Cardiovascular Journal of Africa: Vol 25 No 6 (November/December 2014)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 6, November/December 2014 288 AFRICA
Review Article
South African hypertension practice guideline 2014
Hypertension guideline working group: YK Seedat, BL Rayner, Yosuf Veriava
Abstract
Outcomes: Extensive data from many randomised, controlled
trials have shown the benefit of treating hypertension (HTN).
The target blood pressure (BP) for antihypertensive manage-
ment is systolic < 140 mmHg and diastolic < 90 mmHg, with
minimal or no drug side effects. Lower targets are no longer
recommended. The reduction of BP in the elderly should be
achieved gradually over one month. Co-existent cardiovascu-
lar (CV) risk factors should also be controlled.
Benefits: Reduction in risk of stroke, cardiac failure, chronic
kidney disease and coronary artery disease.
Recommendations: Correct BP measurement procedure is
described. Evaluation of cardiovascular risk factors and
recommendations for antihypertensive therapy are stipulated.
Lifestyle modification and patient education are cornerstones
of management. The major indications, precautions and
contra-indications are listed for each antihypertensive drug
recommended. Drug therapy for the patient with uncom-
plicated HTN is either mono- or combination therapy with
a low-dose diuretic, calcium channel blocker (CCB) and
an ACE inhibitor (ACEI) or angiotensin receptor blocker
(ARB). Combination therapy should be considered ab initio
if the BP is ≥ 160/100 mmHg. In black patients, either a
diuretic and/or a CCB is recommended initially because the
response rate is better compared to an ACEI. In resistant
hypertension, add an alpha-blocker, spironolactone, vasodila-
tor or β-blocker.
Validity: The guideline was developed by the Southern
African Hypertension Society 2014©.
Keywords: South Africa, hypertension, guideline
Submitted 5/8/14, accepted 10/10/14
Cardiovasc J Afr 2014; 25: 288–294
DOI: 10.5830/CVJA-2014-062
This is the sixth hypertension guideline published by the
Southern African Hypertension Society (SAHS). Currently
30.4% of the adult population have hypertension (HTN),1
necessitating a simplified approach to assessment and treatment,
which reflects realistic objectives that can be implemented by
medical practitioners, nurse practitioners and pharmacists to
diminish the impact of HTN and related cardiovascular disease
(CVD) risk in this country. For full details on management not
contained in this document please refer to the more detailed
hypertension guideline 2011.2
Objective
The objective of this guideline was to promote evidence-
based, accessible and comprehensive management of HTN
by healthcare professionals in the public and private sectors.
Applicable HTN and CVD treatment and prevention guidelines
were reviewed as well as HTN trials reporting clinical end-points,
including those with individuals with important co-morbidities
such as diabetes mellitus and chronic kidney disease.3-9
Definition and grading of hypertension
HTN is defined as a persistent elevation of office blood pressure
(BP) ≥ 140/90 mmHg (Table 1). The optimal BP is a value <
130/85 mmHg. High normal is BP levels from 130–139 mmHg
systolic and 85–89 mmHg diastolic. This high-normal group of
subjects is at higher CV risk and is also at risk of developing
HTN, but does not require drug treatment.10 HTN is stratified
into three grades depending on severity, which is useful in
defining the approach to treatment.
Measurement of blood pressure
BP measurement is a vital clinical sign that is poorly performed
by all healthcare professional categories. These recommendations
Department of Medicine, University of KwaZulu-Natal,
Durban, South Africa
YK Seedat, MD, PhD, FRCP (London), FCP (SA)
Department of Medicine, University of Cape Town, Cape
Town, South Africa
BL Rayner, MB ChB, FCP (SA), MMed (UCT), PhD (UCT), brian.
Yosuf Veriava, MB BCh (Wits), FCP (SA), FRCP (London), Hon
PhD (Wits)
Table 1. Definitions and classification of office BP (mmHg).
Adapted from ref 9
Stage Systolic BP (mmHg) Diastolic BP (mmHg)
Normal < 120 < 80
Optimal 120–129 80–84
High normal 130–139 85–89
Grade 1 140–159 90–99
Grade 2 160–179 100–109
Grade 3 ≥ 180 ≥ 110
Isolated systolic ≥ 140 < 90
BP should be categorised into the highest level of BP whether systolic
or diastolic.