These guidelines have been written to provide a straightforward approach to managing hypertension in the community. We have intended that this brief curriculum and set of recommendations be useful not only for primary care physicians and medical students, but for all professionals who work as hands-on practitioners.We are aware that there is a great variability in access to medical care among communities. Even in so-called wealthy countries, there are sizable communities in which economic, logistic, and geographic issues put constraints on medical care. And, at the same time, we are been reminded that even in countries with highly limited resources, medical leaders have assigned the highest priority to supporting their colleagues in confronting the growing toll of devastating strokes, cardiovascular events, and kidney failure caused by hypertension.Our goal has been to give sufficient information to enable healthcare practitioners, wherever they are located, to provide professional care for people with hypertension. All the same, we recognize that it will often not be possible to carry out all of our suggestions for clinical evaluation, tests, and therapies. Indeed, there are situations in which the most simple and empirical care for hypertensionsimply distributing whatever antihypertensive drugs might be available to people with high blood pressure -is better than doing nothing at all. We hope that we have allowed sufficient flexibility in this statement to enable responsible clinicians to devise workable plans for providing the best possible care of hypertension in their communities.We have divided this brief document into the following sections:1. General introduction 2. Epidemiology 3. Special issues with black patients (African ancestry) 4. How is hypertension defined? 5. How is hypertension classified? 6. Causes of hypertension 7. Making the diagnosis of hypertension 8. Evaluating the patient 9. Physical examination 10. Tests
These guidelines have been written to provide a straightforward approach to managing hypertension in the community. We have intended that this brief curriculum and set of recommendations be useful not only for primary care physicians and medical students, but for all professionals who work as hands-on practitioners.We are aware that there is great variability in access to medical care among communities. Even in so-called wealthy countries there are sizable communities in which economic, logistic, and geographic issues put constraints on medical care. And, at the same time, we are been reminded that even in countries with highly limited resources, medical leaders have assigned the highest priority to supporting their colleagues in confronting the growing toll of devastating strokes, cardiovascular events, and kidney failure caused by hypertension.Our goal has been to give sufficient information to enable health care practitioners, wherever they are located, to provide professional care for people with hypertension. All the same, we recognize that it will often not be possible to carry out all of our suggestions for clinical evaluation, tests, and therapies. Indeed, there are situations where the most simple and empirical care for hypertension-simply distributing whatever antihypertensive drugs might be available to people with high blood pressure-is better than doing nothing at all. We hope that we have allowed sufficient flexibility in this statement to enable responsible clinicians to devise workable plans for providing the best possible care for patients with hypertension in their communities.We have divided this brief document into the following sections:
Increased blood pressure (BP) is the leading risk factor for death and disability globally, 1 with more than 40% of the adult population older than 25 years having hypertension.2 Although much of hypertension is preventable, especially by reducing the amount of salt added to foods, hypertension treatment can also prevent the adverse consequences of stroke, heart attack, and heart and kidney failure.2 Unfortunately, about half of patients with hypertension remain undiagnosed. Hence, the World Hypertension League has made the increase in regular BP assessments and encouragement of widespread BP screening programs linked to diagnosis and clinical management of hypertension to be among the highest of priorities.Whether in low-, middle-, or high-resource settings, recommendations for BP assessment are consistent and include a standardized approach to pre-measurement preparation, patient positioning, appropriate cuff selection and placement, measurement technique, and use of accurate BP-measuring devices.4-9 For BP-measuring devices, there is typically a choice between manual devices using the auscultatory technique and either semi-automated (manual inflation) or fully automated (automated inflation) devices using oscillometry.
On the fourth anniversary, it is impossible to discuss hypertension in Haiti without acknowledging the almost incalculable negative impact of the January 12, 2010 earthquake. It was catastrophic not only in terms of death and physical injury, but also the widespread destruction of a tenuous infrastructure and public health system. Yet, paradoxically, this virtual blank slate could be an opportunity to develop an innovative pragmatic approach to the equally devastating problem of hypertension as the most common contributing cause of death in Haiti. Rising Phoenix‐like literally from the ashes and rubble, there are lessons to be learned from the Haiti experience, as a potential model for the management of hypertension in the community in low resource venues in the Caribbean and beyond. Haiti has very poor comparative outcomes, and specific challenges related to high prevalence stroke, renal failure, and heart failure as negative prognostic consequences of undiagnosed and uncontrolled hypertension. There are severe public health challenges related to salt education, as well as societal challenges related to negative social determinants of health and disease, and the structural violence of overwhelming poverty. Pragmatism is necessary as we attempt to combine the tenets of evidence based medicine with reality based medicine restrictions imposed by low resource. It is through the generation of Best Possible Practice (BPP) models of care that colleagues can develop systems of mutual knowledge sharing, service, and support. This approach extends to screening and diagnosis, where there is no electricity for semi‐ or automatic manometric devices and requisite need to train in manual/ auscultatory technique, to education and curricula built specifically around a flexible hypertension community management guideline as the accepted standard to aspire to. A successful approach requires solid guiding principles, including a commitment to best attainable quality and value(s). It also requires standing together as a community of dedicated medical professionals.
Hypertension is one of the most important risk factors for cardiovascular disease. The Global Burden of Disease Study in 2010 described hypertension as the leading risk factor for global disease burden, accounting for 18% of all deaths and 7% of global disabilityadjusted life years.1 Furthermore, hypertension is responsible for 45% of deaths caused by ischemic heart disease and 51% of deaths caused by stroke. As the leading risk for death and disability, hypertension requires a global response. Reducing uncontrolled blood pressure (BP) by 25% is one of nine United Nations targets to reduce noncommunicable diseases (NCDs) by 2025. 3 To that end, hypertension was the feature of World Health Day in 2013.2 The effort to reduce uncontrolled BP is based on two distinct, but integrated, approaches. One is to lower population BP through efforts such as reducing the amount of salt consumed, and the other is to identify people at risk for vascular disease and to clinically manage their hypertension to reduce global cardiovascular risk. 4 The task of clinically managing increased BP globally is daunting. In 2008, 40% of the global population older than 25 years had hypertension, representing approximately 1 billion people. 5 Further, the burden of hypertension is greatest where resources are the lowest. For example, the African region has a hypertension prevalence rate of 46% in adults older than 25 years, compared with the Americas, which have a prevalence rate of 35%. 4 In Haiti, the prevalence rate of hypertension in men and women older than 40 years is 69.1% and 67.2%, respectfully.7 Despite the high burden, awareness, and treatment, control rates are suboptimal in most developing countries, which are disproportionately impacted by hypertension. This also underlines the "know-do gap" in terms of transfer of evidence to policy and practice.Simplistically, the sequential steps to the clinical management of hypertension are: (1) the identification of people whose BP is high; (2) behavioral lifestyle counseling; (3) assessing vascular risk to identify those in whom pharmacologic interventions are cost-effective; (4) prescribing the indicated pharmacologic therapies to reduce vascular risk; and (5) titrating pharmacologic and lifestyle behavior therapy to achieve recommended risk target levels. 8,9 In most low-resource settings (LRS), the current major initial barrier is the identification of people whose BP is high.
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