1. Blood pressure control in primary health care WORKSHOP
Jurate Klumbiene
Kaunas University of Medicine, Kaunas, Lithuania

2. Workshop agenda
Presentation of a patient case in which the patient has hypertension
Identification of the patient’s problems and CVD risk (individual exercise and plenary discussion)
Designing a treatment plan (group work):
Non-pharmacological measures
Treatment goals, pharmacological therapy
Measures to ensure compliance
Presentation of the plans and discussion (plenary presentation)

3. CASE: Alexander is a 56-year-old driver who schedules a visit as part of a regular health examination.
History:
no significant past medical history, no medicine prescriptions
a regular smoker (20cig/day since 25 years old)
drinks a couple bottles of beer a night and "a bit more on the weekend”
no family history of CVD
Physical examination:
Blood pressure (BP) 146/94 (repeated BP – 144/92, 148/98)
Pulse rate 76, regular
Weight kg, height – 178 cm
Waist circumference – 110 cm
The remainder of the physical examination was unremarkable
Laboratory investigations
No abnormalities

4. Task for each participant
Identify the patient’s problems and assess CVD risk.
Use ESH/ESC categorical stratification of cardiovascular risk.

5. The patient’s problems and CVD risk
Plenary discussion
The patient’s problems and CVD risk

6. Tasks for group work Non-pharmacological treatment
Treatment goals and pharmacological therapy
The measures to ensure compliance

7. CLASSIFICATION OF BP LEVELS (European Society of Hypertension and Cardiology, 2007)
CATEGORIES Systolic BP Diastolic BP
Optimal BP < and/or <80
Normal BP and/or 80-84
High-normal BP and/or 85-89
Grade1 hypertension (mild) and/or 90-99
Grade2 hypertension (moderate) and/or
Grade3 hypertension (severe) > and/or >110
Isolate systolic hypertension > and <90

8. Stratification of CVD Risk (2007 Guidelines for the management of arterial hypertension, ESH and ESC)
Other risk factors, OD or disease
Normal BP
High normal BP
Grade 1 HT
Grade 2 HT
Grade 3 HT
No other risk factors
Average
risk
Low
added risk
Moderate added risk
High added risk
1-2 risk factors
Very high added risk
3 or more risk factors, MS, OD or diabetes
Established CVD or renal disease
BP: blood pressure; CVD: cardiovascular; HT: hypertension. Low, moderate, high, very high risk refers to 10 year risk of a CVD fatal or non-fatal event. The term “added” indicates that in all categories risk is greater than average. OD: subclinical organ damage; MS: metabolic syndrome.

9. Presentation of the treatment plans and discussion

10. Blood pressure control
Summary
Blood pressure control

11. TREATMENT GOALS
To achieve a maximum reduction in the long-term total risk of cardiovascular morbidity and mortality (the treatment of all reversible risk factors identified, including smoking, dyslipidaemia or diabetes and the appropriate management of associated clinical conditions, as well as treatment of high blood pressure per se).
Blood pressure, both systolic and diastolic, should be lowered in all hypertensive patients:
At least below 140/90 mmHg.
It may prudent to recommend lowering blood pressure to values within the range /80-85 mm Hg (Reappraisal of European guidelines on hypertension management, 2009).

12. TREATMENT STRATEGIES
Lifestyle measures (non-pharmacological treatment) should be instituted whenever appropriate in all patients, including subjects with high normal blood pressure and patients who require drug treatment.
The purpose of non-pharmacological treatment is to lower blood pressure, to control other risk factors and clinical conditions and to reduce the number and doses of antihypertensive drugs which might be subsequently used.

13. Initiation of antihypertensive treatment (ESH/ESC, 2007)
Other risk factors, OD or disease
Normal BP
High normal BP
Grade 1 HT
Grade 2 HT
Grade 3 HT
No other risk factors
No BP intervention
Lifestyle changes for several months then drug treatment if BP uncontrolled
Lifestyle changes for several weeks then drug treatment if BP uncontrolled
Lifestyle changes + immediate drug treatment
1-2 risk factors
Lifestyle changes
3 or more risk factors, MS, OD or diabetes
Lifestyle changes and consider drug treatment
Lifestyle changes + drug treatment
Diabetes
Established CVD or renal disease