COMMUNITY BASED REHABILITATION

Assignment

SUBMIITED BY SUBMITTED TO
BATCH OF 2016 MRS. REJISHA
SJMC SJMCH
 TABLE OF CONTENTS

S.NO INDEX PAGE NO

1. INTRODUCTION 03
2. EPIDEMIOLOGY 04
3. SCREENING 06
4. DIAGNOSIS 09
5. ASSESSMENT 11
6. EDUCTAION 15
7. LIFESTYLE MODIFICATIONS 16
8. EXERCISES 17
9. PHARMACOLOGICAL MANAGEMENT 19
10. MANAGEMENT OF HYPERTENSION IN INDIA 22
11. ALGORITHM AND PATHWAYS 24
12. COMMUNITY PROGRAMS 27
13. REFERENCES 28
INTRODUCTION :

Definition- Hypertension, also known as high or raised blood pressure, is a

condition in which the blood vessels have persistently raised pressure. Blood
pressure is created by the force of blood pushing against the walls of arteries as it
is pumped by the heart. The higher the pressure, the harder the heart has to pump.

Hypertension is a serious medical condition and can increase the risk of heart,
brain, kidney and other diseases. It is a major cause of premature death worldwide,
with upwards of 1 in 4 men and 1 in 5 women – over a billion people – having the
condition. The burden of hypertension is felt disproportionately in low- and
middle-income countries, where two thirds of cases are found, largely due to
increased risk factors in those populations in recent decades.

BP Systolic (mm Hg) Diastolic (mmHg)

Optimal Less than120 Less than 80
Normal Less than130 85
High normal 130-139 85-89

Hypertension
Grade 1 140-159 90-99
Grade 2 160-179 100-109
Grade 3 more than 180 more than 110

Types of Hypertension-

 Primary- elevation without a known cause. Most prevalent accounting for

more than 90 percent of cases.
 Secondary- a disease process or abnormality involved in its causation. Eg-
glomerulonephritis.
EPIDEMIOLOGY :

Global prevalence
The global prevalence of hypertension was estimated to be1.13 billion in
2015.The overall prevalence of hypertension in adults is around 30-40
percent,with a global age standardized Prevalence of 24 and 20 percent in men
and women respectively.Hypertension becomes progressively more common
with Advancing age,with a prevalence of >60 percent in people aged>60years.
Elevated blood pressure is a leading cause of premature death in 2015,according
to almost 10million deaths and over 200 million DAIYs.
Prevalence in India
In the year 2015-2016,National Family Health Survey-4
Measured blood pressure in women and men age 15-49years.The criteria of high
blood pressure was systolic blood pressureGreater than or equal to140mmHg and
diastolic blood pressure greater than or equal to 90mmHg,or that individual is
currently taking antihypertensive medicine.Based on the measurements
During survey,61percent of women were having blood
Pressure within normal limits,almost 30 percent were
Pre hypertensive and 1percent were taking anti-hypertensives.
The prevalence of hypertension among men aged15-49years
Was somewhat higher than among women,15 percent men
Were hypertensive,43 percent men had normal blood pressure
And same percentage were prehypertensive.One percent
Were on anti-hypertensive medicine.
Risk factors for hypertension
WHO Scientific group has recently reviewed the risk factors for
Essential hypertension . These may be classified as:
1.Non-modifiable risk factors
(a)AGE : Blood pressures rises with age in both sexes and the
Rise is greater in those with higher initial blood pressure.
(b)SEX : Adolescence , men display a higher average level.
Post-menopausal change in women may be the contributory factor for this
change.
(c)GENETIC FACTORS :There is considerable evidence that
Blood pressure levels are determined in part by genetic factors,
And that the inheritance in polygenic.
(d)ETHNICITY: Population studies have consistently revealed
Higher blood pressure levels in black communities than other
Ethnic groups.
2.Modifiable risk factors
(a)OBESITY :The greater the weight gain,the greater the risk of
High blood pressure.
(b)SALT INTAKE:There is an increasing body of evidence to the effect that a
high salt intake increases blood pressure
proportionately.
(c)SATURATED FAT: The evidences suggest that saturated fat
Raises blood pressure as well as serum cholesterol.
(d):DIETARY FIBRE :Several studies indicate that the risk of
CHD and hypertension is inversely related to the consumption
Of dietary fibre. Most fibres reduce plasma total and LDL
cholesterol.
(e)ALCOHOL : High alcohol intake is associated with an
Increased risk of high blood pressure . It appears that alcohol
Consumption raises systolic pressure more than the diastolic.
(f)HEART RATE: Heart rate of the hypertensive group is
Invariably higher.
(g)PHYSICAL ACTIVITY: Physical activity by reducing body
Weight may have an indirect effect on blood pressure.
(h)ENVIRONMENTAL STRESS: Initiated by tension or stress.
SCREENING FOR HYPERTENSION :

