Open Journal Systems

CLINICAL PRACTICE GUIDELINES

Received: October 27^th 2015

Accepted: February 15^th 2016

Key recommendations of the clinical guidelines of arterial hypertension in primary care

Adriana Abigail Valenzuela-Flores,^a Fortino Solórzano-Santos,^b Alma Gabriela Valenzuela-Flores,^c Luis G. Durán-Arenas,^d Samuel Ponce de León-Rosales,^e M. Patricia Oropeza-Martínez,^f Jesús Alejandro Gómez-García,^g Luis A. Moreno-Ruiz,^h Romel Martínez-Vargas,ⁱ Lucía Hernández-Amezcua,^j David Escobar-Rodríguez,^k Enrique Martínez-Flores,^h Arturo Viniegra-Osorio,^a Cecilio Walterio Oest-Dávila,^l Mariana Soria-Guerra^m

^aCoordinación Técnica de Excelencia Clínica; ^bHospital de Pediatría, Centro Médico Nacional Siglo XXI; ^cHospital de Oncología, Centro Médico Nacional Siglo XXI; ^dCentro de Estudios Mexicanos en el Reino Unido, Londres, Inglaterra; ^eDivisión de Investigación, Facultad de Medicina; ^fServicio de Medicina Interna, Hospital General de Zona 8; ^gServicio de Medicina Interna, Hospital de Cardiología 34, Monterrey, Nuevo León, México; ^hHospital de Cardiología, Centro Médico Nacional Siglo XXI; ⁱUnidad de Medicina Familiar 38; ^jHospital General de Zona 27; ^kCoordinación de Áreas Médicas; ^lJefatura de Servicios de Prestaciones Médicas, Sinaloa, México; ^mUnidad de Medicina Familiar 15

^a-c,f-lInstituto Mexicano del Seguro Social

^d,eUniversidad Nacional Autónoma de México

^{a-c,e,f,h-j,m}Ciudad de México, México

Communication with: Adriana Abigail Valenzuela Flores

Telephone: (55) 5553 3589

Email: abigail.val@gmail.com

Background: Hypertension ranks first medical care in first level units. It is estimated that half of the patients with hypertension are uncontrolled. The purpose of this document is to provide recommendations to guide diagnosis and treatment of arterial hypertension in primary care, which have been considered key to the process of care, in order to help health professionals in the clinical decision-making.

Methods: The guide is integrated with recommendations of international guidelines and evidence of published studies indicated the changes regarding the management and treatment of hypertension, as well as differences between the target populations of the guide. Searching for information it is performed by means of a standardized sequence in PubMed and Cochrane Library Plus, from the questions asked. The key recommendations were chosen by a consensus of a group of professionals and health managers.

Conclusions: The key recommendations evidence-based standardized help you make decisions about prevention, diagnosis and treatment in patients with hypertension, and will contribute to reducing cardiovascular risk, promote changes in lifestyle, control the disease and reduce complications.

Keywords: Practice guideline; Hypertension; Blood pressure; Diagnosis; Life style

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Hypertension is the main reason for outpatient visits to family medicine units.¹ According to statisticals from the Instituto Mexicano del Seguro Social (IMSS), the rate of morbidity and mortality in people age 20 to 25 varies between 707.35 and 1162.21² in 2001 and 2012, respectively. The current prevalence of hypertension in our country is 31.5% (95% CI 29.8-33.1), and is higher in patient groups with other diseases, such as obesity or diabetes mellitus. 47.3% of patients know they have high blood pressure at the time of diagnosis; of these, only 73% receive drug treatment, and less than half have the disease under control.³

Hypertension is considered a predictor of morbidity and mortality for vascular diseases, including cerebrovascular disease, myocardial infarction, peripheral arterial disease, and kidney failure. It is a good idea, starting at disease onset, to implement non-pharmacological measures that contribute to treating hypertension. Nevertheless, most patients do not have adequate control of their blood pressure, with a consequent increase in the risk of target organ damage, disability, out-of-pocket expenses, and expenditure of interventions from the Health System, resulting from the high demand for care.

