Transcript 1999 WHO-ISH Hypertension Practice Guidelines for Primary Care

1999 WHO-ISH
Hypertension Practice Guidelines
for Primary Care Physicians
World Health Organization
INTERNATIONAL SOCIETY OF HYPERTENSION
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)
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WHO-ISH Hypertension
Guidelines 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)
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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.
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Global
Goal
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What is the Goal
of 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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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
hypertension
> 140/90
>140/90
>140/90
Levels
Grade 1,2,3
Mild, Moderate,
Severe
Stage 1,2,3
Decision
to treat
Not based on
BP alone, but
assessment of
total CV risk
BP
BP
Target BPs
<130/85
<140/90 (elderly)
<130/80
<140/90 (elderly)
<140/90
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What is New?
Suitable first-line
drug therapy
Combination
therapy
1999 WHO-ISH
1993 WHO-ISH
JNC-VI
6 drug
classes
5 drug
classes
2-3 drug
classes
Low dose
combinations
recommended if
monotherapy
inadequate
Low dose
combinations
may be used to
initiate therapy
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Why BP <130/85 mm Hg
and 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 Hg
and 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)
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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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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
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Relative Risk of CHD and Stroke in
Relation to Patient’s Usual Diastolic BP
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New (1999) WHO-ISH Definitions
and Classification of BP Levels
Category
Systolic BP
(mm Hg)
Diastolic BP
(mm Hg)
Optimal BP
Normal BP
High-Normal
<120
<130
130-139
<80
<85
85-89
Grade 1 Hypertension (mild)
Subgroup: Borderline
Grade 2 Hypertension (moderate)
Grade 3 Hypertension (severe)
140-159
140-149
160-179
>180
90-99
90-94
100-109
>110
Isolated Systolic Hypertension
Subgroup: Borderline
>140
140-149
<90
<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
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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 occasions
Allow 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 Routine
Investigations
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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Which Factors
Influence Prognosis? (2)
• Risk factors of CVD
I. Used for risk stratification
II.Other factors adversely influencing
prognosis
• Target organ damage (TOD)
• Associated clinical conditions (ACC)
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Which Factors Influence Prognosis? (3)
Risk factors for CVD
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
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Which Factors Influence Prognosis? (4)
Risk factors for CVD
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
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Which Factors Influence Prognosis? (5)
Target organ damage (TOD)
• 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
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Which Factors Influence Prognosis? (6)
Associated clinical conditions (ACC)
Cerebrovascular disease
• Ischaemic stroke
• Cerebral haemorrhage
• Transient ischaemic attack (TIA)
Heart disease
•
•
•
•
Myocardial infarction
Angina pectoris
Coronary revascularisation
Congestive heart failure
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Which Factors Influence Prognosis? (7)
Associated clinical conditions (ACC)
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 Factors
Influence Prognosis? (8)
Typical 10 year risk of stroke
or myocardial infarction
Low risk
Medium risk
High risk
Very high risk
=
=
=
=
<15 percent
15-20 percent
20-30 percent
30 percent or higher
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Which Factors
Influence 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 Factors
Influence 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.
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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
Patient Group
Absolute treatment effects (CVD
events prevented per 1000 patients years)
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
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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.
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Management Strategy (1)
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 activity
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Management Strategy (2)
Is patient at:
Very High Risk
High Risk
Medium Risk
Low Risk
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Management Strategy (3)
Stratify Risk
Very High
High
Begin drug
treatment
Begin drug
treatment
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Management Strategy (4)
Stratify risk
Medium
Low
Monitor BP & other
risk factors for 3-6 months
SBP >140
or DBP >90
Begin drug
treatment
Monitor BP & other
risk factors for 6-12 months
SBP <140
or DBP <90
Continue to
monitor
SBP >150
or DBP >95
SBP <150
or DBP <95
Begin drug
treatment
Continue
to 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
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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 main
drug 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.
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Diuretics
Indications
Compelling
Possible
Heart failure
Elderly patients
Systolic hypertension
Diabetes
Contraindications
Compelling
Possible
Gout
Dyslipidaemia
Sexually active
males
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Beta-Blockers
Indications
Compelling
Angina
Possible
Heart failure
After myocardial infarct
Tachyarrhythmias
Pregnancy
Diabetes
Contraindications
Compelling
Asthma and
Chronic obstructive
Pulmonary disease
Heart block (AV 2,3)
Possible
Dyslipidaemia
Athletes and
Physically active
Patients
Peripheral
vascular disease
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1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
Calcium
Antagonists
Indications
Compelling
Possible
Angina
Elderly patients
Systolic hypertension
Peripheral
Vascular disease
Contraindications
Compelling
Heart block (AV 2,3)
Possible
Heart failure*
* verapimil or diltiazem
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ACE Inhibitors
Indications
Compelling
Heart failure
Possible
Left ventricular dysfunct
After myocardial infarct
Diabetic nephropathy
Contraindications
Compelling
Pregnancy
Bilateral renal
artery stenosis
Hyperkalaemia
Possible
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Alpha-Blockers
Indications
Compelling
Prostatic Hypertrophy
Possible
Glucose intolerance
Dyslipidaemia
Contraindications
Compelling
Possible
Orthostatic
hypotension
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Angiotensin II
Antagonists
Indications
Compelling
ACE-I cough
Possible
Heart failure
Contraindications
Compelling
Pregnancy
Bilateral renal
Artery stenosis
Hyperkalaemia
Possible
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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 betablocker
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Other Drugs to Consider
in Hypertension
• Aspirin
• Cholesterol lowering therapy
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Treatment Goal (1)
Reduce total CVD risk
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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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 “highnormal” 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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Follow-up (2)
• 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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How Should Hypertension
During Pregnancy be Diagnosed?
Usually defined by absolute level
of 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 Hypertension
During 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 Hypertension
During 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 Drugs
Most Widely Used Acutely
During Pregnancy
• Nifedipine
• Labetalol
• Hydralazine
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Antihypertensive Drugs
Most Widely Used Chronically
During Pregnancy
• 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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Drugs Most Widely
Avoided 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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Hypertension
in 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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Hypertension
in 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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Hypertension
in Type-2 Diabetics (3)
Good evidence for reduction
in CVD events in diabetic patients treated
with antihypertensive
drugs, including diuretics,
and more recently, beta-blockers
and ACE inhibitors
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Hypertension
in 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 Implementation
Plan 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 Implementation
Plan 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 reduce
the risk of CVD
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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 Copies
of Practice Guidelines
Contact your national
society/league of hypertension, or
Write to:
World Health Organization
Cardiovascular Diseases Programme
CH-1211 Geneva 27, Switzerland
• Fax: +41 22 791 4151
• E-mail: [email protected]
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
78
No-strings-attached Unrestricted
Grant Funding for Practice Guidelines
by Following Companies
Bayer
Bristol-Myers Squibb
Glaxo Wellcome
Merck (MSD)
Novartis
Pfizer
Roche
Searle
Zeneca
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
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