The implementation of the screening programme on hypertension will

require that opportunistic screening for hypertension is offered to all adults during
the course of their visits to health facilities or healthcare providers – i.e. the health
care providers should use the opportunity provided by the visit to screen for
hypertension, and record the measurement in a patient card. Systematic and
sustainable practical methods need to be developed to screen the asymptomatic
population for hypertension and can be integrated with screening of other non-
communicable diseases.
The high risk groups which may be focused on are those with age >50
years)as well as those with diabetes where prevalence of hypertension has been
noted to be more than 30-50%, and yet often remains undetected . Studies in
India have also shown that the risk of hypertension is higher in those who have
general or abdominal obesity and those who consume tobacco or alcohol.There is
a need to spread awareness of these risk factors for hypertension and
cardiovascular disease, through the National Programme for Prevention and
Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke
Implementation of the screening program will require training of the non-
physician aides in the measurement of blood pressure, the availability of an
automated (oscillometric) BP measurement device, and preferably cuffs of 2
sizes to enable measurement of BP in obese patients too. Implementation will
also require that the Bureau of Indian Standards develop a quality standard for
the digital (oscillometric) devices in the market, on the lines of the standards and
validation procedures in UK, USA and Europe. This will ensure that validated
devices are available in the Indian market. At present the Bureau of Indian
Standards has quality standards only for mercury and aneroid
sphygmomanometers.
Use of digital (oscillometric) devices:Guidelines like NICE,ASH/ISH ,
ESC, now suggest the use of electronic BP measurement instruments based on
the oscillometric approach to record BP in both clinic as well as home based
settings. Protocols for the validation, and a list of instruments validated by
organisations like the British Hypertension Society, European Society of
Hypertension, and Association for Advancement of Medical Instrumentation are
also available.
Standardised BP measurement procedure
The screening of hypertension should be done by a physician or trained non
physician staff, using an automated BP instrument or any other validated device,
and following a standardised BP measurement procedure.
Blood pressure should be measured a few (5) minutes after the patient is in a
relaxed state, is seated with the arm at the level of the heart, with legs uncrossed.
The cuff should have a bladder whose length is about 80% and whose breadth is
about 40% of the arm circumference. If the auscultation based method is being
used, the then the cuff should initially be inflated to at least 30 mm Hg beyond
the point of disappearance of the radial pulse. It should then be deflated at a rate
of 2- 3 mm per second. The first and the last audible Korotkoff sounds should be
taken at the systolic BP and diastolic BP respectively. The column should be read
to the nearest 2 mm Hg.
At least 2 readings should be taken at each visit with an interval of at least 1
minute between the measurements. If the two readings are substantially different
a third reading should be taken. The lower of the two readings should be taken as
the representative SBP and DBP.
White coat effect and white coat hypertension:
The white coat effect can occur in all patients with hypertension and can
result in higher BP readings in clinic settings than outside it. It may result in
misclassification of severity of hypertension. The effect varies from minimal to
marked increases in clinic BP readings compared to ambulatory or home
recording with an overall mean increase of 27 mm Hg in the systolic BP
observed in one study. White coat hypertension or isolated clinic hypertension
occurs in persons who are normotensives on out of clinic measurements. The
white coat effect is due to an alerting reaction and reflex activation of the
sympathetic nervous system.
Rescreening, reassessment, and referral of individuals found to have normal
or elevated BP on screening by allied health staff
Depending on the BP readings, the person may be advised review up on an
