1999 WHO-ISHHypertension Practice Guidelines
for Primary Care Physicians
World Health OrganizationINTERNATIONAL SOCIETY OF HYPERTENSION
21999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Working Group: Practice Guidelines
John Chalmers (Australia, Chairman)
Paul Chusid (USA)
Jay N Cohn (USA)
Lars H Lindholm (Sweden, Writing Coordinator)
Ingrid Martin (WHO, Switzerland)
Karl-Heinz Rahn (ISH, Germany)
Peter Sleight (WHL, UK)
31999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
WHO-ISH HypertensionGuidelines Subcommittee
Michael Alderman (USA)Kikuo Arakawa (Japan)Lawrie Beilin (Australia)John Chalmers
(Australia, Chairman)Serap Erdine (Turkey)Masatoshi Fujishima (Japan)Pavel Hamet (Canada)Lennart Hansson (Sweden)Lewis Landsberg (USA)Frans Leenen (Canada)Lars H Lindholm (Sweden)
Liu Lisheng (China)AFB Mabadeje (Nigeria)Stephen MacMahon (Australia)Giuseppe Mancia (Italy)Ingrid Martin (Switzerland)Albert Mimran (France)Karl-Heinz Rahn (Germany)Arturo Ribeiro (Brazil)Peter Sleight (UK)Judith Whitworth (Australia)Alberto Zanchetti (Italy)
The WHO-ISH Guidelines are written for a global audience from communities that vary widely in the nature of their health system and in the availability of resources.
The goal, however, remains universally the same, that is to lower BP and other risk factors in order to reduce the risk of CVD.
41999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
What is the Goalof the Practice Guidelines?
To lower blood pressure (BP) and other risk factors in order to reduce the risk of cardiovascular disease (CVD)
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71999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Why is Hypertension Management Needed? (1)
• 600 million hypertensives in the world
• 3 million die annually as a direct result of hypertension
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Why is Hypertension Management Needed? (2)
The Rule of Halves• Only 1/2 have been diagnosed
• Only 1/2 of those diagnosed have been treated
• Only 1/2 of those treated are adequately controlled
• Thus, only 12.5% overall are adequately controlled
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What is New?1999 WHO-ISH 1993 WHO-ISH JNC-VI
Definition of > 140/90 >140/90 >140/90hypertension
Levels Grade 1,2,3 Mild, Moderate, Stage 1,2,3Severe
Decision Not based on BP BPto treat BP alone, but
assessment oftotal CV risk
Target BPs <130/85 <130/80 <140/90<140/90 (elderly) <140/90 (elderly)
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What is New?
1999 WHO-ISH 1993 WHO-ISH JNC-VI
Suitable first-line 6 drug 5 drug 2-3 drugdrug therapy classes classes classes
Combination Low dose Low dosetherapy combinations combinations
recommended if may be used tomonotherapy initiate therapyinadequate
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Why BP <130/85 mm Hgand Not <140/90 mm Hg? (1)
• The relationship between CV risk and BP is continuous
• Today, more than 50% of all hypertensives have BP >160/90 mm Hg and 75% have BP >140/90
• The major determinant of the risk reduction conferred by antihypertensive therapy is the BP level attained
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Why BP <130/85 mm Hgand Not <140/90 mm Hg? (2)
• In diabetics, there is a clear benefit of lowering BP <85 mm Hg
• The HOT Study showed that lowering BP < 85 mm Hg did not increase CV risk
• The goal should be to attain normal BP (<130/85 mm Hg)
Questions to be Answered (1)• What is high blood pressure?
• Clinical evaluation - what should be done?
• Which factors influence prognosis?
• Do patients benefit from antihypertensive treatment?
• How should hypertension be managed?
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Questions to be Answered (2)• Which drug treatments should be used?
• What treatment goal should be set and how should patients be followed up?
• How should hypertension during pregnancy be handled?
• How should hypertension in Type-2 diabetics be handled?
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151999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
What is High Blood Pressure?
