Academic journal article Bulletin of the World Health Organization

1993 Guidelines for the Management of Mild Hypertension: Memorandum from a WHO/ISH Meeting

Academic journal article Bulletin of the World Health Organization

1993 Guidelines for the Management of Mild Hypertension: Memorandum from a WHO/ISH Meeting

Article excerpt


Patients with hypertension, even those with mild elevation of blood pressure, are at increased risk of cardiovascular disease, whether or not symptoms are present. In most countries, as many as 15-25% of the adult population are found at screening to have raised blood pressure; about two-thirds of them have mild elevation of blood pressure. However, the blood pressure is not persistently raised in all, and not all need to be treated with antihypertensive drugs.

In preparing these guidelines, the WHO/ISH Sub-Committee has been keenly aware that there are marked differences between individual patients with similar levels of hypertension, which have important implications for decisions about treatment. Hypertensive patients with respect to age, blood pressure elevation, organ damage and concomitant risk factors and diseases, and they live in societies where cardiovascular risk and economic resources also differ widely. Accordingly, the guidelines should not be rigid constraints to the practising doctor's decisions. Rather, they provide extensive, critical and well-balanced information on the benefits and limitations of the various diagnostic and therapeutic interventions, so that the physician may exert the most careful judgment in individual cases. Although the most reliable information is that provided by large randomized trials, these have their own limitations and not all aspects of the management of hypertension have been or can be determined by the results of randomized trials. Scientifically sound interpretation and cautious extrapolation of existing data can also be used to influence clinical decision-making.

Cardiovascular risk

Assessment in patients with hypertension

There is a continuum of cardiovascular risk associated with the level of blood pressure: the higher the blood pressure, the higher the risk of both stroke and coronary events [1]. The dividing line between "normotension" and "hypertension" is arbitrary. The current definition is that this line is the level of blood pressure above which intervention has been shown to reduce the risk [2]. It is well established that the lowering of even mildly elevated pressures reduces cardiovascular morbidity and mortality. However, a decision to intervene should not depend on blood pressure alone.

Indeed, among individuals with mild hypertension the risk of serious cardiovascular disease is also determined by a variety of factors other than the level of blood pressure. These include (see Table 1) increasing age, male gender, previous cardiovascular events, target organ damage (such as left ventricular hypertrophy or renal disease), smoking, diabetes, dyslipidaemia (high total and LDL-cholesterol with low HDL-cholesterol), central obesity, and a sedentary lifestyle [3]. The presence of one or more of these factors may be a more important determinant of risk than a mild increase in the level of blood pressure. Since the absolute benefits of antihypertensive treatment will be determined by the absolute risk of cardiovascular disease (i.e., greater benefits among those at higher risk), each of these factors should be assessed prior to making decisions about treatment.

Table 1: Cardiovascular risk factors favouring treatment
Family history of premature cardiovascular disease(a)
Raised systolic blood pressure
Raised diastolic blood pressure
Raised total and LDL cholesterol
Reduced HDL cholesterol
Left ventricular hypertrophy
Previous cardiovascular events(a)
Previous cerebrovascular events(a)
Renal disease
Sedentary lifestyle
(a)Not modifiable.

The absolute risk of serious cardiovascular disease varies greatly among individuals with mild hypertension. At one extreme, in elderly patients with a history of previous cardiovascular disease, at least three to five in every hundred will suffer a further serious event each year [4-7]. …

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