annual or 2 yearly basis, or referral (immediate or deferred) for diagnosis or
treatment of hypertension.
Persons with normal BP (<130/80) should be advised a recheck in 2 years.
Persons with high normal BP: systolic BP of 130-139 mm Hg and diastolic
of 80-89 mm Hg should be advised a recheck in 1 year, or sooner if indicated due
to other risk factors or diseases.
Persons with BP > 140 mm Hg systolic and/or greater than 90 mm Hg
diastolic should be rechecked within 1-2 weeks and then classified as
hypertensive or high normal.
Persons with BP of >160 mm Hg systolic and/or greater than 100 mm Hg
diastolic should be advised early referral to the primary health centre if
measurements have been made at a peripheral health facility below the level of a
primary health centre, for confirmation of the diagnosis of hypertension.
Persons with BP of >180 mm Hg systolic and/or greater than 110 mm
diastolic if documented by a non-physician staff, should be immediately referred
to the primary health centre or community health centre (whichever is nearer to
the residence) for further investigation to exclude any acute target organ damage,
and for initiation of treatment ,which is required on an immediate basis. Patients
documented with this level of BP in a health facility would require assessment
for target organ damage, and gradual reduction of BP over hours and days if
there is no acute target organ damage.
Hypertensive emergencies are potentially life-threatening situations where
hypertension (usually severe and > 180 mm systolic and >120 mm diastolic
associated with the presence of recent onset and progressive target organ damage
resulting in cardiovascular, neurologic, renal and visual dysfunction. These
situations may include severe hypertension associated with acute coronary
syndrome (chest pain), acute left ventricular dysfunction (shortness of breath),
and hypertensive encephalopathy (altered sensorium), stroke (focal
weakness), and renal failure. It is most often associated with severe hypertension,
except in children and pregnant women where hypertensive emergencies can
occur with lower elevations of BP.
All persons who are screened for hypertension should be advised lifestyle
measures including maintaining a daily salt intake appropriate to their
occupation, advice on diet and exercise in case the person is obese, stopping use
of tobacco and moderating consumption of alcohol to reduce their blood pressure
and to reduce their overall risk of cardiovascular complications.
DIAGNOSIS OF HYPERTENSION (HTN)
In India,
 Number of measurements required
- Diagnosis (Dx) should be made in primary health centres and other facilities,
using validated and calibrated blood pressure (BP) measurement devices
(like manual sphygmomanometers and so on) and following standardized BP
measurement procedure.
- Dx should be based on atleast 2 measurements taken in clinic or by a health
provider, on atleast 2 visits which are 1-4 weeks apart.
- Exceptions: in case of hypertensive (HTive) urgencies [severe
asymptomatic HTN with no evidence of acute target organ damage] and
emergencies [severe HTN associated with cardiovascular/neurological/renal
dysfunction, or Grade III-IV HTive retinopathy], where HTN is diagnosed
during 1st visit itself.
- Ambulatory BP monitoring (ABPM) and home-based BP monitoring
(HBPM) is not feasible for most HTive patients in India – not
recommended.
 Classification of HTN in India (according to BP levels)
- HTN should be diagnosed when BP is persistently above a systolic of 140
mm Hg and/or a diastolic of 90 mm Hg.
- Classification according to JNC 7, 2007 and JNC 8, 2014, and NICE
guidelines (table given below):
• define only 2 stages of HTN, collapsing Stage 3 HTN into Stage 2 (as they
are considered to be therapeutically similar)
• and the nomenclature of BP below 140 mm Hg also differ, as compared to
WHO/ISH and ESH/ESC guidelines.
{JNC = Joint National Committee
NICE = National Institute for Clinical Excellence}
- Following is the classification based on WHO/ISH and ESH/ESC
guidelines (table given below):
• This is important for prognosis (Grade III HTN is associated with high
cardiovascular risk) and therapy (indicates need for immediate referral and
initiation of therapy).
• This is adopted over JNC and NICE guidelines, to retain Grade III HTN
and, avoid the “prehypertension” category that includes all with BP of 120
– 139 mm Hg (SBP) and 80 – 89 mm Hg (DBP) [as it may become a source
of anxiety].

