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Health Surveillance and Disease Prevention and Control / Chronic Diseases / Hypertension

Managing Hypertension in Primary Care in the Caribbean

Caribbean hypertension guidelines

Full-Text Guide (70 pp, PDF, via CHRC)
Preface (text in second column)
Aim and Objectives (text in second column)
Introduction (text in third column)
Overview of Hypertension

Section I: Establishing the Diagnosis of Hypertension
o Definition and Classification
o Screening for High Blood Pressure
o Measurement of Blood Pressure by Ascultation
o Establishing the Diagnosis and Recommendations for Follow-up

Section II: Evaluating the Patient
o The Initial Visit
- Medical History
- Physical Examination..
- Laboratory Investigations and Other Diagnostic Procedures
o Follow-up Visits
- Every Visit
- Annual Visit
o Ambulatory Blood Pressure Monitoring

Section III: Management of Hypertension
o Management according to Stage o Non-pharmacological Management
o Pharmacological Management
o General Approach
o Antihypertensive drugs
o Drug Therapy Guidelines
o Complicated and Resistant Hypertension
o Adherence
o Withdrawal
o Education
o Guidelines for Referral

Section IV: Management of Hypertension in Special Situations
o The Elderly
o The Diabetic Patient
o The Patient with Cardiac Failure
o The Patient with Renal Failure
o The Patient with Myocardial Infarction
o The Patient with Angina
o The Pregnant Patient
o The Patient with Osteoarthritis
o Hypertensive Emergencies

References & Abbreviations
Appendices

Hypertension is one of the most important preventable causes of premature mortality worldwide. The World Health Report 2001 indicated that high blood pressure is estimated to cause 7.1 million deaths annually i.e. about 13% of all deaths and comprises 4.4% of the global disease burden. In the Americas, the number of persons with hypertension is conservatively estimated to be 140 million. Prevalence figures for hypertension in populations over 40 years range widely.

- Caribbean Health Research Council (CHRC)
- PAHO Hypertension Page

CARMEN
CARMEN: A Network for Integrated Prevention & Control of Chronic Noncommunicable Diseases (CNCDs) in the Americas

CHRC

One of the mandates of the Caribbean Health Research Council (CHRC) is to promote evidence-based practice; and in 1995 and 1998, it produced two booklets, which have just been updated: Managing Diabetes in Primary Care and Managing Hypertension in Primary Care in the Caribbean. Those clinical guidelines were distributed throughout the Primary Health Care system of the entire English speaking Caribbean, targeting all primary care doctors, nurses, nurse practitioners and other health care personnel involved in the care of persons with diabetes and hypertension. Since then, there have been significant advances in the management of the two conditions, hence the need for updated manuals that would take into account the most recent international guidelines and regional expert opinions on the management of high blood pressure, diabetes, obesity and related dyslipidemia.

These updated manuals are geared to the culture, economic situation and health care systems in the Caribbean and are designed to serve as key tools in improving patient care. Cultural and economic differences may call for different local strategies, but the most important goal is to ensure that these diseases are managed effectively, thus reducing morbidity and mortality.

This document provides a straightforward approach to the diagnosis as well as the management of hypertension at the primary care level. It stresses the importance of non-drug or lifestyle management as a necessary prerequisite and the need to educate patients, families and the community. It also offers the scope to rationalize and standardize management providing evidence-based recommendations as far as possible.

It is envisioned that these guidelines will be applied systematically and thus lead to improved care and outcomes in persons with hypertension in the Caribbean. We also hope that the collaboration between the CHRC, PAHO, regional opinion leaders and other agencies will accelerate a more effective and comprehensive approach to the prevention and control of chronic non communicable diseases.

Aim: To produce a unified, evidence-based approach to the management of hypertension in the Caribbean through both a patient-centered and a public health approach.

Objectives

  • To promote the primary prevention of hypertension through the adoption and maintenance of healthy lifestyles.
  • To promote early and accurate diagnosis of hypertension.
  • To improve the quality of care of persons with hypertension.
  • To prevent or delay the onset of co-morbid conditions of diabetes, obesity and dyslipidaemia.
  • To prevent and treat acute and long-term complications of hypertension.
  • To promote education and empowerment of patients, families, communities and healthcare workers.

In the Caribbean, the prevalence of hypertension is estimated to be 26% and as high as 55% in studies of populations over 25 and over 40 years, respectively.

Hypertension is also the cause of considerable mortality in this region; and figures from the Caribbean Epidemiology Centre (CAREC) show that hypertensive disease was the fifth leading cause of death in 2000. It should be noted that the leading causes of death were cerebrovascular disease (including stroke), heart failure and ischaemic heart disease, which are known complications of hypertensive disease. Hypertension is termed "the silent killer," as hypertensives are often asymptomatic.

The factors which contribute to hypertension are similar to those of the other major chronic noncommunicable diseases, such as obesity and diabetes. These include unhealthy diet, high salt intake, inadequate exercise, and excessive use of alcohol. The prevalence of hypertension also usually rises with age.

Findings from the International Comparative Study of Hypertension in Blacks (ICSHIB) indicated that, among persons affected, the awareness of hypertension (>140/90 mmHg) was 65%, treatment was 50% and control 25%, with control rates ranging from 38% in Barbados to 13% in Saint Lucia. In the more recent Barbados Eye Studies, there was little or no improvement (awareness 63%, treatment 53% and control 19%). These figures point to the need for greater public education, improved access to services and greater cooperation between patient and healthcare worker to ensure adherence to treatment goals, since better control will dramatically reduce complications, morbidity, and mortality.

Recent publications urge early and aggressive approaches to prevention and management of hypertension. A new category of pre-hypertension has been described and this warns of the need to start/continue the promotion of healthy lifestyles in those in this category. Tight control of the hypertension itself requires a patient-centered approach of lifestyle modification and drug therapy.

Primary prevention of hypertension must be the goal of the health system and requires actions that target the general population as well as individuals, especially those at higher risk for hypertension. The commonality of many risk factors for hypertension and diabetes justifies an integrated approach to the prevention and control of both. The fact that cardiovascular diseases resulting from hypertension and diabetes account for about 40% of Caribbean mortality further justifies this approach and highlights its urgency.