• BP levels are continuously related to the risk of CVD
• Definition of hypertension or raised BP is arbitrary
• Even within the normotensive range, people with the lowest BP levels have the lowest rates of CVD
Relative Risk of CHD and Stroke in Relation to Patient’s Usual Diastolic BP
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New (1999) WHO-ISH Definitionsand Classification of BP Levels
Category Systolic BP Diastolic BP(mm Hg) (mm Hg)
Optimal BP <120 <80Normal BP <130 <85High-Normal 130-139 85-89
Grade 1 Hypertension (mild) 140-159 90-99 Subgroup: Borderline 140-149 90-94Grade 2 Hypertension (moderate) 160-179 100-109Grade 3 Hypertension (severe) >180 >110
Isolated Systolic Hypertension >140 <90 Subgroup: Borderline 140-149 <90
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Clinical Evaluation - What Should Be Done?
• Confirm elevation of BP
• Exclude or identify secondary causes of hypertension
• Determine presence of target organ damage and quantify extent
• Search for other CV risk factors and clinical conditions that may influence prognosis and treatment
How to Record BP (1)
Measure BP several times on separate occasions with the patient in sitting position
Use a mercury sphygmomanometer or other non-invasive device
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How to Record BP (2)Measure BP several times on several occasionsAllow the patient to sit for several minutes before measuring BP
Use a cuff with a bladder that is 12-13 cm X 35 cm, larger for fat arms
Use phase 5 Korotkoff sounds (disappearance) to measure diastolic BP
Measure BP in both arms at first visit
Measure BP in standing position in elderly subjects and diabetic patients
Place sphygmomanometer cuff at heart level, whatever the position of the patient
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Multiple BP Measurements Recommended
Because BP is characterized by large spontaneous variations, diagnosis should be based on multiple BP measurements taken on several separate occasions
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Minimum RoutineInvestigations
Clinical and family history
Full physical examination as described in medical textbooks
Laboratory investigations, including:– urinalyses for blood, protein, and glucose– microscopic examination of the urine– blood chemistry for potassium, creatinine, fasting glucose,
and total cholesterol
Electrocardiography (ECG)
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“Isolated” Office Hypertension
In some patients office BP is persistently elevated whereas daytime BP outside clinic environment is not. Continuing debate whether “isolated” office hypertension (“white coat hypertension”) is an innocent phenomenon or carries an increased risk of CVD
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Ambulatory BP Monitorings Should be Considered, if:
Unusual variability of BP over the same or different visits
“Isolated” office (“white coat”) hypertension in subjects with low CV risk
Symptoms suggesting hypotensive episodes
Hypertension resistant to drug treatment
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Ambulatory BP Monitoring
BP values obtained by home measurement or ambulatory monitoring are several mm Hg lower than office measurement
Average 24 hour or home BP values around 125/80 mm Hg = office BP 140/90 mm Hg
Reliable information about long-term prognostic value of ambulatory and home monitoring is awaited
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Which Factors Influence Prognosis? (1)
Decisions should not be made on BP alone, but also on presence of other risk factors, target organ damage, and
concomitant diseases, as well as on other aspects of patients’ personal, medical, social, economic, ethnic, and
cultural characteristics
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• Risk factors of CVD
I. Used for risk stratificationII. Other factors adversely influencing
prognosis
• Target organ damage (TOD)
• Associated clinical conditions (ACC)27
Which Factors Influence Prognosis? (2)
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Which Factors Influence Prognosis? (3)
I. Used for risk stratification• Levels of systolic and diastolic blood
pressure (Grades 1-3)• Men >55 years• Women >65 years• Smoking• Total cholesterol >6.5 mmol/L (250 mg/dl)• Diabetes• Family history of premature
cardiovascular disease
Risk factors for CVD
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Which Factors Influence Prognosis? (4)
II.Other factors adversely influencing prognosis• Reduced HDL cholesterol• Raised LDL cholesterol• Microalbuminuria in diabetes• Impared glucose tolerance• Obesity• Sedentary lifestyle• Raised fibrinogen• High risk socioeconomic group• High risk ethnic group• High risk geographic region
Risk factors for CVD
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Which Factors Influence Prognosis? (5)
Target organ damage (TOD)
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• Left ventricular hypertrophy (electrocardiogram, echocardiogram, or radiogram)