BP CLASSIFICATION SBP (mm Hg) DBP (mm Hg)

Optimal BP <120 <80

Normal BP 120 – 129 80 – 84

High Normal BP 130 – 139 85 – 89

Grade I HTN 140 – 159 90 – 99

Grade II HTN 160 – 179 100 – 109

Grade III HTN 180 or above 110 or above

Isolated Systolic HTN >140 <90

HTive Urgency >180 >110

HTive Emergency >180 >110 – 120

{WHO/ISH = World Health Organization / International Society of HTN

ESH/ESC = European Society of HTN / European Society of Cardiology}

 Time frame for recheck and review of elevated BP readings (in case of grade
I and II hypertension)
- Grade I HTive individuals should have their BP rechecked every 4 weeks.
- Grade II HTive individuals should have their BP rechecked every 2 weeks.
- In general, lifestyle modifications advised to all with BP >120 mm Hg (SBP)
and/or >80 mm Hg (DBP).
ASSESSMENT OF HYPERTENSION

Assessment of the patient with hypertension has been divided into 5 categories: -

1. Assessing the patient on the lifestyle related issues and

cardiovascular risk factors and also the capability of the individual
capacity and determination to change these factors.
-Assessing the patient with hypertension is aimed at assessing the overall
cardiovascular risk for cardiovascular events like stroke, ischemic heart
disease, and peripheral artery disease.
-Overall lifestyle history should be assessed such as smoking history, diet
with regard to salt and fat content and exercise pattern should be enquired.
- Examination of body weight and height should be measured along with
the calculation of body mass index
[Weight in kg/ Height in metre square] and also evaluation of blood
glucose to rule out undetected diabetes.
2. Assessing the target organ damage related to hypertension.
-The physician can detect target organ damage by eliciting symptoms of
shortness of breath, decreased urine output, and noting signs of heart failure
like swelling of feet and other signs of heart failure
-The target organs affected by hypertension are the brain, heart, kidney and
eye
- A history of breathlessness on walking briskly or climbing the stairs may
indicate it affects on the heart, as does the complaints of swelling over both
feet.
- On examination the presence of pulsatile elevation of jugular venous
pressure, presence of edema on the feet and presence of changes of
hypertensive retinopathy indicate target organ damage.
3.Assessing the presence of associated clinical conditions like diabetes,
kidney disease or symptomatic cardiovascular disease
-Hypertension often occurs in association with other clinical conditions like
coronary artery disease: myocardial infarction or angina pectoris, cerebrovascular
disease: history of ischemic or hemorrhagic stroke and chronic kidney disease:
diabetic or non-diabetic.
- Patient with hypertension along with these conditions the choice of therapy
may vary including the intake of drugs. Example- beta-blockers are no longer
considered as the first choice of drugs in hypertension but preferred drugs in the
presence of angina or past history of infarction.

4.Assessing the clues of secondary cause of hypertension.

 -There are clues to presence of secondary causes of hypertension, which may be
noticed during the evaluation of the patient.
- These are important to recognize because an underlying secondary cause may
result in difficult to control hypertension.