Because of this, and the variability of medical practice, it is necessary to have a Clinical Practice Guideline (CPG) to help guide health personnel in clinical decision-making, thereby contributing to improved quality care for patients with hypertension.

Organizations like NICE⁵ (National Institute for Health Care Excellence) have proposed prioritizing a subset of all of the CPG recommendations that are key to the process of care and that can contribute in a specific way to standardizing clinical practices.

This document presents the key recommendations drawn from the CPG for the diagnosis and treatment of hypertension in primary care,⁴ and whose objectives are to identify cardiovascular risk factors in a timely manner, to provide treatment and follow-up according to the person’s conditions, and to identify benchmarks. The target population is people over 18.

The recommendations are aimed at general family practitioners, internists, geriatricians, cardiologists, nurses, and nutrition, rehabilitation, and physical therapists.

Methodology

In updating the guide on hypertension, recommendations from international guidelines were adopted and adapted, as well as evidence from published studies that indicated changes regarding the management and treatment of hypertension, as well as differences between the population groups treated in the guide. The search for these guides was done using a standardized sequence. Evidence and recommendations were integrated based on the methodology previously described.⁶ The clinical questions were organized around prevention, diagnosis, and treatment of hypertension as well as clinical monitoring.

This document summarizes the guide recommendations identified as a key and prioritized to be implanted into the care process. The key recommendations were chosen by consensus of a group of professionals and health managers involved in the care of patients with hypertension. The selection criteria used were: clinical relevance and applicability of the recommended interventions, and their potential contribution to health and organizational outcomes. The score of these recommendations (R-score) is the score assigned with Shekelle’s modified classification⁷ and the scales of the reference guides.

These recommendations (key) are strengthened and supplemented by other published evidence, even after the issuance of the guide. Searches were made in PubMed and Cochrane Library Plus using the terms (Mesh) and keywords: hypertension, diagnosis, therapy, adverse effects, classification, diet, therapy, radiography, therapeutic use, and drug effects.  

Recommendations

The key recommendations are listed below, the numeral preceding them corresponds to the order assigned in the flow chart (Figure 1).

Prevention

There is evidence that multiple factors influence the development of hypertension.^8-10 Recommendations should be directed towards: maintaining a body mass index less than 25 (R-I),¹⁰ regularly performing moderate physical activity and relaxation therapy (R-B),¹¹ and keeping a proper meal plan (R-I),¹⁰ (R-B),¹¹ including high consumption of fruits and vegetables, low intake of saturated fats and salt, as well as stopping smoking, alcoholism, (R-I)¹⁰ and drugs.

Clinical diagnosis

The comprehensive assessment of high blood pressure includes a study protocol that requires thorough analysis of the clinical data and additional tests as well as the classification of hypertension.

When doing a clinical history, it is recommended from the first consultation to identify familial predisposition, interrogating background (R-I)¹⁰ and factors related to the development of hypertension. Physical examination includes collecting anthropometric data (R-III),¹⁰ (R-D):¹¹ weight, height, waist circumference, and calculation of body mass index, as well as taking blood pressure and radial pulse (R-I),¹⁰ for the timely identification of arrhythmias.

The diagnosis of hypertension is established after two determinations (R-I),¹⁰ with elevated blood pressure at subsequent appointments (R-D).¹¹ Diagnosis is considered likely when there are high blood pressure numbers equal to or greater than 140/90 mmHg. However, the diagnosis of hypertension can be integrated from the first medical visit for people who come with signs of alarm or hypertensive emergency, patients with diabetes with target organ damage (TOD), or signs of moderate to severe kidney failure (glomerular filtration rate < 60 mL / min / m²), presenting figures of more than 140/90 mm Hg (R-C).¹¹

Different models have been proposed for cardiovascular risk stratification; the SCORE model (Sistematic Coronary Risk Evaluation)¹⁰ was proposed to establish the risk a person has of dying from a vascular event within 10 years (R- IIa),¹⁰ (R-B).¹¹

Diagnostic tests

Once clinical diagnosis is established, it is necessary to define objective parameters to determine if there is target organ damage, which are:

• Cardiovascular: it is essential to establish cardiovascular risk (R-IIa),¹⁰ (R-A)¹¹ early, letting one assess damage opportunely and select treatment strategies according to the particular risk, thus modifying the person’s prognosis.^12-15  
• Renal evaluation is made, identifying microalbuminuria with 30-300 mg / dl in general urinalysis and glomerular filtration rate of 30 to 60 ml / min (R-I),¹¹ lipid profile and blood chemistry (R-D)¹¹ including glucose tolerance curve, urea, creatinine, and uric acid.
• Central nervous system and eyes: it is recommended to test visual acuity and the fundus (R-IIa)^10,16 and to investigate neurological disorders periodically to identify the presence of damage.⁸

In medical units with the resources and qualified personnel to make and interpret electrocardiograms, it is suggested to conduct baseline tests (R-IIb)¹⁰ with 12 derivations (R-C),¹¹ to detect ventricular hypertrophy and atrial block. It is recommendable to make and interpret Holter monitoring (R-IIb) for blood pressure,¹⁰ in the following conditions:^14,15 discordance of blood pressure recorded at home and at clinic, ruling out "white coat" hypertension, suspected nocturnal hypertension due to renal impairment or sleep apnea, and suspected autonomic hypotension.

Studies such as echocardiography (R-D)¹¹ and ultrasonography (vascular, carotid, and peripheral blood) are complementary; doing these is determined based on clinical data and patient conditions.

Treatment

The goal of treatment is to control and maintain blood pressure in the recommended goal and to reduce the risk of vascular events and death of people with hypertension.¹⁷

Medication treatment

Various treatment regimens can be used to achieve and maintain the recommended goal. However, the quality of the evidence is limited for analyzing outcomes (cardiovascular, cerebrovascular, renal events and death) on these regimens.¹⁸

The initial treatment for patients with hypertension is established with the following drugs known as first-line (R-I),¹⁰ (R-A, B):¹¹

• Thiazide/thiazide-type diuretics
• Renin-angiotensin system (angiotensin-converting-enzyme inhibitor [ACEI] or angiotensin II receptor blockers [ARBs]).
• Beta blockers (Beta-B).
• Prolonged action calcium antagonist (Ca-A).

The drug choice is recommended based on the conditions of each person and possible combinations with first-line drugs.^16,17,19 Treatments were pooled for two types of people: those with no special conditions, and those with special conditions (Figure 2, Table I):

Population without special conditions

First-line drugs are recommended with rational prescribing, at a low dose and gradually increasing, depending on the response and tolerance of the individual, the presence of adverse reactions to drugs, and adequate control of blood pressure (BP).¹² Before adding a second or third drug to the chosen regimen, it is suggested to administer maximum doses of the prescribed drugs tolerated by the person (R-C).¹⁵ When the blood pressure remains above the control target, for systolic blood pressure (SBP) ≥ 20 mmHg, and for diastolic blood pressure (DBP) ≥ 10 mmHg, drug combination is needed, such as:^12,16 thiazide/thiazide-type diuretics, renin-angiotensin system (ACE inhibitors or ARBs) and Ca-A (R-III),¹⁰ (R-B).¹¹ The combination of two different renin-angiotensin system drugs¹⁵ is not recommended (R-III),¹⁰ (R-A),¹¹ unless there is an absolute indication.

In uncontrolled isolated systolic hypertension,^15,16 it is suggested to combine two first-line drugs (R-A)¹¹ or alternatively use alpha-blockers, ACE inhibitors, or Ca-A (R-D)¹¹ if the person presents adverse reactions. In the case of poor tolerance, contraindications to potassium-sparing drugs, or lack of treatment efficacy, consider the use of Beta-B (R-C).¹⁰

Patients with adequate blood pressure control (< 140/90 mmHg) with a regimen that includes a Beta-B^15,16 that has been used for a long time, do not represent an absolute indication to be replaced, (R-IIa)¹⁰ when they are less than 60 years old (R-B).¹¹ There is evidence that at older ages, Beta-B causes cerebrovascular disease affecting 16% of people who take it.¹⁷