• Proteinuria and/or slight elevation of plasma creatinine concentration 106-177 mmol/L (1.2-2.0 mg/dl)
• Ultrasound or radiological evidence of atherosclerotic plaque (carotid, iliac, and femoral arteries, aorta)
• Generalised or focal narrowing of the retinal arteries
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Which Factors Influence Prognosis? (6)
Associated clinical conditions (ACC)
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Cerebrovascular disease• Ischaemic stroke• Cerebral haemorrhage• Transient ischaemic attack (TIA)
Heart disease• Myocardial infarction• Angina pectoris• Coronary revascularisation• Congestive heart failure
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Which Factors Influence Prognosis? (7)
Associated clinical conditions (ACC)
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Renal disease• Diabetic nephropathy• Renal failure, plasma creatinine concentration
>177 mmol/L (>2.0 mg/dl)Vascular disease
• Dissecting aneurysm• Symptomatic arterial disease
Advanced hypertensive retinopathy• Haemorrhages or exudates• Papilloedema
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Which FactorsInfluence Prognosis? (8)
Low risk = <15 percent
Medium risk = 15-20 percent
High risk = 20-30 percent
Very high risk = 30 percent or higher
Typical 10 year risk of strokeor myocardial infarction
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Which FactorsInfluence Prognosis? (9)
Example 1:
65-year old man with diabetes, TIAs, and BP of 145/90 mm Hg will have annual risk of major CVD event 20 times greater than 40-year old man with same BP but without diabetes or history of CVD
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Which FactorsInfluence Prognosis? (10)
Example 2:
40-year old man with BP of 170/105 mm Hg will have risk of major CV event 2-3 times greater than man of same age with BP of 145/90 mm Hg and similar other risk factors
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Stratifying Risk - Quantifying Prognosis
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Do Patients Benefit from Antihypertensive Treatment? (1)
Yes, the randomized trials conducted to date have shown
clear evidence of a lower incidence of major CVD events after high BP was treated with
anti-hypertensive drugs. 371999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
381999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Do Patients Benefit from Antihypertensive Treatment? (2)
There is as yet no evidence that the main benefit of treating
hypertension is due to a particular drug property rather
than to lowering BP per se.
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Effects of Antihypertensive Treatment in Randomised Controlled Trials
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Absolute Effects of Antihypertensive Treatment
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10/5 mm Hg 20/10 mm Hg
Low risk patients <5 <9
Medium risk patients 5-7 8-11
High risk patients 7-10 11-17
Very high risk patients >10 >17
Patient Group Absolute treatment effects (CVDevents prevented per 1000 patients years)
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Larger Risk Reductions?
• The estimates of antihypertensive benefits shown were reported from trials of about 5 years duration.
• It is possible that long-term treatment over decades might produce larger risk reductions.
411999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Initiate lifestyle measures wherever appropriate in all patients, including those
who require drug treatment
• Smoking cessation
• Weight reduction
• Moderation of alcohol consumption
• Reduction of salt intake
• Increased physical activity42
Management Strategy (1)
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Management Strategy (2)
Is patient at:
Very High Risk
High Risk
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Medium Risk
Low Risk
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Management Strategy (3)Stratify Risk
Very High
High
Begin drugtreatment
Begin drugtreatment
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Management Strategy (4)Stratify risk
Medium
Monitor BP & otherrisk factors for 3-6 months
SBP >140or DBP >90
Begin drugtreatment
SBP <140or DBP <90
Continue tomonitor
Low
Monitor BP & otherrisk factors for 6-12 months
SBP >150or DBP >95
Begin drugtreatment
SBP <150or DBP <95
Continueto monitor
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Principles of Drug Treatment (1)
• Use a low dose of one drug to initiate therapy
• If good response and tolerability but inadequate control increase the dose of the first drug
• If little response or poor tolerability change to another drug class
461999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Principles of Drug Treatment (2)
• It is often preferrable to add a small dose of a second drug rather than increase the dose of the first drug
• Use long-acting drugs providing 24-hour efficacy on a once daily basis. Improves adherence to therapy and minimizes BP variability.