5. Assessment of overall cardiovascular risk of a patient.

Grade 1 HT Grade 2 HT Grade 3 HT
No risk factor Low risk Moderate risk High risk
1-2 risk factor Moderate risk Moderate to High risk
High risk
> 3 risk factor Moderate to High risk High risk
High risk
Organ damage, High risk High risk Very High risk
diabetes, CKD
stage 3
Symptomatic Very High risk Very High risk Very High risk
CVD [stroke,
coronary artery
disease],
diabetes with
organ damage
Framework for assessment of patients with hypertension in the health
system in India

It is important that the patient with hypertension require a continuum of care with
participation of health care providers at all levels.
Assessment, management and long term care of patient with hypertension is
necessary
The health system needs to strengthen in terms of availability of diagnostic tests
where the government should take initiative about basic evaluation of the patient
with hypertension possible at sub-centre, PHC level and CHC level.
The table below details the role of different cadres of health workers can play in
the assessment of patients.
Village Sub centre PHC [Primary CHC
[Village [Trained health care [Specialist]
health auxiliaries] physician]
worker]
History of ✔ ✔ ✔ ✔
cardiovascular
risk factors-
smoking, diet,
exercise,
diabetes
History ✔ ✔ ✔ ✔
suggestive of
target organ
damage
History of ✔ ✔ ✔ ✔
associated
clinical
conditions,
coronary
artery disease,
stroke
History of Suspect in Suspect in ✔ ✔
secondary case of case of
causes of hypertension hypertension
hypertension not not
responding responding
to medicines to medicines
refer refer
Examination Obesity: - Obesity: - Obesity: - Obese: -
for risk weight, weight, weight, weight, height,
factors height height height, waist diabetes-
circumference, fasting plasma
fasting glucose,
capillary hyperlipidemia-
blood glucose lipid profile
Examination Edema Edema Clinical signs Clinical signs+
of end organ of heart investigation
damage/ failure. for selected
secondary Clinical clues causes like
causes of to secondary kidney disease
hypertension hypertension
Investigation Motivate the Motivate the Urinalysis: Fating plasma
patient to patient to proteinuria, glucose, lipid
undergo undergo Fasting profile
evaluation evaluation glucose
MANAGEMENT
EDUCATION OF A PATIENT WITH HYPERTENSION-
Implementation of patient education-
-Patient education related to hypertension is a part of the initial care and should
be reinforced during the continuing care of patients with hypertension, e.g.
during annual reviews.
-It can be delivered by both physician and non-physician staff and can be
supported by aids like patient information leaflets (attached). Non physician staff
at the community level can reinforce messages related to healthy living,
monitoring of BP and adhering to treatment.
-Patient education will facilitate the patient’s participation and cooperation in the
management of a life-long disease. They should understand the following
features of the disease and its management:

a. The disease is asymptomatic but is a risk factor for serious consequences like
heart attacks, strokes, heart and kidney failure, which can be prevented by
controlling hypertension to a target BP which is usually less than 140 mm
systolic and 90 mm diastolic. The disease is persistent and although it cannot
be cured it can be controlled.

b. Healthy living habits (lifestyle modification) like stopping smoking, eating a

healthy diet lower in salt and saturated fat, exercising losing weight has many
benefits with no cost. It can reduce blood pressure, may suffice for the
management of grade 1 hypertension, reduce the dosage of medicines required
for control of grade 2 and 3 hypertension, and help reduce the overall risk of
heart attacks and stroke.

c. The assessment of damage to the heart, kidney, vessels in the eye, and to
detect the presence of associated conditions like diabetes are needed to
determine the overall risk of cardiovascular and to frame an effective
treatment regime.

d. Medications may have to be taken life long, and monitoring with regular
checks of blood pressure is required to note their efficacy. Taking medications
regularly without BP checks is suboptimal, as is checking BP regularly
without regular intake of medications. Most drugs can be given only once a
day and can control BP with minimal side effects.

Patient education should be given in an empathic and culturally appropriate

manner. It should elicit their views of the disease, and their expectations from
treatment. It can be given by both physicians and non-physician staff.
LIFESTYLE MODIFICATIONS :

 Weight reduction
- Reduce salt intake to < 100 mmol/day (< 5g NaCl
or <2.4 g Na+/day).
-Consume at least five portions/day of fresh fruit and
vegetables.
- Reduce the intake of total and saturated fat
-Those individuals who are overweight or obese, can adopt of the Dietary
Approaches to Stop Hypertension (DASH) eating plan. The diet emphasizes
vegetables , fruits and low dietary foods and moderate amount of whole grains,
fish poultry and nuts. Initially the individual can consume 2,300 mg a day and
gradually decrease 1,500mg sodium a day.

