1999 WHO-ISH Hypertension Practice Guidelines for Primary Care Physicians

1
1999 WHO-ISHHypertension Practice Guidelinesfor
Primary Care Physicians

• World Health Organization
• INTERNATIONAL SOCIETY OF HYPERTENSION

2
Working Group Practice Guidelines

• John Chalmers (Australia, Chairman)
• Paul Chusid (USA)
• Jay N Cohn (USA)
• Lars H Lindholm (Sweden, Writing Coordinator)
• Ingrid Martin (WHO, Switzerland)
• Karl-Heinz Rahn (ISH, Germany)
• Peter Sleight (WHL, UK)

3
WHO-ISH HypertensionGuidelines Subcommittee

• Michael Alderman (USA)
• Kikuo Arakawa (Japan)
• Lawrie Beilin (Australia)
• John Chalmers(Australia, Chairman)
• Serap Erdine (Turkey)
• Masatoshi Fujishima (Japan)
• Pavel Hamet (Canada)
• Lennart Hansson (Sweden)
• Lewis Landsberg (USA)
• Frans Leenen (Canada)
• Lars H Lindholm (Sweden)

Liu Lisheng (China) AFB Mabadeje
(Nigeria) Stephen MacMahon (Australia) Giuseppe
Mancia (Italy) Ingrid Martin (Switzerland) Albert
Mimran (France) Karl-Heinz Rahn (Germany) Arturo
Ribeiro (Brazil) Peter Sleight (UK) Judith
Whitworth (Australia) Alberto Zanchetti (Italy)
4

• The WHO-ISH Guidelines are written for a global
  audience from communities that vary widely in the
  nature of their health system and in the
  availability of resources.
• The goal, however, remains universally the same,
  that is to lower BP and other risk factors in
  order to reduce the risk of CVD.

4
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
5
Global Goal
5
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
6
What is the Goalof the Practice Guidelines?

• To lower blood pressure (BP) and other risk
  factors in order to reduce the risk of
  cardiovascular disease (CVD)

6
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
7
Why is Hypertension Management Needed? (1)

• 600 million hypertensives in the world
• 3 million die annually as a direct result of
  hypertension

8
Why is Hypertension Management Needed? (2)

• The Rule of Halves
• Only 1/2 have been diagnosed
• Only 1/2 of those diagnosed have been treated
• Only 1/2 of those treated are adequately
  controlled
• Thus, only 12.5 overall are adequately controlled

9
What is New?
1999 WHO-ISH 1993 WHO-ISH JNC-VI Definition of
gt 140/90 gt140/90 gt140/90 hypertension Levels Gra
de 1,2,3 Mild, Moderate, Stage
1,2,3 Severe Decision Not based on BP BP to
treat BP alone, but assessment of total CV
risk Target BPs lt130/85 lt130/80 lt140/90 lt140/90
(elderly) lt140/90 (elderly)
9
10
What is New?
10
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
11
Why BP lt130/85 mm Hgand Not lt140/90 mm Hg? (1)

• The relationship between CV risk and BP is
  continuous
• Today, more than 50 of all hypertensives have BP
  gt160/90 mm Hg and 75 have BP gt140/90
• The major determinant of the risk reduction
  conferred by antihypertensive therapy is the BP
  level attained

12
Why BP lt130/85 mm Hgand Not lt140/90 mm Hg? (2)

• In diabetics, there is a clear benefit of
  lowering BP lt85 mm Hg
• The HOT Study showed that lowering BP lt 85 mm Hg
  did not increase CV risk
• The goal should be to attain normal BP (lt130/85
  mm Hg)

13
Questions to be Answered (1)

• What is high blood pressure?
• Clinical evaluation - what should be done?
• Which factors influence prognosis?
• Do patients benefit from antihypertensive
  treatment?
• How should hypertension be managed?

13
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
14
Questions to be Answered (2)

• Which drug treatments should be used?
• What treatment goal should be set and how should
  patients be followed up?
• How should hypertension during pregnancy be
  handled?
• How should hypertension in Type-2 diabetics be
  handled?

14
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
15
What is High Blood Pressure?

