The SA Journal Diabetes & Vascular Disease Vol 15 No 2 (November 2018)

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VOLUME 15 NUMBER 2 • NOVEMBER 2018 77
SA JOURNAL OF DIABETES & VASCULAR DISEASE PASCAR ROADMAP
A simple and practical treatment algorithmusing these thresholds
is recommended (Fig. 2). Our schedule should consider patient
costs (including transport and loss of wages because of time off to
attend clinic visits), which affect treatment adherence and burden
to the healthcare system.
Table 2. Blood pressure guidelines
ASH/ISH AHA/ACC/ US JNC 8 South Africa
WHO PEN1 NICE 20112 ESH/ESC 20133 20144 CDC 20135 2014 6 2015 7 Egypt 20138
Definition of ≥ 140/90 ≥ 140/90 and ≥ 140/90 ≥ 140/90 ≥ 140/90 Not addressed ≥ 140/90 ≥ 140/90 (high risk) –
hypertension daytime ABPM 150/95 (low risk) and
(mmHg) (or home BP) daytime ABPM (or
≥ 135/85 home BP) ≥ 135/85
Drug therapy in > 160/100 ≥ 160/100 or ≥ 140/90 ≥ 140/90 ≥ 140/90 < 60 years, ≥140/90 ≥ 140/90 for
low-risk patients daytime ABPM ≥140/90; high risk and
after non-pharmacological ≥ 150/95 ≥ 60 years, ≥ 160/100 for
treatment ≥ 150/90 low risk
(mmHg)
First-line therapy < 55 years, low- < 55 years, ACE inhibitor or Low-dose ACE inhibitor ACE inhibitor Any of diuretics,
dose thiazide ACE inhibitor ARB; beta-blocker; diuretic or ARB; or ARB; betablockers,
diuretic and/or or ARB; ≥ 55 CCB; diuretic CCB; diuretic CCB; diuretic CCB, ACEIs
≥ 60 years, ACE inhibitor; years or African CCB/diuretic CCB/diuretic or ARBs. preferably
≥ 55 years, CCB ancestry, CCB in people in people a thiazide diuretic. In
and/or low-dose of African of African elderly (> 65 years) or
thiazide diuretic ancestry ancestry in blacks, start with
diuretic or CCB.
Beta-blockers as No No (step 4) Yes (in specific No (step 4) No (step 3) No (step 4) No (step 4) Yes, in specific e.g.
first-line drug subgroups) young, particularly
those with tachycardia
Diuretic Thiazides, Chlortalidone, Thiazides, Thiazides, Thiazides Thiazides, Thiazide or Thiazides,
indapamide chlortalidone, chlortalidone, chlortalidone, thiazide-like chlorthalidone,
indapamide indapamide indapamide (indapamide) amiloride or
spironolactone
Initiate drug Not mentioned Not mentioned In patients with ≥ 160/100 ≥ 160/100 ≥ 160/100 ≥ 160/100 Diuretic +
therapy with two markedly elevated beta-blockers/
drugs (mmHg) BP or patients with CCB/ACEIs/ARBs
high overall CV risk if BP > 170/105
Blood pressure < 140/90 < 140/90; < 140/90; elderly < 140/90; < 140/90; < 60 years, < 140/90 < 150/95 in
target (mmHg) ≥ 80 years, < 80 years, SBP ≥ 80 years, lower targets < 140/90; low-risk
< 150/90 140–150, SBP < 150/90 may be ≥ 60 years patients and in
< 140 in fit patients; appropriate in < 150/90 elderly (> 65 years).
elderly ≥ 80 years, some patients, < 140/90: ≥ 2 risk
SBP 140–150 including the factors, CKD, TOD
elderly < 130/80: HF or CKD
when associated with
proteinuria > 1 g/24
hours.
Blood pressure < 130/80 Not addressed < 140/85 < 140/90 < 140/90; < 60 years, < 140/90 < 140/90 mmHg
target in patients lower targets < 140/90; or < 130/80 if
with diabetes may be ≥ 60 years, associated with
mellitus (mmHg) considered < 150/90 proteinuria
> 1 g/24 hours
ABPM, ambulatory blood pressure monitoring; ACC, American College of Cardiology; ACE inhibitor, angiotensin converting enzyme inhibitor; AHA, American Heart
Association; ARB, angiotensin receptor blocker; ASH, American Society of Hypertension; BP, blood pressure; CCB, calcium channel blocker; CDC, Centers for Disease Control
and Prevention; CKD, chronic kidney disease; CV, cardiovascular; ESC, European Society of Cardiology; ESH, European Society of Hypertension; ISH, International Society of
Hypertension; NICE, National Institute for Health and Care Excellence; SBP, systolic blood pressure; TOD, target-organ damage; US JNC 8, Eighth US Joint National Committee;
WHO PEN, World Health Organisation Package of Essential Non-communicable disease interventions.
1World Health Organisation. Implementation tools: package of essential non-communicable (PEN) disease interventions for primary healthcare in low-resource settings.
Available at: Accessed April 8, 2015.
2National Institute for Health and Care Excellence. NICE guidelines [CG127]. Hypertension: clinical management of primary hypertension in adults. Available at:
Accessed April 8, 2015.
3Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension
of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013; 34: 2159–2169.
4Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of
Hypertension and the International Society of Hypertension. J Hypertens 2014; 32: 3–15.
5Go AS, Bauman MA, Coleman King SM, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American
College of Cardiology, and the Centers for Disease Control and Prevention. J Am Coll Cardiol 2014; 63: 1230–1238.
6James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the
Eighth Joint National Committee (JNC 8). J Am Med Assoc 2014; 311: 507–520.
7Seedat Y, Rayner B, Veriava Y. South African hypertension practice guideline 2014. Cardiovasc J Afr 2014; 25(6): 288–194.
8The Egyptian Hypertension Society: Egyptian hypertension guidelines. Egypt Heart J 2014; 66(2): 79–132.
Because of the asymptomatic nature of hypertension, long-term
medication adherence is poor. Patients and healthcare practitioners
must be educated on non-pharmacological BP control methods
(see Fig. 2). We encourage patient education using text messages,
e-mails or social media (WhatsApp or Facebook), all of which are