This is a short professional article for my medical colleagues practising in Nigeria. I know how boring it is to comb through long guidelines and extract information, therefore, this article is a summary of the current guidelines on hypertension. The article draws from the International Society of Hypertension (ISH) and The Nigerian Hypertension Society’s (NHS) latest guidelines.
A Patient Walks Into Your Clinic
Their blood pressure is greater than or equal to 140/90mmHg at the first office reading, you measure it twice after the first time (making sure, the patient is well rested with appropriate cuff, positioning, and technique) You take the average of the 2nd and 3rd readings.
It Is Still High, What Next?
If the average is still greater than 140/90mmHg, then you schedule another clinic visit in a few days, give instructions to the patient to avoid taking coffee and other stimulants a day before and on the morning of the visit. Ensure he comes in the morning avoiding any form of exercise. When he gets to the clinic, he should be well-rested for 30 minutes before the second office reading is taken. Get three readings using the appropriate cuff and technique and find the average.
Make The Diagnosis
If the blood pressure is still greater than or equal to 140/90 mmHg, then you can make a diagnosis of high blood pressure.
Note: there is a possibility of white coat hypertension, to be ruled out with home/ambulatory BP reading. Read the guidelines for more if you suspect this.
After The Diagnosis, What Next?
Assess for the cardiovascular risk factors and hypertension mediated organ damage (HMOD).
Classify into low risk, moderate risk and high risk (check the NHS guideline) as this will determine therapy.
You can send the article below to your patients to consolidate your counselling at diagnosis
For stage 1 (BP 140-159/90-99 mmHg) and low risk, prescribe lifestyle modifications for 3 months, if no change after 3 months, commence medication in addition to lifestyle modification.
For stage 1 moderate and high risk, stage 2 (160-179/100-109 mmHg) and stage 3 (>180/110 mmHg) hypertension, start medication immediately and commence lifestyle modification.
- Once-daily dosing over multiple dosing. E.g. Amlodipine (once daily) over Nifedipine (twice daily).
- Low dose multi-drug therapy preferred as commencement therapy especially if not stage 1 low risk.
Medications (In Nigerian patient)
- Start with low dose ACEi/ARB + CCB or CCB + Diuretic combination
- ACEi/ARB is advised if there is a renal problem or diabetes mellitus as it has an effect on proteinuria (reduces it).
If this dose doesn’t work, increase the dose. If it still doesn’t work at the maximum dose, you add the third group (e.g if on Indapamide (diuretic) and Amlodipine (CCB), you add Lisinopril (ACEi)). Finally, if that doesn’t work, the guidelines recommend adding Spironolactone.
There are a number of other medications like beta-blockers, centrally acting medications, alpha-blockers, etc, that have peculiar uses in different scenarios.
Usually, you should aim to achieve BP control over 3 months.
Compulsory tests to run at diagnosis: E/U/Cr, FLP, FBS, Urinalysis, ECG, CXR and other ancillary ones to rule out/in secondary causes.
Markedly elevated BP with evidence of hypertension mediated organ damage e.g. Papilledema. This requires rapid reduction to forestall further damage. The use of IV antihypertensive like Labetalol is indicated.
Markedly elevated BP with no evidence of HMOD. No need for a rapid reduction, as they will benefit from oral drugs.
Dowload the ISH 2020 guideline below.
Download the NHS 2020 guideline below.