• BP levels are continuously related to the risk of
  CVD
• Definition of hypertension or raised BP is
  arbitrary
• Even within the normotensive range, people with
  the lowest BP levels have the lowest rates of CVD

16
Relative Risk of CHD and Stroke in Relation to
Patients Usual Diastolic BP
16
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
17
New (1999) WHO-ISH Definitionsand Classification
of BP Levels
Category Systolic BP Diastolic BP (mm Hg) (mm
Hg) Optimal BP lt120 lt80 Normal
BP lt130 lt85 High-Normal 130-139 85-89 Grade 1
Hypertension (mild) 140-159 90-99 Subgroup
Borderline 140-149 90-94 Grade 2 Hypertension
(moderate) 160-179 100-109 Grade 3 Hypertension
(severe) gt180 gt110 Isolated Systolic
Hypertension gt140 lt90 Subgroup
Borderline 140-149 lt90
18
Clinical Evaluation - What Should Be Done?

• Confirm elevation of BP
• Exclude or identify secondary causes of
  hypertension
• Determine presence of target organ damage and
  quantify extent
• Search for other CV risk factors and clinical
  conditions that may influence prognosis and
  treatment

19
How to Record BP (1)

• Measure BP several times on separate occasions
  with the patient in sitting position
• Use a mercury sphygmomanometer or other
  non-invasive device

19
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
20
How to Record BP (2)

• Measure BP several times on several occasions
• Allow the patient to sit for several minutes
  before measuring BP
• Use a cuff with a bladder that is 12-13 cm X 35
  cm, larger for fat arms
• Use phase 5 Korotkoff sounds (disappearance) to
  measure diastolic BP
• Measure BP in both arms at first visit
• Measure BP in standing position in elderly
  subjects and diabetic patients
• Place sphygmomanometer cuff at heart level,
  whatever the position of the patient

20
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
21
Multiple BP Measurements Recommended

• Because BP is characterized by large spontaneous
  variations, diagnosis should be based on multiple
  BP measurements taken on several separate
  occasions

21
22
Minimum RoutineInvestigations

• Clinical and family history
• Full physical examination as described in medical
  textbooks
• Laboratory investigations, including
• urinalyses for blood, protein, and glucose
• microscopic examination of the urine
• blood chemistry for potassium, creatinine,
  fasting glucose, and total cholesterol
• Electrocardiography (ECG)

22
23
Isolated Office Hypertension

• In some patients office BP is persistently
  elevated whereas daytime BP outside clinic
  environment is not. Continuing debate whether
  isolated office hypertension (white coat
  hypertension) is an innocent phenomenon or
  carries an increased risk of CVD

23
24
Ambulatory BP Monitorings Should be Considered,
if

• Unusual variability of BP over the same or
  different visits
• Isolated office (white coat) hypertension in
  subjects with low CV risk
• Symptoms suggesting hypotensive episodes
• Hypertension resistant to drug treatment

24
25
Ambulatory BP Monitoring

• BP values obtained by home measurement or
  ambulatory monitoring are several mm Hg lower
  than office measurement
• Average 24 hour or home BP values around 125/80
  mm Hg office BP 140/90 mm Hg
• Reliable information about long-term prognostic
  value of ambulatory and home monitoring is awaited

25
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
26
Which Factors Influence Prognosis? (1)

• Decisions should not be made on BP alone, but
  also on presence of other risk factors, target
  organ damage, and concomitant diseases, as well
  as on other aspects of patients personal,
  medical, social, economic, ethnic, and cultural
  characteristics

26
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
27
Which Factors Influence Prognosis? (2)

• Risk factors of CVD
• I. Used for risk stratification
• II. Other factors adversely influencing
  prognosis
• Target organ damage (TOD)
• Associated clinical conditions (ACC)

27
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
28
Which Factors Influence Prognosis? (3)
Risk factors for CVD

• I. Used for risk stratification
• Levels of systolic and diastolic blood pressure
  (Grades 1-3)
• Men gt55 years
• Women gt65 years
• Smoking
• Total cholesterol gt6.5 mmol/L (250 mg/dl)
• Diabetes
• Family history of premature cardiovascular disease

28
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
29
Which Factors Influence Prognosis? (4)
Risk factors for CVD

• II. Other factors adversely influencing prognosis
• Reduced HDL cholesterol
• Raised LDL cholesterol
• Microalbuminuria in diabetes
• Impared glucose tolerance
• Obesity
• Sedentary lifestyle
• Raised fibrinogen
• High risk socioeconomic group
• High risk ethnic group
• High risk geographic region

