An Approach for Sub-Saharan Africa
0CTOBER 2010
Dr. Linda Hawker, MD, CCFP
General Practice
Kelowna BC Canada
Contents based
on the WHO CVD - Risk
Management Package
For low and medium resource
settings
2002
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“Hypertension plays a major role in the development
of cerebrovascular disease, ischemic heart disease,
cardiac and renal failure. Treating hypertension has
been associated with about a 40% reduction in the
risk of stroke and about a 15% reduction in the risk of
myocardial infarction.”
“Hypertension remains inadequately managed
everywhere.”
(2003 WHO / ISH statement on the
management of hypertension)
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Appropriate assessment and management of
cardiovascular risk is vital to prevent fatal and
non fatal heart attacks and strokes and to
improve health outcomes of those at high
risk of cardiovascular disease (CVD).
Hypertension is a major risk factor in
development of CVD.
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Three major risk categories
Likelihood of stroke, heart attack in next 10
years:
◦ 1. Low risk : less than 15%
◦ 2. Medium risk : 15 – 20%
◦ 3. High risk: more than 20%
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High Blood pressure
Males over 55 years
Females over 65 years
Smoking
Total cholesterol > 6.1 mmol/l
LDL (“bad”) cholesterol > 4.0 mm/l
HDL (“good”) cholesterol , M<1,
F<1.2mmol/l
History of CVD in parents, siblings or children
before age 50
Obesity, physical inactivity
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Left ventricular hypertrophy (EKG or echo)
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Microalbuminuria (20- 300 mg/day)
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X –ray or ultrasound evidence of artery plaque
(aorta, carotid, coronary, femoral)
Hypertensive retinopathy grade 3 or 4
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Diabetes
History of TIA or stroke
Heart disease : angina, heart attack,
congestive failure
Kidney disease :
◦ High creatinine: Females >120, Males >133umol/l
◦ Albuminuria >300 mg/day or >0.3 gms/L random
History of Peripheral Vascular Disease
Blood
Risk factors
Disease History :
Pressure
140-159
90-99
160-179
100-109
>180
>110
Medium risk
High risk
No other risk factors:
Low risk
1- 2 risk factors:
Medium risk
Medium risk
High risk
3 or more risks
Or TOD, or ACC:
High risk
High risk
High risk
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BP < 140/90 if uncomplicated
BP < 130/80 if
 Diabetes
 Chronic renal disease
 History of heart disease, TIA, stroke,PVD
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Manage risk factors, TOD and ACC
Educate your patients
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Lifestyle Modification
◦ Weight reduction – aim for BMI 25 or less
◦ Limit salt intake – one teaspoon per day or less!
◦ Limit alcohol – 2 drinks/day men,1drink/day
women
◦ Stop smoking
◦ Regular exercise – brisk walk for 30-60 min/day
◦ Healthy diet – low in fat, sugar and refined foods,
high in fresh fruits, vegs, fish. Low fat dairy foods.
◦ Reinforce lifestyle message at every visit
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For most patients, if there is no compelling
reason for another class of drug, a low dose
diuretic should be the first choice of therapy.
The major classes of drugs are equal in
effectiveness and safety. If there is a specific
indication (eg: renal disease), use the most
cost effective drug of the appropriate class.
1. Thiazides
◦
Moduret (combo amiloride, HCT)
2. Beta Blockers
Atenolol, Propanolol
3. Calcium Channel Blockers
Nifedipine (short acting-not
recommended)
4. ACE Inhibitors
Captopril
5. Other: hydralazine, methyldopa
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Start with low dose thiazide diuretic, then
add:
Kidney disease +/- Diabetes: ACE inhibitor
Heart disease:
◦ Post heart attack: ACE inhibitor
◦ Angina: Beta blocker
◦ Congestive Heart failure: Beta blocker, ACE
inhibitor, diuretic – thiazide, furosemide,
spironolactone
◦ Left ventricular hypertrophy: ACE inhibitor
ACE inhibitors/ ARB
Pregnancy
Hyperkalemia
Beta Blockers
Severe bradycardia, < 50
COPD
Diuretics
Gout
Diastolic BP over 120mmHg with acute end organ
damage
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Encephalopathy
Papilledema
Angina, heart attack
Transient ischemic attack, stroke
Acute renal failure
Acute pulmonary edema
Aortic dissection
Admit to CCU, aim to lower BP to 160-180/100110 by 2 hours, may need IV meds
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Diastolic BP over 120 mmHg without acute
end organ damage
Admit and aim to lower BP to 160/100 over
24-48 hours. Note: Too rapid lowering of BP
can cause ischemia to brain, heart, kidneys
Use oral meds – diuretics, B Blockers, ACEI,
Methyldopa
DO NOT USE FAST ACTING NIFEDIPINE
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Hypertension, proteinuria, edema after 20wks
BP 180/110 or greater x 2
Treatment:
 Give IV fluids, avoid diuretics
 IV hydralazine 5 mg over 5 mins, repeat
in 20 mins. Aim: BP 140-160/90-100
Deliver as soon as possible!
Hypertension may persist post delivery
Use methyldopa
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Detect – take BP
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Identify and Stratify Risk Factors
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Treat according to risk/assoc. disease
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Follow
Educate your patients about
cardiovascular disease risks
Make them partners in treatment