Key Messages From Hypertension Guidelines Explained – Dr. Hidayatul Radziah Ismawi



In order to ensure that all health care providers, regardless of whether they work in primary care (like Klinik Kesihatan), tertiary care (general hospitals) or private general practices (GP), are up to date with the latest development and evidence based approach to patient management, they can refer to what is known as clinical practice guidelines (CPG). These CPGs serve as a reference for doctors and other health care providers in order to best manage the patient and is regularly updated by a prestigious panel of specialists according to their respective fields. Although the public need not know the content of these CPGs in detail, a breakdown of the key messages might prove to be very enlightening.

Ready to learn the latest core issues about hypertension? Read on.

Hypertension is defined as persistent elevation of systolic BP of 140 mmHg or greater and/or diastolic BP of 90 mmHg or greater.

Have you noticed that when informing you of your blood pressure the nurse or doctor will mention 2 numbers or that it is written as one number on top of another number (Eg: 120/80 mmg Hg) ? Both numbers are important as they indicate different things. Systolic blood pressure (the top number) is the pressure exerted on your arteries as your heart pushes blood through them and to the rest of the body. Diastolic blood pressure (the bottom number) is the pressure in your arteries when your heart rests in between each heart beat. So if your BP is persistently 140/90 mmHg or higher, you will be diagnosed as having hypertension.

The prevalence of hypertension in Malaysians aged 18 years and above was 32.7% and for aged 30 years and above was 43.5% in 2011.

The popular belief that hypertension is an OLD PEOPLE disease is false. The 2011 Health & Morbidity survey found that 32.7% of Malaysians above the age of 18 had hypertension. The percentage of hypertensive people above the age of 30 was 43.5%. This means that almost HALF of those above the age of 30 are hypertensive, and almost ONE THIRD of those above 18 are hypertensive.

Hypertension is a silent disease; the majority of cases (61%) in the country remain undiagnosed. Blood pressure should be measured at every chance encounter.

Since the early stages of hypertension may not present with any noticeable symptoms, more than 60% of people with hypertension are walking around, leading their everyday lives without knowing that they actually have hypertension. That is why the doctor should always take your blood pressure any time you visit them, even if you see them for what may seem like a totally unrelated reason. This will help to “catch” this silent disease and allow patients to be managed earlier.

Untreated or sub-optimally controlled hypertension leads to increased cardiovascular, cerebrovascular and renal morbidity and mortality.

Countless research have proven that high blood pressure that is not controlled leads to numerous complications. Heart attacks, heart failure, stroke, kidney failure are just to name a few. This is why doctors insist that patients are diagnosed early, take their medications as prescribed, do the lifestyle changes as advised (exercise, eat healthy, stop smoking) and see the doctor for a regular follow up.

A systolic BP of 120 to 139 and/or diastolic BP of 80 to 89 mmHg is defined as prehypertension and should be treated in certain high risk groups.

Pre-hypertension basically means the stage just before hypertension. These are the group of people with BP which are higher than their optimum BP but do not yet meet the criteria to be diagnosed as hypertensive. Simply put, these are the “almost but not quite”. Some studies have shown that pre-hypertensive people are at similar risks as hypertensive people for various complications. As many as 1/3 of hypertension related deaths from heart disease are actually from this group. Hence people who fall under this category should be aware that they might also be at risk and take the necessary action, which includes lifestyle modifications. Some pre-hypertensive people with other risk factors such as diabetes or kidney disease/impairment may need to be started on medication.

Therapeutic lifestyle changes should be recommended for all individuals with hypertension and pre-hypertension.

It is sometimes hard for patients to accept that it takes more than pill popping to deal with hypertension and pre hypertension. Unfortunately, doctors often find that it is harder to get patients to make (and more importantly stick to) conscious healthy life changes such as weight reduction, decrease salt intake, avoidance of alcohol, regular physical exercise, healthy eating and relaxation therapy. It is important to remember that the key to lifestyle changes is to be consistent and this requires effort from the patient and support from those around them, such as family, friends and even the doctor.

Decisions on pharmacological treatment should be based on global vascular risks and not on the level of blood pressure per se.

When deciding which type of medication to use in a patient with hypertension, the doctor will consider more than just their BP measurement. The patient’s other risk factors for heart disease, stroke and kidney disease will also be taken into consideration. Personalized treatment catered to each individual will result in a more effective control of hypertension in patients.

In patients with newly diagnosed uncomplicated hypertension and no compelling indications, choice of first line monotherapy includes ACEIs, ARBs, CCBs, diuretics and beta blockers. Beta blockers is now recommended based on evidence from newer meta analyses since the last edition.

There are various types of anti-hypertensive drugs available, each with different mechanism of action. Your doctor will usually prescribe a “first line” or most commonly used and well known drug to begin with unless there are contraindications or reasons to choose a different kind of drug. It is important to discuss the medication with your doctor to know exactly how and when to take it, what the possible side effects are and how to detect whether or not the drug is doing what it is supposed to do. Do not hesitate to ask your doctor if you have any questions regarding your medication. Try and remember the name of your anti-hypertensive (write it down or save it on your smartphone) and the amount you are required to take, so that if any doctor other than your regular physician asks, you can give them the answer. This will greatly help any attending doctors.

Only 35% of Malaysian patients achieved blood pressure control (<140/90 mmHg) while on treatment. Every effort should be made to achieve target blood pressure. Target blood pressure depends on specific patient groups.

Sadly, many people with hypertension do not reach good blood pressure controls. Sometimes, the medication still needs to be adjusted or the patient is not taking the correct dose, skips their medication or adjusts the medication without consulting their doctors. This is dangerous. Uncontrolled hypertension can lead to devastating consequences such as a cardiac event or a haemorrhagic stroke (brain bleed). Other patients refuse to make any lifestyle changes at all and some seek alternative treatment with unregistered “medication” that can have unwanted results. The key is to work closely with your doctor towards achieving your desired blood pressure control. Good knowledge regarding your disease, its symptoms, complications and management will help greatly towards achieving that goal.

So now you know the latest on hypertension, pass the knowledge on.

Dr. Hidayatul Radziah is a trainee lecturer of Pharmacology at a local university. She is the current Chief Editor of The Malaysian Medical Gazette. Find out more about her at The Team page.

2 comments for “Key Messages From Hypertension Guidelines Explained – Dr. Hidayatul Radziah Ismawi

  1. Dr.J
    March 16, 2015 at 9:06 pm

    Hi, do correct me if I’m wrong, from what I read and remember, beta blockers are not the drug if choice for hypertension, but ACE inhibitor/CCB? Even UK / NICE guideline suggested that.

    • Hidayah
      March 17, 2015 at 9:12 am

      Dear Dr,

      Thank you for the question. This recommendation was made by our latest CPG based on data from the latest meta analyses. Other than the JNC guideline and NICE guidelines, all other guidelines still recommend beta-blockers as 1st line in newly diagnosed uncomplicated hypertension. Further more all guidelines recommend beta blockers in young patients intolerant to ACE I/ ARBs, women of child bearing age and those with increased sympathetic drive. However, as is good practice with any initiation of therapy, the choice of anti-hypertension should be individualized to each patient.

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