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Principles of Drug Treatment (3)
• More evidence of beneficial CVD effects with older drugs (e.g., diuretics and beta-blockers)
• Evidence of benefit with newer drugs (e.g., ACE inhibitors and calcium antagonists) is accumulating.
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Principles of Drug Treatment (4)
There are six maindrug classes used worldwide - diuretics, beta-blockers, ACE
inhibitors, calcium antagonists, alpha blockers, and angiotensin
II antagonists.
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Principles of Drug Treatment (5)
All 6 classes are suitable for the initiation and maintenance of BP lowering therapy, but the choice
of drugs will be influenced by cost and by many factors for special groups
of patients. In some parts of the world, reserpine and methyldopa are
also used frequently.
501999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Indications
Compelling PossibleHeart failure Diabetes
Elderly patients
Systolic hypertension
Diu
reti
cs
Contraindications
Compelling PossibleGout Dyslipidaemia
Sexually active
males511999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
IndicationsCompelling Possible
Angina Heart failure
After myocardial infarct Pregnancy
Tachyarrhythmias DiabetesContraindications
Compelling Possible
Asthma and Dyslipidaemia
Chronic obstructive Athletes and
Pulmonary disease Physically active
Heart block (AV 2,3) Patients
Peripheral
vascular disease
Beta
-Blo
ckers
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IndicationsCompelling PossibleAngina Peripheral
Elderly patients Vascular disease
Systolic hypertension
Calc
ium
Anta
gonis
ts
Contraindications
Compelling PossibleHeart block (AV 2,3) Heart failure*
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* verapimil or diltiazem
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
IndicationsCompelling Possible
Heart failure
Left ventricular dysfunct
After myocardial infarct
Diabetic nephropathy
ContraindicationsCompelling Possible
Pregnancy
Bilateral renal
artery stenosis
Hyperkalaemia
AC
E Inhib
itors
541999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Indications
Compelling Possible
Prostatic Hypertrophy Glucose intolerance
Dyslipidaemia
Contraindications
Compelling Possible
Orthostatic
hypotension
Alp
ha-B
lock
ers
551999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Indications
Compelling Possible
ACE-I cough Heart failure
ContraindicationsCompelling Possible
Pregnancy
Bilateral renal
Artery stenosis
Hyperkalaemia
Ang
iote
nsi
n II
Anta
gonis
ts
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Combination Therapy (1)
In most patients, appropriate combination therapy produces BP
reductions that are twice as great as those obtained with monotherapy, for
example, 12-22 mm Hg systolic BP and 7-14 mm Hg diastolic BP for patients
with initial BP of >160/95 mm Hg
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Combination Therapy (2)Effective drug combinations to treat hypertension are:
• diuretic and beta-blocker• diuretic and ACE inhibitor (or
Angiotensin II antagonist)• calcium antagonist (dihydropyridine) and
beta-blocker• calcium antagonist and ACE inhibitor• alpha-blocker and beta-blocker
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Other Drugs to Consider in Hypertension
• Aspirin
• Cholesterol lowering therapy
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Treatment Goal (1)
Requires treatment of all reversible risk factors, such as smoking, raised cholesterol, or diabetes, and the management of associated clinical conditions, as well as treatment of raised BP
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Reduce total CVD risk
Treatment Goal (2)
The goal of antihypertensive treatment should be to achieve “optimal” or “normal” BP in young, middle-aged, or diabetic subjects (below 130/85 mm Hg), and at least “high-
normal” BP in elderly patients (below 140/90 mm Hg)
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Follow-Up (1)
• Follow-up during evaluation and stabilisation of treatment should be frequent to monitor BP and other risk factors
• Follow-up is important to establish good relations with the patient and to educate the patient, so that he/she takes responsibility for the life-long control
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• Good communication between physician and patient is essential because treatment of hypertension is for life
• Adequate information about BP and high BP, about risks and prognosis, about expected benefits of treatment, and about risks and side effects of treatment are essential for satisfactory life-long control of hypertension which is poor in many countries today
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Follow-up (2)
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How Should HypertensionDuring Pregnancy be Diagnosed?
