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VOLUME 11 NUMBER 4 • NOVEMBER 2014
141
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
Goals of treatment
There has been considerable controversy about BP goals and
SAHS accepts that to simplify management, a universal goal of
antihypertensive treatment is < 140/90 mmHg regardless of CV
risk and underlying co-morbidities.
5
The only exception is that in
patients over 80 years of age, therapy should be initiated if SBP is
> 160 mmHg and the goal is between 140 and 150 mmHg, based
on the HYVET study in which the majority of patients received
indapamide and the ACEI perindopril.
15
SAHS does not support the JNC-8 committee recommendations
of a goal BP < 150/90 mmHg for persons over 60 years without
diabetes and CKD, as (1) increasing the target will probably reduce
the intensity of antihypertensive treatment in a large population
at high risk for cardiovascular disease, (2) the evidence supporting
increasing the SBP target from 140 to 150 mmHg in persons
aged 60 years or older was insufficient, (3) the higher SBP goal in
individuals aged 60 years or older may reverse the decades-long
decline in CVD, especially stroke mortality.
8,16
It is also essential to control hyperlipidaemia and diabetes
through lifestyle and drug therapy, according to the Society for
Endocrine Metabolism Diabetes of South Africa and South African
Heart Association/Lipid and Atherosclerosis Society of Southern
Africa guidelines, respectively.
17,18
Aspirin should not be routinely
prescribed to hypertensives (especially if BP is not controlled),
19
and
should mainly be used for secondary prevention of CVD (transient
ischaemic attack, stroke, myocardial infarction).
Management of hypertension
All patients with HTN should receive lifestyle counselling as outlined
in Table 6, and this is the cornerstone of management. The approach
to drug treatment is outlined in Fig. 1. If the SBP is ≥ 180 mmHg or
the DBP is ≥ 110 mmHg then refer to section 8 on severe (grade 3)
HTN, as this section does not apply.
Before choosing an antihypertensive agent, allow for
considerations based on the cost of the various drug classes, patient-
related factors, conditions favouring use and contra-indications,
complications and target-organ damage (TOD) (Tables 4, 7).
In otherwise uncomplicated primary HTN, the initial first choice
of antihypertensive drug is a diuretic (thiazide-like or thiazide), ACEI
or ARB, and/or CCB used as mono- or combination therapy (Fig. 2).
Combination therapy should be considered if clinically appropriate
ab initio if BP is ≥ 160/100 mmHg (Fig. 1) as this is associated with
better clinical outcomes and earlier achievement of goal BP.
20,21
Table 5.
Routine investigations
Test
Comment
Height, weight, BMI
Ideal BMI < 25 kg/m
2
, overweight 25–
30 kg/m
2
, obese > 30 kg/m
2
Waist circumference
Men < 102 cm; women < 88 cm. South
Asians and Chinese: men < 90 cm and
women < 80 cm
Electrolytes
Low potassium may indicate primary
aldosteronism, or effects of diuretics
ECG
S in V1 plus R in V5 or V6 > 35 mm or R in
aVL > 11 mm or Cornel product (R in aVL +
S in V3 + 6 in females) × QRS duration >
2 440 (mm/ms)
Echocardiogram (if indicated
and facilities available)
LVH: men > 115 g/m
2
and women > 95 g/m
2
Fasting glucose
Consider HBA
1c
or GTT if impaired fasting
glucose (6.1–7.1 mmol/l)
Cholesterol
If total cholesterol > 5.1 mmol/l – fasting
lipogram
Creatinine
Calculate eGFR
Uric acid
High uric acid is relative contra-indication
to diuretics
Dipsticks urine
If abnormal, urine microscopy and protein
estimation
Fig. 1.
Overview of approach to treatment.
Table 6.
Recommended lifestyle changes
Modification
Recommendation
Approx
↓
SBP
(mmHg)
Weight reduction
BMI 18.5–24.9 kg/m
2
5–20 per 10 kg
Dash diet
↓
saturated fat and
total fat,
↑
fruit and
vegetables
8–14
Dietary Na
+
< 100 mmol or 6 g
NaCl/day
2–8
Physical activity
Brisk walking for 30
minutes per day most
days
4–9
Moderation of
alcohol
No more than two
drinks per day
2–4
Tobacco
Complete cessation
–
Fig. 2.
Initial choices of antihypertensive treatment or combinations.