 Physical activity
-Physical activity includes ADL, like walking and cycling , household work and
work related activity
-Regular aerobic exercises can reduce systolic blood pressure average of 4mmHg
and diastolic blood pressure by an average of 2.5mmHg .
-Chronically sedentary individuals are suggested to not start vigorous physical
activity but should increase the duration and intensity gradually.
- Activities like taking the stairs instead of the lift , cycling or walking to nearby
locations etc. Can be inculcated in daily routine.

 Decrease Alcohol consumption

- Reducing alcohol intake to mild to moderate cosumption in one - two weeks
can lower the blood pressure substantially .
- Heavy drinkers who cut back to moderate drinking can lower their systolic
blood pressure by 2-4mmHg and diastolic pressure by 1-2mmHg .

 Tobacco cessation
- All smokers should be encouraged to quit smoking and should be supported by
caregivers , even though quitting may not reduce the blood pressure directly but
markedly reduces overall cardiovascular risk
- Nicotine patch or chewing gums can be prescribed for chronic smokers.

 Stress Management
-In hypertensive patients in whom stress may be contributing to blood pressure
elevation , stress management should be considered as an intervention.
Exercise for Hypertension :

EXERCISE TESTING:
Exercise testing for individuals with hypertension vary depends on:
 BP level
 presence of other CVD risk factors
 target organ disease
 clinical CVD
Recommendations include the following:
• Individuals with hypertension whose BP is not controlled (i.e., resting SBP 140
mm Hg and/or DBP 90 mm Hg) should consult with their physician prior to
initiating an exercise program.
When medical evaluation and management is taking place, the majority of these
individuals may begin light to moderate intensity (40%–60% VO2R)

EXERCISE PRESCRIPTION:
Aerobic exercise training (Moderate 40%–60% heart rate reserve to vigorous
60%–90% HRR or VO2R and light 30%–40% HRR or VO2R) leads to
reductions in resting BP of 5–7 mm Hg in individuals with hypertension
Emphasis should be placed on aerobic activities; however, these may be
supplemented with moderate intensity resistance training.
Warm-up: at least 5–10 min of light-to-moderate intensity cardiorespiratory and
muscular endurance activities
Conditioning: at least 20–60 min of aerobic, resistance, neuromotor, and/ or
sports activities
Cool-down: at least 5–10 min of light-to-moderate intensity cardiorespiratory and
muscular endurance activities
Stretching: at least 10 min of stretching exercises performed after the warm-up
or cool-down phase

In individuals with hypertension, the following Ex Rx is recommended:

Pharmacological management of Hypertension

The drugs used for the management of patients with hypertension are given as
follows:
Diuretics Frusemide,Indapamide,Spironolactone,
Chlorthalidone
Drugs acting on renin-angiotensin
system
1. ACE Inhibitors Captopril, Enalapril, Ramipril
2. Angiotensin II Receptor Losartan, Valsartan, Candesartan
Blockers
3. Renin Inhibitor Aliskiren

Sympatholytic drugs
1. Centrally acting drugs Clonidine, Methyldopa
2. Ganglion blockers Trimethaphan
3. Adrenergic neuron blockers Reserpine
4. Alpha blockers
5. Beta blockers Prazosin, Terazosin
6. Mixed Alpha and Beta Propranolol, Atenolol
blockers Labetalol, Carvedilol
Calcium channel blockers Nifedipine, Nicardipine
Vasodilators Hydralazine, sodium nitroprusside
Adjunct drugs
1. Statins Atorvastatin, Pravastatin
2. Antiplatelet drugs Aspirin