Usually defined by absolute levelof BP (for example, 140/90 mm Hg or over)
or an increase in BP from pre-conception or first trimester (for example, SBP rise of >25
mm Hg and/or DBP rise of >15 mm Hg)
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How Should HypertensionDuring Pregnancy be Defined?
Hypertension in pregnancy usually defined as:
pre-existing chronic hypertension de novo diagnosed, gestational hypertension or
pre-eclampsia pre-eclampsia superimposed on chronic
hypertension
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How Should HypertensionDuring Pregnancy be Handled?
• BP above 170/110 mm Hg should be lowered to protect mother from risk of stroke or eclampsia
• Opinion is divided on the need for drug treatment for BP below this level
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Antihypertensive DrugsMost Widely Used Acutely
During Pregnancy
• Nifedipine
• Labetalol
• Hydralazine
671999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
• Beta-blockers:oxprenolol, pindolol, labetalol
atenolol, however, is associated with fetal growth retardation when used long-term throughout pregnancy
• Methyldopa
• Prazosin, hydralazine, nifedipine, and isradipine
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Antihypertensive DrugsMost Widely Used Chronically
During Pregnancy
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
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Drugs Most WidelyAvoided During Pregnancy
• ACE inhibitors (associated with possible adverse fetal effects)
• Angiotensin ll antagonists (effects may be similar to ACE inhibitors)
• Diuretics used infrequently because of concerns of reducing already compromised plasma volume
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Hypertensionin Type-2 Diabetics (1)
• Diabetes and hypertension are multiplicative risk factors for CVD
• Absence of hypertension in diabetes is associated with a better long-term survival
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Hypertensionin Type-2 Diabetics (2)
• Progressive decline in glomerular function can be slowed with antihypertensive treatment
• Similar lifestyle measures are recommended for hypertension and diabetes
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Hypertensionin Type-2 Diabetics (3)
Good evidence for reductionin CVD events in diabetic patients treated
with antihypertensivedrugs, including diuretics,
and more recently, beta-blockersand ACE inhibitors
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Hypertensionin Type-2 Diabetics (4)
The goal of antihypertensive treatment in Type-2 diabetics should be to achieve
“optimal” or “normal” BP (that is below 130/85 mm Hg)
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What is the ImplementationPlan for Practice Guidelines? (1)
• Publication in as many national medical journals as possible
• Over 2 million brochures to be printed in English and several other languages
• Distribution worldwide with assistance of national hypertension and GP societies
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What is the ImplementationPlan for Practice Guidelines? (2)
• Funding by multiple pharmaceutical companies with no-strings-attached unrestricted educational grants
• Presentations at symposia, congresses, medical meetings, hospitals, medical schools, etc.
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Summary (1)
The goal of the 1999 WHO-ISH Hypertension Practice Guidelines is to
lower BP and other risk factors in order to reducethe risk of CVD
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771999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Summary (2)
The goal of the 1999 WHO-ISH Hypertension Practice Guidelines
is to lower BP and other risk factors in order to reduce the risk of CVD -- in
primary care settings outside the hospital
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How to Get Additional Copiesof Practice Guidelines
Contact your nationalsociety/league of hypertension, or
Write to: World Health OrganizationCardiovascular Diseases ProgrammeCH-1211 Geneva 27, Switzerland
781999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
• Fax: +41 22 791 4151• E-mail: [email protected]