29
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
30
Which Factors Influence Prognosis? (5)
Target organ damage (TOD)

• Left ventricular hypertrophy (electrocardiogram,
  echocardiogram, or radiogram)
• Proteinuria and/or slight elevation of plasma
  creatinine concentration 106-177 mmol/L (1.2-2.0
  mg/dl)
• Ultrasound or radiological evidence of
  atherosclerotic plaque (carotid, iliac, and
  femoral arteries, aorta)
• Generalised or focal narrowing of the retinal
  arteries

30
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
31
Which Factors Influence Prognosis? (6)
Associated clinical conditions (ACC)

• Cerebrovascular disease
• Ischaemic stroke
• Cerebral haemorrhage
• Transient ischaemic attack (TIA)
• Heart disease
• Myocardial infarction
• Angina pectoris
• Coronary revascularisation
• Congestive heart failure

1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
31
32
Which Factors Influence Prognosis? (7)
Associated clinical conditions (ACC)

• Renal disease
• Diabetic nephropathy
• Renal failure, plasma creatinine concentration
  gt177 mmol/L (gt2.0 mg/dl)
• Vascular disease
• Dissecting aneurysm
• Symptomatic arterial disease
• Advanced hypertensive retinopathy
• Haemorrhages or exudates
• Papilloedema

1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
32
33
Which FactorsInfluence Prognosis? (8)
Typical 10 year risk of stroke or myocardial
infarction

• Low risk lt15 percent
• Medium risk 15-20 percent
• High risk 20-30 percent
• Very high risk 30 percent or higher

33
34
Which FactorsInfluence Prognosis? (9)

• Example 1
• 65-year old man with diabetes, TIAs, and BP of
  145/90 mm Hg will have annual risk of major CVD
  event 20 times greater than 40-year old man with
  same BP but without diabetes or history of CVD

34
35
Which FactorsInfluence Prognosis? (10)

• Example 2
• 40-year old man with BP of 170/105 mm Hg will
  have risk of major CV event 2-3 times greater
  than man of same age with BP of 145/90 mm Hg and
  similar other risk factors

35
36
Stratifying Risk - Quantifying Prognosis
36
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
37
Do Patients Benefit from Antihypertensive
Treatment? (1)

• Yes, the randomized trials conducted to date have
  shown clear evidence of a lower incidence of
  major CVD events after high BP was treated with
  anti-hypertensive drugs.

37
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
38
Do Patients Benefit from Antihypertensive
Treatment? (2)

• There is as yet no evidence that the main benefit
  of treating hypertension is due to a particular
  drug property rather than to lowering BP per se.

38
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
39
Effects of Antihypertensive Treatment in
Randomised Controlled Trials
39
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
40
Absolute Effects of Antihypertensive Treatment
10/5 mm Hg 20/10 mm Hg Low risk
patients lt5 lt9 Medium risk patients 5-7 8-11
High risk patients 7-10 11-17 Very high risk
patients gt10 gt17
Patient Group Absolute treatment effects
(CVD events prevented per 1000 patients years)
40
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
41
Larger Risk Reductions?

• The estimates of antihypertensive benefits shown
  were reported from trials of about 5 years
  duration.
• It is possible that long-term treatment over
  decades might produce larger risk reductions.

41
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
42
Management Strategy (1)

• Initiate lifestyle measures wherever appropriate
  in all patients, including those who require drug
  treatment
• Smoking cessation
• Weight reduction
• Moderation of alcohol consumption
• Reduction of salt intake
• Increased physical activity

42
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
43
Management Strategy (2)

• Is patient at

Very High Risk
43
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
44
Management Strategy (3)

• Stratify Risk

Very High
Begin drug treatment
Begin drug treatment
44
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
45
Management Strategy (4)

• Stratify risk

Medium
Low
Monitor BP other risk factors for 3-6 months
Monitor BP other risk factors for 6-12 months
SBP gt140 or DBP gt90 Begin drug treatment
SBP lt140 or DBP lt90 Continue to monitor
SBP gt150 or DBP gt95 Begin drug treatment
SBP lt150 or DBP lt95 Continue to monitor
45
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
46
Principles of Drug Treatment (1)

• Use a low dose of one drug to initiate therapy
• If good response and tolerability but inadequate
  control increase the dose of the first drug
• If little response or poor tolerability change to
  another drug class

46
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
47
Principles of Drug Treatment (2)

• It is often preferrable to add a small dose of a
  second drug rather than increase the dose of the
  first drug
• Use long-acting drugs providing 24-hour efficacy
  on a once daily basis. Improves adherence to
  therapy and minimizes BP variability.