Guidelines for Initiating Drug Therapy

 Drug therapy in patients with grade I hypertension uncomplicated by any
organ damage, without coexisting diabetes mellitus, clinical cardiovascular
disease should be initiated after a trial of 1-3 months of lifestyle
modifications.
 Drug therapy is indicated in all patients with Grade 2 and Grade 3
hypertension and should be combined with lifestyle measures.
 Drug therapy is initiated in patients with Grade 2 hypertension on
confirmation of the diagnosis on repeat BP measurements in the visits
subsequent to the initial visit when Grade 2 Hypertension was first
detected. If the initial screening by the non-physician medical staff
revealed Grade 2 hypertension, then therapy can be initiated on the first
visit of the patient to the primary health centre/community health centre.
  Drug therapy in patients with Grade 3 hypertension is initiated after repeat
measurements in the initial visit confirm the severe elevation of the blood
pressure.
Preferred Recommendations of Drug Therapy
 The primary issue in treatment of hypertension is reduction of
cardiovascular risk by effective control of blood pressure. Overall the
benefits of antihypertensive treatment are due to lowering of blood
pressure rather than choice of therapy. Many patients will require more
than one drug for control of hypertension.
 All classes of drugs have approximately the same efficacy on lowering of
blood pressure, and on outcomes, although beta-blockers have been
associated with lesser protection against strokes. All combinations of drugs
are not however similarly efficacious, and some are preferred.
 The different classes of drugs have differing side effect profiles and
requirements for monitoring, which may influence their use and
prescription in the health system.
 In the absence of any associated clinical conditions which indicates for the
use of a particular drug, a long acting calcium channel blocker, a low dose
thiazide diuretic, or a low cost ACE inhibitor may be used as the initial
antihypertensive drug.
 The presence of associated clinical conditions (diabetes, clinical
cardiovascular disease, chronic kidney disease) in a patient may provide
compelling indication for the use of specific classes of drugs.
 Preferred drugs for treatment of patients with diabetes and hypertension
are ACE inhibitors, especially in those with proteinuria. Calcium channel
blockers /low dose diuretics may be used in addition if required to achieve
control.
 Preferred drugs for patients with heart failure and hypertension are ACE
inhibitors, diuretics (including loop diuretics) and beta-blockers.
 Preferred drugs for patients with coronary artery disease and hypertension
are beta-blockers, ACE Inhibitors or calcium channel blockers.
 The specific drugs within these classes recommended on the basis of
availability and affordability include amlodipine, (a long acting calcium
channel blocker); enalapril or lisinopril, (ACE inhibitor); low dose
hydrochlorothiazide, (thiazide) and if required and losartan, (a low
costnangiotensin II receptor blocker).
 Angiotensin receptor blockers have a mode of action, efficacy and
indications similar to ACE inhibitors, but are currently more expensive
than them. They should therefore be used in the place of ACE inhibitors,
in case there are side effects like cough, angioedema.
MANAGEMENT OF HYPERTENSION IN INDIA.

1)LIFE-STYLE MODIFICATION
 Appropriate lifestyle measures may avoid the need of drug therapy in
borderline HTN individuals.
 Preventing/Correcting Obesity.
 Reducing Alcohol intake.
 Restricting Salt intake.
 Indulging in physical activity.
 Less stress.
 Quit smoking.
 Potassium rich diet.
 Dietary Sodium.
2)PHARMACOLOGICAL MANAGEMENT
 Drugs should only be given when the BP is more than 140/90mm Hg or
when the patient is not responding to lifestyle modifications.
 Classification of Antihypertensive drugs:-
1)Diuretics:-
-Thiazides:- Hydrochlorothiazide,Chlorthalidone
High ceiling:- Furosemide.
K+sparing:-Spironolactone

2)ACE Inhibitors:-
- Lisinopril,Ramipril
3)Angiotensin (AT1 receptor)blockers:-
- Losarten,Candesartin,Valsarten

4)Direct Renin Inhibitors:-

-Aliskiren

5)CCB(Calcium Channel Blockers):-

-Verapamil,Diltiazem,Nifedipine

6)B-adrenergic blockers:-
-Nonselective:- Propanolol
-Cardioselective:-Metoprolol

