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VOLUME 11 NUMBER 4 • NOVEMBER 2014
139
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
South African hypertension practice guideline 2014
Hypertension guideline working group: YK Seedat, BL Rayner, Yosuf Veriava
Correspondence to: Brian L Rayner
Department of Medicine, University of Cape Town, Cape Town
e-mail:
brian.rayner@uct.ac.zaYK Seedat
Department of Medicine, University of KwaZulu-Natal, Durban, South Africa
Yosuf Veriava
Department of Medicine, University of Cape Town, Cape Town
Previously published in
Cardiovasc J Afr
2014;
25
(6): 288–294
S Afr J Diabetes Vasc Dis
2014;
11
: 139–144
Abstract
Outcomes:
Extensive data frommany randomised, controlled
trials have shown the benefit of treating hypertension
(HTN). The target blood pressure (BP) for antihypertensive
management is systolic < 140 mmHg and diastolic < 90 mmHg,
with minimal or no drug side effects. Lower targets are no
longer recommended. The reduction of BP in the elderly
should be achieved gradually over one month. Co-existent
cardiovascular (CV) risk factors should also be controlled.
Benefits:
Reduction in risk of stroke, cardiac failure, chronic
kidney disease and coronary artery disease.
Recommendations:
Correct BP measurement procedure is
described. Evaluation of cardiovascular risk factors and
recommendationsforantihypertensivetherapyarestipulated.
Lifestylemodification and patient education are cornerstones
of management. The major indications, precautions and
contra-indications are listed for each antihypertensive
drug recommended. Drug therapy for the patient with
uncomplicated HTN is either mono- or combination therapy
with a low-dose diuretic, calcium channel blocker (CCB) and
an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB).
Combination therapy should be considered ab initio if the BP
is ≥ 160/100 mmHg. In black patients, either a diuretic and/
or a CCB is recommended initially because the response rate
is better compared to an ACEI. In resistant hypertension, add
an alpha-blocker, spironolactone, vasodilator or
β
-blocker.
Validity:
The guideline was developed by the Southern
African Hypertension Society 2014
©
.
Keywords:
South Africa, hypertension, guideline
This is the sixth hypertension guideline published by the Southern
African Hypertension Society (SAHS). Currently 30.4% of the adult
population have hypertension (HTN),
1
necessitating a simplified
approach to assessment and treatment, which reflects realistic
objectives that can be implemented by medical practitioners, nurse
practitioners and pharmacists to diminish the impact of HTN and
related cardiovascular disease (CVD) risk in this country. For full
details on management not contained in this document please
refer to the more detailed hypertension guideline 2011.
2
Objective
The objective of this guideline was to promote evidence-based,
accessible and comprehensive management of HTN by healthcare
professionals in the public and private sectors. Applicable HTN and
CVD treatment and prevention guidelines were reviewed as well
as HTN trials reporting clinical end-points, including those with
individuals with important co-morbidities such as diabetes mellitus
and chronic kidney disease.
3-9
Definition and grading of hypertension
HTN is defined as a persistent elevation of office blood pressure (BP)
≥ 140/90 mmHg (Table 1). The optimal BP is a value < 130/85 mmHg.
High normal is BP levels from 130–139 mmHg systolic and 85–89
mmHg diastolic. This high-normal group of subjects is at higher CV
risk and is also at risk of developing HTN, but does not require drug
treatment.
10
HTN is stratified into three grades depending on severity,
which is useful in defining the approach to treatment.
Measurement of blood pressure
BP measurement is a vital clinical sign that is poorly performed by all
healthcare professional categories. These recommendations apply
to both clinic and self-measurement of BP. Failure to follow these
Table 1.
Definitions and classification of office BP (mmHg). Adapted
from ref 9
Stage
Systolic BP
(mmHg)
Diastolic BP
(mmHg)
Normal
< 120
and
< 80
Optimal
120–129
and/or
80–84
High normal
130–139
and/or
85–89
Grade 1
140–159
and/or
90–99
Grade 2
160–179
and/or
100–109
Grade 3
≥ 180
and/or
≥ 110
Isolated systolic
≥ 140
and/or
< 90
BP should be categorised into the highest level of BP whether systolic or diastolic.
Table 2.
Recommendations for blood pressure measurement
Allow patient to sit for 3–5 minutes before commencing measurement
The SBP should be first estimated by palpation to avoid missing the ausculta-
tory gap
Take two readings 1–2 minutes apart. If consecutive readings differ by > 5
mm, take additional readings
At initial consultation measure BP in both arms, and if discrepant use the
higher arm for future estimations
The patient should be seated, back supported, arm bared and arm supported
at heart level
Patients should not have smoked, ingested caffeine-containing beverages or
food in previous 30 min
An appropriate size cuff should be used: a standard cuff (12 cm) for a normal
arm and a larger cuff (15 cm) for an arm with a mid-upper circumference >
33 cm (the bladder within the cuff should encircle 80% of the arm)
Measure BP after 1 and 3 minutes of standing at first consultation in the eld-
erly, diabetics and in patients where orthostatic hypotension is common
When adopting the auscultatory measurement use Korotkoff 1 and V (disap-
pearance) to identify SBP and DBP respectively
Take repeated measurements in patients with atrial fibrillation and other
arthythmias to improve accuracy