47
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
48
Principles of Drug Treatment (3)

• More evidence of beneficial CVD effects with
  older drugs (e.g., diuretics and beta-blockers)
• Evidence of benefit with newer drugs (e.g., ACE
  inhibitors and calcium antagonists) is
  accumulating.

48
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
49
Principles of Drug Treatment (4)

• There are six maindrug classes used worldwide -
  diuretics, beta-blockers, ACE inhibitors, calcium
  antagonists, alpha blockers, and angiotensin II
  antagonists.

49
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
50
Principles of Drug Treatment (5)

• All 6 classes are suitable for the initiation and
  maintenance of BP lowering therapy, but the
  choiceof drugs will be influenced by cost and by
  many factors for special groupsof patients. In
  some parts of the world, reserpine and methyldopa
  arealso used frequently.

50
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
51
Indications
Compelling PossibleHeart failure DiabetesElderly
patients Systolic hypertension
Diuretics
Contraindications
Compelling PossibleGout Dyslipidaemia Sexually
active males
51
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
52
Indications
Compelling PossibleAngina Heart failureAfter
myocardial infarct PregnancyTachyarrhythmias Diab
etes
Contraindications
Beta-Blockers
Compelling PossibleAsthma and Dyslipidaemia
Chronic obstructive Athletes and Pulmonary
disease Physically activeHeart block (AV
2,3) Patients Peripheral vascular disease
52
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
53
Indications
Compelling PossibleAngina PeripheralElderly
patients Vascular disease Systolic
hypertension
Calcium Antagonists
Contraindications
Compelling PossibleHeart block (AV 2,3) Heart
failure
verapimil or diltiazem
53
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
54
Indications
Compelling PossibleHeart failure Left
ventricular dysfunctAfter myocardial
infarctDiabetic nephropathy
ACE Inhibitors
Contraindications
Compelling PossiblePregnancyBilateral renal
artery stenosisHyperkalaemia
54
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
55
Indications
Compelling PossibleProstatic Hypertrophy Glucose
intolerance Dyslipidaemia
Alpha-Blockers
Contraindications
Compelling Possible Orthostatic
hypotension
55
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
56
Indications
Compelling PossibleACE-I cough Heart failure
Angiotensin II Antagonists
Contraindications
Compelling PossiblePregnancyBilateral renal
Artery stenosisHyperkalaemia
56
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
57
Combination Therapy (1)

• In most patients, appropriate combination therapy
  produces BP reductions that are twice as great as
  those obtained with monotherapy, for example,
  12-22 mm Hg systolic BP and 7-14 mm Hg diastolic
  BP for patients with initial BP of gt160/95 mm Hg

57
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
58
Combination Therapy (2)

• Effective drug combinations to treat hypertension
  are
• diuretic and beta-blocker
• diuretic and ACE inhibitor (or Angiotensin II
  antagonist)
• calcium antagonist (dihydropyridine) and
  beta-blocker
• calcium antagonist and ACE inhibitor
• alpha-blocker and beta-blocker

58
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
59
Other Drugs to Consider in Hypertension

• Aspirin
• Cholesterol lowering therapy

59
60
Treatment Goal (1)
Reduce total CVD risk

• Requires treatment of all reversible risk
  factors, such as smoking, raised cholesterol, or
  diabetes, and the management of associated
  clinical conditions, as well as treatment of
  raised BP

60
61
Treatment Goal (2)

• The goal of antihypertensive treatment should be
  to achieve optimal or normal BP in young,
  middle-aged, or diabetic subjects (below 130/85
  mm Hg), and at least high-normal BP in elderly
  patients (below 140/90 mm Hg)

61
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
62
Follow-Up (1)

• Follow-up during evaluation and stabilisation of
  treatment should be frequent to monitor BP and
  other risk factors
• Follow-up is important to establish good
  relations with the patient and to educate the
  patient, so that he/she takes responsibility for
  the life-long control

62
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
63
Follow-up (2)

• Good communication between physician and patient
  is essential because treatment of hypertension is
  for life
• Adequate information about BP and high BP, about
  risks and prognosis, about expected benefits of
  treatment, and about risks and side effects of
  treatment are essential for satisfactory
  life-long control of hypertension which is poor
  in many countries today

63
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
64
How Should HypertensionDuring Pregnancy be
Diagnosed?

