Executive Summary

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Background

Hypertension is a chronic long-term condition where blood pressure is increased. In adults, blood pressure is considered to be normal under a systolic value of 140 mmHg and under a diastolic value of 90 mmHg.

A person is considered to have high blood pressure if the systolic value is equal to or above 140 mmHg, the diastolic value is equal to or above 90 mmHg, or if both are higher than these readings. It is a complex condition with many causes including lifestyle factors, such as physical inactivity, a salt-rich diet with high processed and fatty foods, and alcohol and tobacco use.

Hypertension is known as “silent killer” because people with high blood pressure may not feel symptoms. The only way to know is to routinely check blood pressure. Pharmacologic and nonpharmacologic interventions together requires for effective hypertension treatment and management and prevent target organ damage.

Diagnosis of HTN

Most people with hypertension do not feel any symptoms. Individuals with extremely high blood pressure may experience headaches, blurred vision, chest pain, and other related symptoms. Regular monitoring of blood pressure is crucial for early detection. Left untreated, hypertension can lead to the development of serious health conditions such as kidney disease, heart disease, and stroke.

Diagnosis of HTN is usually based on the average of two or more readings taken on separate occasions. Hypertension is defined as 140/90 mmHg or higher. Severe hypertension is 160/100 mmHg and higher and may require immediate or emergency treatment.

Management of HTN

Controlling hypertension is associated with a reduction in mortality and adverse cardiovascular outcomes, and both non-pharmacological and pharmacological interventions are essential to treatment. HTN is a global epidemic and hence many guidelines and pharmacologic options are available to prevent the morbidity and mortality associated with HTN. The national guideline of HTN in Bangladesh is updated and second version is also aim to prevent these similar aim.

Although lifestyle modifications are frequently neglected, they should be started early and continued indefinitely. For some individuals, the management of blood pressure necessitates the use of multiple antihypertensive agents.

The pharmacological management should be started with any one of either Calcium channel blocker (CCB), ACEI or ARB or Thiazide diuretics. The primary health care of Bangladesh is settled with first line CCB (Amlodipine) followed by second line ARB (Losartan potassium) and third line Thiazide diuretics (Hydrochlorothiazide) with defined protocol.

Combining therapies prove effective, especially for those in stage 2HTN. Regardless of the chosen medication, the foremost objective in HTN treatment is achieving the target blood pressure. Effective communication among physicians, healthcare providers, and patients plays a pivotal role in the successful management of HTN.

Hypertensive crisis

Hypertensive crisis is a severe clinical condition in which a sudden increase in arterial blood pressure can lead to acute vascular damage of vital organs. A thorough assessment must be performed to differentiate between urgency and emergency. Timely detection, evaluation and adequate treatment are crucial to preventing permanent damage to vital organs.

Secondary hypertension and Resistant hypertension

Resistant hypertension may have no symptoms for a longer period, but then can cause heart attack, stroke, and vision and kidney damage. Pseudoresistant hypertension is important to diagnose and treat. Assessment and treatment of resistant hypertension includes addressing any identifiable conditions or causes and adjusting medications in a personalized way.

Hypertension in patients with diabetes mellitus

ACEIs are the preferred choice for cardiovascular and renal protection in diabetic patients as they have no adverse effects on lipid and carbohydrate metabolism. If ACEIs are not tolerated, ARBs can be considered, offering similar efficacy and better tolerance.

Diuretics can be used alone or with ACEIs/ARBs at the lowest effective dose to minimize adverse metabolic effects.

CCBs have minimal metabolic impact, and non-dihydropyridine CCBs may be preferable for reducing proteinuria in diabetic nephropathy.

Beta-blockers are an option when other medications are unsuitable, but caution is advised, especially in type 1 diabetes. Peripheral alpha blockers don't affect carbohydrate or lipid metabolism but may worsen orthostatic hypotension in autonomic neuropathy.

Hypertension in coronary artery diseases

Individuals who have both hypertension and HFrEF should be treated with medications. Beta-blockers and MRAs are effective in improving clinical outcome in patients with HFrEF compared to diuretics. Antihypertensive treatment is frequently required for patients with HFpEF. Same BP threshold and target for drug treatment recommended for HFrEF should be applied in HFpEF.

Hypertension management in stroke

Stroke is a medical emergency of cerebrovascular disease. Although many strokes are treatable, some can lead to disability or death. Therefore, immediate treatment for stroke may help prevent life-threatening consequences. Blood pressure below 185/105 is needed if patient undergo thrombolysis in ischemic stroke and a blood pressure above 220/110, then immediate reduction is important (10-20% reduction in the first hour, reaching 160/100 mmHg in 6 hours, reduce to target in 2-3 days).

Hypertension in children and adolescents

A well-taken history provides clues about the cause of hypertension and guides the selection and sequencing of ensuing investigations. Symptoms and signs are not specific in neonates and are absent in older children unless the hypertension is severe.

Children are at greater risk of hypertensive emergencies due to an underlying condition. Severe hypertension requires urgent consultation and management. Hypertension associated with encephalopathy is a medical emergency.

Hypertension in Chronic Kidney Disease (CKD)

CKD is becoming more widespread in Bangladesh and its connection to the onset of CVD is notably significant. HTN plays a dual role as both a cause and consequence of CKD, impacting a substantial majority of CKD patients. Effectively managing HTN is crucial for individuals with CKD, lowering BP in CKD slows disease progression and reduces incident CVD.

Non-pharmacological interventions are useful in reducing BP in CKD but are rarely sufficient to control BP adequately.

Patients with CKD and hypertension will often require a combination of antihypertensive medications to achieve target BP. It's worth noting that specific pharmacological treatments not only contribute to blood pressure regulation but also offer additional kidney- and heart-protective benefits.

Hypertensive disorder in pregnancy

Hypertension in pregnancy is a condition affecting 5%–10% of pregnancies worldwide. Recent survey by NIPORT 2022, MOHFW has revealed that prevalence of pregnancy induced hypertension (PIH) in Bangladesh is 10.1% (95% CI, 9.0, 11.2) among pregnant women with gestational age >20 weeks.

Pre-eclampsia and eclampsia are one of the common obstetric emergencies. About 4.6% of pregnancy are complicated with pre-eclampsia. Eclampsia is the cause of 24% maternal death in Bangladesh. Most of the pre-eclampsia and eclampsia are preventable.

Role of non-physician professionals in hypertension control

Strengthening primary health care for tackling the increasing burden of NCDs in Bangladesh is critically important, where the non-physician professional such as SACMO, nurse and CHW, who are based at community clinics, union-subcenters and Upazila Health Complexes could play a pivotal role in screening, provisional diagnosis, early detection, management, referral and follow-up of patients with NCDs.