A PRACTICAL APPROACH TO HYPERTENSION

Dr. George Thomas (Siloam Clinic, Panampilly Nagar) discussed a clinical classification of hypertension based on an international publication (see box). The present classifications have many drawbacks and do not consider the treatment outcomes that can give valuable insights. So treatment outcomes and the qualitative aspects are used in this classification. The key to the clinical classification is the definition of normal BP. The normal value could be different based on the clinical circumstance. Hypertension is defined as any value above this. The principle of this classification is to find out the intensity of treatment required to bring down the BP to normal or target level. In this classification there is a category of low normal where the BP is lower than normal in perfectly healthy adults who require no treatment. High normal can be controlled by life style modifications. This class will also include drug-induced hypertension, which can be controlled by stopping the offending drugs. Mild to moderate hypertension requires medication for control. This includes patients with risk factors like diabetes. For convenience, this class is arbitrarily sub-classified into mild and moderate, Mild hypertension can be controlled with one anti-hypertensive medication. This is consistent with the sequential drug monotherapy. Moderate hypertension requires 2 or more anti-hypertensive drugs for control. Severe hypertension includes cases where optimum therapy
fails to achieve adequate BP control. This is after excluding all the factors of inadequate response to treatment. Optimum therapy would strike a balance between therapeutic effect and side effects. Similarly patients with target organ damage (TOD), malignant hypertension and patients presenting with hypertensive emergencies come in this category. By following this classification it would become mandatory for the physician to look for the qualitative aspects of hypertension like hypertension causing drugs, risk factors and target organ damage. The classification is very adaptive and universal. It can be used for various age groups and etiologies. It is also future-proof. In contrast to the present classifications, patients under treatment are ipso facto included in this classification. The drawbacks in this classification are similar to the existing numerical classifications. Usage algorithm: Evidence based value for normal BP is determined for the particular category of
patients. BP readings are taken as recommended. If the value is greater than the normal BP then the patient has hypertension. Look for target organ damage. If present, the category is severe. Similarly if the presenting symptom is hypertensive emergency or urgency then too the category is severe. If TOD or hypertensive emergency / urgency is absent, look for cardiovascular risk factors. If present, the category is mild to moderate. Institute drug treatment. If no risk factors present,
try life style modification. If successful, the category is high normal. If not successful try one drug. If the BP gets controlled then the category is mild. If not, add additional medications till control achieved or side effects occur. If the BP gets controlled the category is moderate. If not controlled then again the category is severe. This classification of hypertension is minimally dependant on the numerical values. Higher values may turn out to be more benign and lower values may need
more powerful treatment regimes. As the classification less dependant on numerical values it provides a simple, practical and qualitative classification of hypertension. For details search Google with key words Clinical Classification of Hypertension for the top site or email the speaker at dr.georgethoms @yahoo.com.
CLINICAL CLASSIFICATION OF HYPERTENSION - Rule : Normal BP is to be defined : For example for adults > 18 years this is defined as a BP of 120 mm Hg systolic and 80 mmHg diastolic. Low normal - Requires no treatment High normal - Requires lifestyle modification only. May involve withdrawal of hypertension causing medications. Exclude secondary hypertension. Mild to moderate - Requires antihypertensive drug for control. Includes patients with risk factors for whom drug therapy is recommended. a) Mild hypertension - Requires only one antihypertensive drug for control. b) Moderate hypertension - Requires 2 or more antihypertensive drugs for control. Severe hypertension - Inadequate control with optimum therapy and / or - Presence of target organ damage and / or
- Hypertensive emergencies / urgencies.