7)Beta and Alpha adrenergic blockers:-

-Prazosin,Terazosin
 8)Centrally Acting:-
-Clonidine,Methyldopa

 For most hypertensive patients,one drug usually a thiazide-type diuretic is

given initially.
 Low dose aspirin (81mg once/day)appears to reduce incidence of cardiac
events in hypertensive patients.
 Some Antihypertensive drugs are contraindicated in certain disorders like B
blockers in asthma.
 Thiazide-type diuretics appear to be particularly effective in people above
60 years of age and blacks
 ACE Inhibitors or angiotensin 2 receptor blockers are indicated in people
having diabetes.
 B blockers/Calcium Channel Blockers are given to patients suffering from
Angina Pectoris
PATHWAYS/ ALGORITHMS IN SCREENING, DIAGNOSIS, ASSESSMENT

Diagnosis pathway
MANAGEMENT PATHWAY
1)lifestyle modification

 Less stress
 Dietary sodium
 Quite smoking
 Less salt intake
 Redicing alchohol
 Increase physical activity
 App.lifestyle measures
  Correcting obesity
2)pharmacological management
 Drugs should only be given when BP is more than 140/90mmHg
 Antihypertensive drugs
COMMUNITY PROGRAMMES:
 Community intervention program in the age of mobile technology and
social media (2020): This program was emphasized to create awareness
among all groups of people on hypertension via sending people
encouraging messages to exercise, get a proper and undisturbed sleep,
reduce stress, avoid excessive work time. Messages were sent from time to
time to create awareness about prevention formation or decreasing levels of
high blood pressure and thus leading to live a healthier life.
 Implementing recommendations of dietary salt intake: According to
National High Blood Pressure Education program (NHBPEP) it
recommends no more than 2,400 mg sodium/day for adults. In this
program, they advised the food manufacturers, restaurants to start initiative
to reduce salt in food items, as excessive salt intake was proportional to
increased levels of blood pressure. Modified foods with low sodium levels,
and creating awareness among population to start using low sodium foods
were created.
 India hypertension control initiative (IHCI): Introduced by Ministry of
health and family welfare in the year 2017. This program was initially
introduced in 25 districts over 6 states aimed at implementing quality
hypertension treatment for over 15 crore population by 2025 to prevent risk
of non-communicable diseases like heart attack, stroke and kidney failure.
This program is a team-based effort involving nurses, health workers and
ASHA’s to step into root level of the community to create awareness,
encouraging people to get tested and provide appropriate measures.
 National program for prevention and control of diabetes, CVD and stroke
(NPCDCS): Major objectives of this program was to reduce risk of non-
communicable disease by modifying the possible risk factors. A common
modifiable risk factor found was hypertension. Therefore, measures were
taken to reduce blood pressure levels in these individuals, thereby
preventing the risk of occurrence of stroke, heart attack etc.
 National Tobacco control Programme: India launched this program in 2007
mainly aimed at reducing usage of tobacco. Tobacco chewing and smoking
were concerned with high levels of blood pressure. The secondary aims of
this program were prevention of formation of new cases of hypertension
and reducing existing cases by creating awareness on ill effects of smoking
and tobacco use. Thus, indirectly aimed to reduce blood pressure levels.
REFERENCES :
1. Screening, Diagnosis, Assessment, and Management of Primary
Hypertension in Adults in India.
2. Rabindra Nath Roy ,Indranil Sah.Mahajan and Gupta’s textbook of
preventive and social medicine.4th edition.
3. Standard treatment guidelines hypertension- Ministry of health and family
welfare, government of India. Feb 2016
4. Kazim Husain. Alcohol induced hypertension : mechanisim and prevention.
5. American College of Sports Medicine: http://www.acsm.org to access the
position stand on exercise and hypertension
6. American Heart Association: http://www.american heart.org
7. National Heart Lung and Blood Institute: http://www.nhlbi.nih.gov/hbp
8. Textbook of Pharmacology(4th Edition) (Padmaja Udaikumar)
9. Davidsons Principles and Practice of Medicine (19th Edition)
10. (Christopher Haslett,Edwin R Chilverts,Nicholas A Boon,Nicki R
Colledge)
11. Park’sTextbookofPREVENTIVEANDSOCIALMEDICINE