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 290 AFRICA
Goals of treatment
There has been considerable controversy about BP goals and
SAHS accepts that to simplify management, a universal goal of
antihypertensive treatment is < 140/90 mmHg regardless of CV
risk and underlying co-morbidities.5 The only exception is that in
patients over 80 years of age, therapy should be initiated if SBP
is > 160 mmHg and the goal is between 140 and 150 mmHg,
based on the HYVET study in which the majority of patients
received indapamide and the ACEI perindopril.15
SAHS does not support the JNC-8 committee recommendations
of a goal BP < 150/90 mmHg for persons over 60 years without
diabetes and CKD, as (1) increasing the target will probably reduce
the intensity of antihypertensive treatment in a large population
at high risk for cardiovascular disease, (2) the evidence supporting
increasing the SBP target from 140 to 150 mmHg in persons
aged 60 years or older was insufficient, (3) the higher SBP goal in
individuals aged 60 years or older may reverse the decades-long
decline in CVD, especially stroke mortality.8,16
It is also essential to control hyperlipidaemia and diabetes
through lifestyle and drug therapy, according to the Society for
Endocrine Metabolism Diabetes of South Africa and South
African Heart Association/Lipid and Atherosclerosis Society
of Southern Africa guidelines, respectively.17,18 Aspirin should
not be routinely prescribed to hypertensives (especially if BP
is not controlled),19 and should mainly be used for secondary
prevention of CVD (transient ischaemic attack, stroke,
myocardial infarction).
Management of hypertension
All patients with HTN should receive lifestyle counselling as
outlined in Table 6, and this is the cornerstone of management.
The approach to drug treatment is outlined in Fig. 1. If the SBP
is ≥ 180 mmHg or the DBP is ≥ 110 mmHg then refer to section 8
on severe (grade 3) HTN, as this section does not apply.
Before choosing an antihypertensive agent, allow for
considerations based on the cost of the various drug classes,
patient-related factors, conditions favouring use and contra-
indications, complications and target-organ damage (TOD)
(Tables 4, 7).
In otherwise uncomplicated primary HTN, the initial first
choice of antihypertensive drug is a diuretic (thiazide-like
or thiazide), ACEI or ARB, and/or CCB used as mono- or
combination therapy (Fig. 2). Combination therapy should be
considered if clinically appropriate ab initio if BP is ≥ 160/100
mmHg (Fig. 1) as this is associated with better clinical outcomes
and earlier achievement of goal BP.20,21 Fixed-drug combinations
are preferred because of better patient adherence and control of
BP.22 A treatment algorithm is outlined in Fig. 1 if the goal is not
reached after initial treatment.
Table 4. Major risk factors, target-organ damage (TOD) and complications. Adapted from the ESH/ESC guidelines9
Major risk factors TOD Complications
• Levels of systolic and diastolic BP
• Smoking
• Dyslipidaemia:
–– total cholesterol > 5.1 mmol/l, OR
–– LDL > 3 mmol/l, OR
–– HDL men < 1 and women < 1.2 mmol/l
• Diabetes mellitus
• Men > 55 years
• Women > 65 years
• Family history of early onset of CVD:
–– Men aged < 55 years
–– Women aged < 65 years
• Waist circumference: abdominal obesity:
–– Men ≥ 102 cm
–– Women ≥ 88 cm
–– The exceptions are South Asians and Chinese:
men: > 90 cm and women: > 80 cm.
• LVH: based on ECG
–– Sokolow-Lyons > 35 mm
–– R in aVL > 11 mm
–– Cornel > 2 440 (mm/ms)
• Microalbuminuria: albumin creatine
ratio 3–30 mg/mmol preferably spot
morning urine and eGFR > 60 ml/min
• Coronary heart disease
• Heart failure
• Chronic kidney disease:
–– macroalbuminuria > 30 mg/mmol
–– OR eGFR < 60 ml/min
• Stroke or TIA
• Peripheral arterial disease
• Advanced retinopathy:
–– haemorrhages OR
–– exudates
–– papilloedema
Table 5. Routine investigations
Test Comment
Height, weight, BMI Ideal BMI < 25 kg/m2, overweight
25–30 kg/m2, obese > 30 kg/m2
Waist circumference Men < 102 cm; women < 88 cm. South
Asians and Chinese: men < 90 cm and
women < 80 cm
Electrolytes Low potassium may indicate primary
aldosteronism, or effects of diuretics
ECG S in V1 plus R in V5 or V6 > 35 mm or
R in aVL > 11 mm or Cornel product
(R in aVL + S in V3 + 6 in females) ×
QRS duration > 2 440 (mm/ms)
Echocardiogram (if indicat-
ed and facilities available)
LVH: men > 115 g/m2 and women >
95 g/m2
Fasting glucose Consider HBA1c or GTT if impaired
fasting glucose (6.1–7.1 mmol/l)
Cholesterol If total cholesterol > 5.1 mmol/l – fast-
ing lipogram
Creatinine Calculate eGFR
Uric acid High uric acid is relative contraindica-
tion to diuretics
Dipsticks urine If abnormal, urine microscopy and
protein estimation
Table 6. Recommended lifestyle changes
Modification Recommendation Approx ↓ SBP
(mmHg)
Weight reduction BMI 18.5–24.9 kg/m2 5–20 per 10 kg
Dash diet ↓ saturated fat and total fat,
↑ fruit and vegetables
8–14
Dietary Na+ < 100 mmol or 6 g NaCl/day 2–8
Physical activity Brisk walking for 30 minutes
per day most days
4–9
Moderation of alcohol No more than two drinks
per day
2–4
Tobacco Complete cessation –