blood pressure > 210/120 mmHg, no drug
            treatment should be instituted during the first two office  visits so as to rule
            out the presence of "white coat" hypertension.

·            Duration of blood pressure monitoring before initiating drug therapy varies
            depending upon blood pressure level, risk profile and response to life style
            modification.

·            Threshold for antihypertensive drug treatment is 160/100 mmHg in low
            risk group, 140-150/90 mmHg for intermediate risk group and 135-140/85
            mmHg in high risk group.The previous blood pressure cut points are the
            average of blood pressure readings taken on three separate office visits at
            least one week apart.

·            Start with a small dose of thiazide diuretics in all patients with mild to
            moderate hypertension unless they are contraindicated or there are specific
            indications for other agents.

·            In absence of adequate blood pressure response (fall in systolic blood
            pressure by 10 mmHg and diastolic blood pressure by 5 mmHg) after one to
            two months of drug therapy, add another drug from a different pharmacologic
            group or use single dose combination.

·            Treatment and follow-up should continue indefinitely.

·            Recheck blood pressure at one to two monthly intervals until blood pressure
            remains at target level for two consecutive visits  then recheck at 3 to 6 month
            intervals depending upon the risk profile.

·            Antihypertensive drugs require a period of up to two months to achieve their
            maximal hypotensive effect¹⁸. Do not change drugs at short intervals.

Hypertension Associated with Target Organ Damage

·            Treatment should be more aggressive in this group aiming at a target blood pressure
            less than 135/85 mmHg and initiated after a shorter monitoring period
            (two to four weeks).

·            Drugs of first choice depend upon TOD:

          -            Renal disease: ACE-inhibitors or angiotensin receptor blockers (ARBs)+
                      thiazide diuretics (loop diuretic if serum creatinine is above 2.5 mg/dl).

          -            Cerebrovascular disease: reduce the blood pressure after the acute phase of
                        stroke by thiazide diuretic, and if necessary ACE- inhibitors, ARBs or
                        Ca antagonist. Urgent blood pressure lowering is recommended in cerebral
                        infarction if blood pressure is 220/120 mmHg or greater (180/105
                        mmHg in patients with cerebral hemorrhage).
                        Do not lower mean blood pressure by more than 25% in the first two hours
                        , then toward 160/100 mmHg within the next six hours.

          -            Coronary disease: beta adrenergic blockers, ACE-inhibitors and if necessary
                        Calcium  antagonists.

          -            Heart failure: ACE-inhibitors + thiazide diuretics.

Hypertension in Special Groups

·            Elderly: start with small dose of thiazide diuretics and add calcuim antagonists or
            ARBs if necessary. Check blood pressure always in the supine and standing
            positions. Be aware of the marked fluctuations in blood pressure, the auscultatory
            gap when measuring blood pressure and the frequent comorbid conditions.

·            Diabetes mellitus: initiate drug therapy within days after confirming the diagnosis of
            hypertension aiming at a target blood pressure of less than 140/85 mmHg, and even
            lower levels in presence of proteinuria. Start with ACE-inhibitors and add thiazide
            diuretics, calcium antagonists, beta blockers or ARBs if necessary. In presence of
            protenuria ARBs may replace ACE-inhibitors as initial therapy.

Compliance

·            Non compliance is probably the major cause of failure to control hypertension.

·            Measures to improve compliance include patient education, use of less expensive
            medications, single daily dosage, fixed dose drug combination, continuous monitoring
            by spouse, nurse or doctor and home blood pressure self measurement.

Implementation Strategies

·            Adoption of the guidelines by government agencies as the standard of care to be
            followed by physicians.

·            Increase physician's awareness: printed material, seminars and meetings.

·            Educational sessions with local opinion leaders nationwide.

·            Reminder system and audit with feedback if available.

References

1. Ibrahim MM, Rizk H, Apple LJ, et al. For the NHP investigation team. Hypertension,
   prevalence, awareness, treatment and control in Egypt. Results from the Egyptian
   National hypertension Project (NHP). Hypertension 1995; 26:880.
2. Rockstroh J.K., Schmieder RE, Schlaich MP, et al. Renal and systemic hemodynamics
   in black and white hypertensive patients. Am J Hypertens 1997; 10:971.
3. Savage DD, Watkins LO, Grim CE, Kumanyika SK. Hypertension in black populations.
   In Laragh JH, Brenner BM (eds). Hypertension: Pathophysiology, Diagnosis and management,
   1^st edu. Raven Press, Ltd: New York, 1990, pp 1837-1852.
4. Weissberg PL, Woods KL, West MJ, Beevers DG. Genetic and ethnic influences on the
   distribution of sodium and potassium in normotensive and hypertensive subjects.
   J Clin Hypertens 1987; 3:20.
5. Schmieder RE, Rockstroh JK, Luchters G, et al. Comparison of early target organ damage
   between blacks and whites with mild systemic arterial hypertension. Am J Cardial 1997; 79:1695
6. Klagg ML, Whelton PK, Randall BL et al. End-stage renal disease in African American and white
   men: 16 year MRFIT findings. JAMA 1997; 227:1293.
7. Appel LJ, Moor TJ, Obarzanek E, et al. for the DASH Collaborative Research Group. A clinical
   trial of the effects of dietary patterns on blood pressure. N Engl J Med. 1997; 336:1117.
8. Sacks FM, Svetkey LP, Vollmer WM, et al. For the DASH-Sodium Collaborative Research Group.
   Effects on blood pressure of reduced dietary sodium and the Dietary Approach to Stop
   Hypertension (DASH) diet.  N Engl J Med 2001; 334:3.
9. Parag KB, Seedat YK. Do angiotensin-converting enzyme inhibitors work in black hypertensives?
   A review. J Hum Hypertens 1990; 4: 450.
10. Seedat YK. Varying responses to hypotensive agents in different racial groups: black versus white
    differences. J Hypertens 1989; 7:515.
11. Ibrahim MM, Appel LJ, Rizk HH et al. Cardiovascular risk factors in normotensive and hypertensive
    Egyptians. J Hypertens 2001; 19: 1993.
12. Chalmers J, MacMahons, Mancia G, et al. WHO-ISH Hypertension Guidelines Committee. 1999
    World Health Organization. International Society of Hypertension Guidelines for the Management
    of Hypertension. J Hypertens 1999; 17:151.
13. Perloff D, Grim C, Flock J, et al. Human blood pressure determination by sphygmomanometry.
    Circulation 1993; 88: 2460.
14. Kannel WB. Blood pressure as a cardiovascular risk factor. JAMA 1996;275:1571.
15. Kannel WB. Risk stratification in hypertension: New insights from the Framingham Study.
    Am J Hypertens 2000; 13:35.
16. Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.
    The Sixth Report. Arch Intern Med 1997; 157:2413.
17. Miller ER, Erlinger TM, Young DR et al. Results of the Diet, Exercise and Weight Loss Intervention
    Trial (DEW-IT). Hypertension 2002; 40:612.
18. Ibrahim MM, Mossallam R. Clinical evaluation of atenolol in hypertensive patients. Circulation 1981; 64:368.

	Journal | Newsletter | Books | Guidelines |