• Usually defined by absolute levelof BP (for
  example, 140/90 mm Hg or over) or an increase in
  BP from pre-conception or first trimester (for
  example, SBP rise of gt25 mm Hg and/or DBP rise of
  gt15 mm Hg)

64
65
How Should HypertensionDuring Pregnancy be
Defined?

• Hypertension in pregnancy usually defined as
• pre-existing chronic hypertension
• de novo diagnosed, gestational hypertension or
  pre-eclampsia
• pre-eclampsia superimposed on chronic hypertension

65
66
How Should HypertensionDuring Pregnancy be
Handled?

• BP above 170/110 mm Hg should be lowered to
  protect mother from risk of stroke or eclampsia
• Opinion is divided on the need for drug treatment
  for BP below this level

66
67
Antihypertensive DrugsMost Widely Used
AcutelyDuring Pregnancy

• Nifedipine
• Labetalol
• Hydralazine

67
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
68
Antihypertensive DrugsMost Widely Used
ChronicallyDuring Pregnancy

• Beta-blockers
• oxprenolol, pindolol, labetalol
• atenolol, however, is associated with fetal
  growth retardation when used long-term throughout
  pregnancy
• Methyldopa
• Prazosin, hydralazine, nifedipine, and isradipine

68
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
69
Drugs Most WidelyAvoided During Pregnancy

• ACE inhibitors (associated with possible adverse
  fetal effects)
• Angiotensin ll antagonists (effects may be
  similar to ACE inhibitors)
• Diuretics used infrequently because of concerns
  of reducing already compromised plasma volume

69
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
70
Hypertensionin Type-2 Diabetics (1)

• Diabetes and hypertension are multiplicative risk
  factors for CVD
• Absence of hypertension in diabetes is associated
  with a better long-term survival

70
71
Hypertensionin Type-2 Diabetics (2)

• Progressive decline in glomerular function can be
  slowed with antihypertensive treatment
• Similar lifestyle measures are recommended for
  hypertension and diabetes

71
72
Hypertensionin Type-2 Diabetics (3)

• Good evidence for reductionin CVD events in
  diabetic patients treated with antihypertensivedr
  ugs, including diuretics,and more recently,
  beta-blockersand ACE inhibitors

72
73
Hypertensionin Type-2 Diabetics (4)

• The goal of antihypertensive treatment in Type-2
  diabetics should be to achieve optimal or
  normal BP (that is below 130/85 mm Hg)

73
74
What is the ImplementationPlan for Practice
Guidelines? (1)

• Publication in as many national medical journals
  as possible
• Over 2 million brochures to be printed in English
  and several other languages
• Distribution worldwide with assistance of
  national hypertension and GP societies

74
75
What is the ImplementationPlan for Practice
Guidelines? (2)

• Funding by multiple pharmaceutical companies with
  no-strings-attached unrestricted educational
  grants
• Presentations at symposia, congresses, medical
  meetings, hospitals, medical schools, etc.

75
76
Summary (1)

• The goal of the 1999 WHO-ISH Hypertension
  Practice Guidelines is to lower BP and other risk
  factors in order to reducethe risk of CVD

76
77
Summary (2)

• The goal of the 1999 WHO-ISH Hypertension
  Practice Guidelinesis to lower BP and other risk
  factors in order to reduce the risk of CVD -- in
  primary care settings outside the hospital

77
78

• How to Get Additional Copiesof Practice
  Guidelines
• Contact your nationalsociety/league of
  hypertension, or
• Write to World Health Organization Cardi
  ovascular Diseases Programme CH-1211 Geneva 27,
  Switzerland

• Fax [phone]
• E-mail watsonm_at_who.ch

78
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS
79
No-strings-attached UnrestrictedGrant Funding
for Practice Guidelinesby Following Companies

• Bayer
• Bristol-Myers Squibb
• Glaxo Wellcome
• Merck (MSD)
• Novartis
• Pfizer
• Roche
• Searle
• Zeneca

79
1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR
PRIMARY CARE PHYSICIANS