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. 2013 Jan 17;8(1):e53744. doi: 10.1371/journal.pone.0053744

Table 6. Recommendations from Clinical Practice Guidelines about Managing Patients with Hypertension.

ITEM SOA 2006 IND 2007 POL 2007 MAL 2008 EUR 2009 JAP 2009 LAT 2009 AUS 2010 CAN 2011 SAU 2011 NICE 2011
Advice about Lifestyle changes
Maintain weight √ √ √ √ √ √ √ √ √ √ √
Lower sodium intake √ √ √ √ √ √ √ √ √ √ √
Limit alcohol √ √ √ √ √ √ √ √ √ NR √
Follow nutrition guidelines √ √ √ √ √ √ √ √ √ √ √
Limit sugar intake √ NR √ NR NR NR NR √ √ NR NR
Lower fat intake √ √ √ √ √ √ √ NR √ √ √
moderate-intensity exercise for at least 30 minutes on most or preferably all days of the week NR NR NR √ √ √ √ NR √ NR √
Stop smoking √ √ √ √ √ √ √ √ √ √ √
Other
Dietary supplements NR NR NR √ NR NR NR NR NR NR NR
Increasing K NR NR NR NR NR NR √ NR √ NR NR
Stress management NR NR NR √ NR √ NR NR √ NR √
When to initiate Therapy?
Low added risk despite a period of 6–12 months of lifestyle modification and observation √ 3 months cut-off NR √1 √ 3 months cut-off √ √ √2 √ NR
Moderate added risk despite a period of 3–6 months of lifestyle modification and observation √ 2–3 months cut-off NR √3 √ 1 month cut-off √ √ √4 √ NR
High or very high added risk √ √ √ √5 √ √ √ √ √ √ √
How to initiate drug therapy?
Step 1 Use a low-dose diuretic as initial therapy √ √ NR NR NR NR NR NR NR √ NR
use agent from any of the 5 classes (A,B,C,D) as first line NR √ √ √ √ √ √ √ √ √ √6
Step 2: Consider costs, other conditions contraindications and if OK prescribe ACE-Is and CCBs √ √ √ √ √ √ √ √ √ √ √
Other second-line medication from the 5 classes √ √ √ √ √ √ √ √ √ √ √
Step 3: Other third-line medication? Add A or C A or B+C+D A diuretic should be one of them Combination of therapies √ Add a third agent √ √ Yes if not controlled Renin inhibitors A+C+D
Adjustment of therapy
Strategies:
Increase dose of 1st agent NR NR NR √ NR √ NR NR NR NR √
Substitute with another agent NR √ NR √ NR √ NR NR NR NR NR
Add another agent √ √ NR √ √ √ NR NR NR NR √
Other Strategies NR intensify life style long acting mono-therapy NR NR give drug twice daily NR NR Changes in nocturnal BP NR NR
Choice of anti-hypertension therapy
Start with mono-therapy and move to combo therapy √ √ √ √ √ √ not clear √ √7 √ √
and/or two drug combination as initial NR √ NR NR NR NR NR NR NR √7 NR
Recommendations about combination therapy
Which drug combination? D+BB various various various Various Various Not clear A+C various A+C A+C
Considerations for special groups
Elderly √ √ NR √ √ √ √ √ NR √ √
Diabetics √ √ √ √ √ √ √ √ √ √ NR
Proteinuria √ √ NR √ √ √ √ √ √ √ √
Renal insufficiency √ NR NR √ NR √ √ NR √ √ NR
renal failure NR √ √ NR √ √ √ NR NR NR √8
Bilateral artery stenosis NR NR NR √ NR √ NR NR NR NR NR
Heart Failure √ √ √ √ √ √ √ √ √ √ √
Post MI √ √ √ √ √ √ √ √ √ √ NR
Angina √ √ √ √ √ √ √ √ √ √ NR
Peripheral vascular disease √ √ √ NR √ √ √ NR NR √ NR
Carotid atherosclerosis √ NR NR NR √ √ NR NR NR NR NR
CCB for Supraventricular tachycardia √ NR NR NR √ √ √ NR NR √ NR
Left ventricular dysfunction/LVH √ NR √ √ √ √ √ NR √ √ √
Tachyarrhythmias √ √ NR √ √ NR √ √ √ √ NR
COPD √ √ √ √ √ √ NR √ NR √ NR
Pregnancy √ √ √ √ √ √ √ √ NR √ NR
Metabolic Syndrome NR √ √ NR √ √ √ NR NR √ NR
Resistant Hypertension √ NR NR NR √ √ NR NR NR √ √
HTN Emergencies
Hospitalization and IV drugs √ √ NR √ NR √ √ NR NR √ NR
Recommendations on managing associated risk factors
Antiplatelet therapy8 √ √ √ √ √ √ √ √ √ √ √13
Lipid Lowering agent8 NR √ √ √9 √ √ √ √ √ √ √13
Glycemic control NR √10 NR NR √11 NR √12 NR NR NR NR
Frequency of follow up
Frequency of follow up during stabilization phase NR NR NR NR NR NR NR Every 6 weeks or as needed NR Monthly or according to risk NR
Frequency of follow up for patients with stabilized hypertension √14 √15 NR √14 NR NR NR √16 NR √15 √17
Assessment of compliance discussed √ NR NR √ √ √ NR NR √ √ √
Strategies to improve adherence discussed √ NR NR √ NR √ NR √ √ √ √
“When to Refer?” discussed √ √ NR √ NR √ √ √ √18 √ √

SOA: South Africa; IND: India; POL: Poland; MAL: Malaysia; EUR: Europe; JAP: Japan; LAT: Latin America; AUS: Australia; CAN: Canada and SAU: Saudi Arabia and NICE (The UK's National Institute for Health and Clinical Excellence). NR: not reported. A: angiotensin converting enzyme inhibitor (ACEI), or angiotensin receptor blockers (ARB), C: calcium channel blocker (CCB), D: Diuretic.

1

And if SBP>150 and or DBP>95- treat.

2

If the SBP> or  = 140 mm Hg or DBP> or  = 90 mm Hg across 5 visits.

3

if SBP = 120–159 mmHg AND/OR DBP = 80–99 mmHg.

4

If, at visit 2 within one month, SBP is > or  = 140 mm Hg and/or DBP is > or  = 90 mm Hg.

5

If SBP = 120–159 mmHg AND/OR DBP = 80–99 mmHg with high risk or if SBP 160 mmHg AND/OR DBP 100 mmHg regardless of risk.

6

NICE CPG favored A for those below 55 years and C, D, for those aged 55 years or older and for black patients.

7

Yes if SBP>10 mmHg above target.

8

Recommended in at least certain high risk groups.

9

Recommended for those with atherosclerotic renal artery stenosis only.

10

No target level stated.

11

A1c<6.5 mmol/L.

12

A1c between 6.5–7% in patients with HTN, DM and nephropathy.

13

Referred to previous guideline version.

14

Every 3–6 months;

15

Every 3 months for high risk patients and every 6 months for low risk patients;

16

Every 3 months for the first year then 6-monthly thereafter;

17

Once a year.

18

For pheochromocytoma cases only.