0CTOBER 2010 An Approach for Sub-Saharan Africa

Dr. Linda Hawker, MD, CCFP General Practice Kelowna BC Canada

Contents based on the WHO CVD - Risk Management Package For low and medium resource settings 2002

 “Hypertension plays a major role in the development of cerebrovascular disease, ischemic heart disease, cardiac and renal failure. Treating hypertension has been associated with about a 40% reduction in the risk of stroke and about a 15% reduction in the risk of myocardial infarction.”  “Hypertension remains inadequately managed everywhere.” (2003 WHO / ISH statement on the management of hypertension)

 Appropriate assessment and management of cardiovascular risk is vital to prevent fatal and non fatal heart attacks and strokes and to improve health outcomes of those at high risk of cardiovascular disease (CVD).  Hypertension is a major risk factor in development of CVD.

 Three major risk categories  Likelihood of stroke, heart attack in next 10 years: ◦ 1. Low risk : less than 15% ◦ 2. Medium risk : 15 – 20% ◦ 3. High risk: more than 20%

 High Blood pressure  Males over 55 years  Females over 65 years  Smoking  Total cholesterol > 6.1 mmol/l  LDL (“bad”) cholesterol > 4.0 mm/l  HDL (“good”) cholesterol, M<1, F<1.2mmol/l  History of CVD in parents, siblings or children before age 50  Obesity, physical inactivity

 Left ventricular hypertrophy (EKG or echo)  Microalbuminuria ( mg/day)  X –ray or ultrasound evidence of artery plaque (aorta, carotid, coronary, femoral)  Hypertensive retinopathy grade 3 or 4

 Diabetes  History of TIA or stroke  Heart disease : angina, heart attack, congestive failure  Kidney disease : ◦ High creatinine: Females >120, Males >133umol/l ◦ Albuminuria >300 mg/day or >0.3 gms/L random  History of Peripheral Vascular Disease

Blood Pressure Risk factors >180 Disease History : >110 No other risk factors: Low risk Medium risk High risk 1- 2 risk factors: Medium risk Medium risk High risk 3 or more risks High risk High risk High risk Or TOD, or ACC:

 BP < 140/90 if uncomplicated BP < 130/80 if  Diabetes  Chronic renal disease  History of heart disease, TIA, stroke,PVD  Manage risk factors, TOD and ACC  Educate your patients

 Lifestyle Modification ◦ Weight reduction – aim for BMI 25 or less ◦ Limit salt intake – one teaspoon per day or less! ◦ Limit alcohol – 2 drinks/day men,1drink/day women ◦ Stop smoking ◦ Regular exercise – brisk walk for min/day ◦ Healthy diet – low in fat, sugar and refined foods, high in fresh fruits, vegs, fish. Low fat dairy foods. ◦ Reinforce lifestyle message at every visit

 For most patients, if there is no compelling reason for another class of drug, a low dose diuretic should be the first choice of therapy.  The major classes of drugs are equal in effectiveness and safety. If there is a specific indication (eg: renal disease), use the most cost effective drug of the appropriate class.

1. Th i azides ◦ Moduret (combo amiloride, HCT) 2. Beta Blockers Atenolol, Propanolol 3. Calcium Channel Blockers Nifedipine (short acting-not recommended) 4. ACE Inhibitors Captopril 5. Other: hydralazine, methyldopa

 Start with low dose thiazide diuretic, then add:  Kidney disease +/- Diabetes: ACE inhibitor  Heart disease: ◦ Post heart attack: ACE inhibitor ◦ Angina: Beta blocker ◦ Congestive Heart failure: Beta blocker, ACE inhibitor, diuretic – thiazide, furosemide, spironolactone ◦ Left ventricular hypertrophy: ACE inhibitor

ACE inhibitors/ ARB Pregnancy Hyperkalemia Beta Blockers Severe bradycardia, < 50 COPD Diuretics Gout

Diastolic BP over 120mmHg with acute end organ damage  Encephalopathy  Papilledema  Angina, heart attack  Transient ischemic attack, stroke  Acute renal failure  Acute pulmonary edema  Aortic dissection Admit to CCU, aim to lower BP to / by 2 hours, may need IV meds

 Diastolic BP over 120 mmHg without acute end organ damage  Admit and aim to lower BP to 160/100 over hours. Note: Too rapid lowering of BP can cause ischemia to brain, heart, kidneys  Use oral meds – diuretics, B Blockers, ACEI, Methyldopa DO NOT USE FAST ACTING NIFEDIPINE

 Hypertension, proteinuria, edema after 20wks  BP 180/110 or greater x 2 Treatment:  Give IV fluids, avoid diuretics  IV hydralazine 5 mg over 5 mins, repeat in 20 mins. Aim: BP / Deliver as soon as possible! Hypertension may persist post delivery Use methyldopa

 Detect – take BP  Identify and Stratify Risk Factors  Treat according to risk/assoc. disease  Follow

Educate your patients about cardiovascular disease risks Make them partners in treatment