Population with special conditions

In adults over 80 years²⁰ who do not have diabetes mellitus or target organ damage, initiate drug treatment when SBP ≥ 160 mmHg (R-I)¹⁰ and maintain SBP < 150 mmHg,5 since this has been associated with an increased risk of cardiovascular and cerebral events.¹² Drugs for isolated systolic hypertension are:^15-17 thiazide/thiazide-type diuretics and Ca-A, avoiding Beta-B (R-III).¹¹ When the person is fragile, it is recommended to individualize the case and monitor treatment side effects (R-I).¹⁰ In older adults, recommended drugs are: thiazide diuretics, ACE inhibitors, ARBs, and Ca-A (individualized according to comorbidities). Beta-B is a less effective option and if it is decided to discontinue them, withdrawal must be done gradually.^5,11-13 If despite the use of 3 drugs, there is not proper control, it is recommended to seek the possible causes (R-C),¹² such as poor adherence to treatment, diastolic volume overload, drug interactions, and associated conditions^16,19,21 (obesity, smoking, excessive alcohol intake, insulin resistance, pseudo-resistance to treatment, and pseudo-hypertension).

• If the person has SBP between 140 and 160 mmHg with high CVR due to TOD, diabetes mellitus (DM), cardiovascular disease (CVD) or chronic kidney disease (CKD),^15-17 drug treatment must be initiated (R-I)¹⁰ (R-C).¹¹
• The following drugs are recommended in patients with DM, in order of preference: ACE inhibitors or ARBs, b) Ca-A, and c) thiazide diuretics at low doses.
• The presence of CKD, albumin in urine, and other comorbidities should be evaluated in choosing a drug.^15,16 Combination therapy is recommended: ACE inhibitors or ARBs (R-A)¹¹ especially in cases of DM with proteinuria (or microalbuminuria), plus a long-acting Ca-A; the recommended goal is to achieve SBP < 130 mmHg (R-IIb),¹⁰ (R-C)¹¹ and DBP < 80 mmHg (R-A).¹¹
• In patients with metabolic syndrome: a) start with general measures including weight reduction and physical exercise; and b) choose combination therapy (R-I, IIa):¹⁰ ACE inhibitors or ARBs, especially in people with proteinuria (or microalbuminuria), long-acting Ca-A, potassium-sparing diuretics.
• In patients with ischemic heart disease,^13-16 it is recommended to maintain figures < 130/80 mmHg; Beta-B or Ca-A are preferred as initial therapy in the presence of stable angina (R-B),¹¹ and Beta-B in patients with recent myocardial infarction (R-I).¹⁰ Use the combination of ACE inhibitors and Ca-A in patients at high cardiovascular risk (R-A).¹¹ It is recommended to avoid using Ca-a in the presence of heart failure.¹¹
• In the presence of heart failure and systolic dysfunction, ACE inhibitors and Beta-B are recommended as initial therapy. (R-IIa).¹⁰ If associated with severe left ventricular dysfunction, diuretics, Beta-B, and ACE inhibitors or ARBs are recommended.
• For patients with arterial hypertension associated with cerebrovascular disease, the combination of ACE inhibitors and thiazides/thiazide-type diuretics is recommended (R-B),¹¹ maintaining recommended target SBP < 140 mmHg (R-IIa).¹⁰
• In patients with hypertension and renal failure not associated with DM and in the absence of renal artery stenosis,^15,16 ACE inhibitors are recommended as first-line (R-A).¹¹
• In hypertension and diabetic or non-diabetic nephropathy, combination therapy is recommended (R-I),¹⁰ with: a) ACE inhibitors or ARBs, b) long-acting Ca-A, c) loop diuretics to replace the thiazide when creatinine serum is 1.5 mg / dL or GFR < 30 mL / min / 1.73 m. Maintain the recommended goal: SBP < 130 mmHg in the presence of proteinuria (R-IIb).¹⁰

Non-pharmacological treatment

The CARDIOTENS study in Spain²² revealed that lack of BP control is associated with factors related to lifestyle and diet, specifically, obesity and smoking, this control being the cornerstone of hypertension treatment.¹⁶ It is recommended to include in the diet^23,24 salt consumption of no more than 5 g (R-I),¹⁰ decreasing progressively to 3 g per day,¹⁶ which provides long-term benefits (R-B).¹¹ With this measure, blood pressure is reduced 5.8 mmHg on average.²⁴ Hence, implementing health policies that include participation and social responsibility on the part of the food industry¹² may help to decrease salt intake in the diet of the population, because 80% of total daily salt intake is found in packaged products.¹⁰ Health personnel should provide advice to reduce salt and sodium intake^8,16 and should also advise the patient to reduce body weight²⁵ or maintain a BMI of 25 kg / m² or less (R-I),¹⁰ (R-C)¹¹. For patients with hypertension, it is recommended to eat fish at least 2 times per week, consume 300 to 400 grams of fruits and vegetables a day, and adopt an eating plan called DASH (Dietary Approaches to Stop Hypertension)^8,16 which lowers blood pressure 8 to 14 mmHg.^13,26 This diet includes high consumption of fruits, vegetables, low-fat dairy products, dietary and soluble fiber, whole grains, and vegetable proteins (R-I),¹¹ low saturated fat and cholesterol, and high magnesium, potassium, and calcium (R-B).¹¹

Other recommendations that contribute to changing lifestyles include: limiting alcohol consumption (R-I)¹⁰ to 2 glasses or less a day, without exceeding 14 and 9 standard drinks a week for men and women, respectively (R-B).¹¹ Also encourage quitting smoking (R-I)¹⁰ and attending support groups. As for the consumption of caffeinated beverages, there is insufficient scientific evidence about its association with elevated blood pressure figures.²⁷

There are five basic actions that help change lifestyle and help reduce and maintain blood pressure in the recommended target and reduce CVR.^10,23

• Food plan: DASH.
• Reduce sodium intake below 1500 mg (2/3 teaspoon of salt a day); considering the patient’s age and comorbidities, and the sodium content of foods (processed and packaged).
• Quit smoking.
• Reduce alcohol consumption.
• Make an exercise plan (with the three phases: warm-up, aerobic / strength, and cool-down), including walking (30 to 45 min) or swimming.
• It is important to emphasize to the patient that physical exercise^28-31 is to be done 5 to 7 days a week (R-I),¹⁰ since it has been shown to reduce DBP and SBP.^18,21,23 Hence the need to provide a supervised exercise plan (Annex I). Elderly patients are advised to practice yoga 3 times a week³² or Tai Chi.

Monitoring and follow-up

Control of factors associated with hypertension^8,23,25,27 is an essential part of integrated care, such as overweight and obesity, diets high in sodium and saturated fat, and lack of physical activity.

Monitoring is proposed:¹⁰

• Patients with hypertension with low CVR and controlled blood pressure (goal reached) every three months, depending on clinical response and effective control of modifiable factors.
• Patients with high CVR or lack of blood pressure control are recommended evaluation every 2 to 4 weeks; the case must be individualized.
• The frequency of test determinations are set based on the patient’s conditions and comorbidities; it is suggested to do tests at least once a year to detect TOD in a timely manner.

Benchmarks

There are several situations in which it is recommended to refer the patient with hypertension to second or third level of care (R-C),¹¹ including:

• Suspicion of secondary hypertension (renovascular or endocrine).
• Hypertensive crisis (or emergency) with or without TOD injury.
• Inclusion of a fourth drug to control blood pressure.
• Patient with complications (hypertension difficult to control, evidence or suspicion of TOD).
• Annual checkup with internal medicine and ophthalmology in order to detect and control the development of TOD in a timely manner.
• Special situations with complications from hypertension.

Conclusions

The great variability in care and the increasing population with hypertension in our country, requires the guide for hypertension for the purpose of standardizing the care process between first-level units and referrals to hospitals.

It is important to adopt the key recommendations in this guide, which are priorities to be implemented according to the needs, context, and organizational structure; and the importance of defining the support instruments to encourage the use of these recommendations and reduce complications of the disease.

Acknowledgments

To the authorities and health staff of IMSS for their valuable support and contribution in updating the guide and integrating this document. Also, to the designer David Escobar Rodriguez for the design of 3D models. The contributions presented in this paper are part of the project SALUD-2012-1-181352 of CONACYT.

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