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GUIDELINES
FOR BERMUDA
2011

GOVERNMENT OF BERMUDA
Ministry of Health
Department of Health
HYPERTENSION GUIDELINES
FOR BERMUDA
Government of Bermuda Ministry of Health Department of Health
P.O. Box HM 1195, Hamilton HM EX Bermuda Hypertension Task Group Hypertension Task Group (2011) Hypertension Guidelines for Bermuda Government of Bermuda: Department of Health Abbreviations . i
Introduction . 1
Task Group Members . 3
Diagnosis and Classification . 4
Measurement of Blood Pressure . 4Classification and Diagnosis of Hypertension . 6Algorithm 1: For Screening and Identifying Hypertension . 7Evaluation and Assessment . 10Cardiovascular Risk Assessment . 12Complicated and Resistant Hypertension . 13Hypertensive Urgencies . 15Malignant Hypertension . 15Management of Hypertension .17Strategies to Improve Adherence . 18 Lifestyle Management . 20
Management . 20Regular Physical Activity . 20Dietary Modification . 20Weight Reduction/Maintenance . 21Alcohol . 22Smoking Cessation . 22Stress Management . 23 Pharmacological Management . 24
Algorithm 2: Choosing Drugs For Patients Newly Diagnosed With Hypertension . 26Drug Price Comparison. 28 Diabetes . 30
Algorithm 3: Treatment Algorithm For Persons With Diabetes and Hypertension . 33 Renal Disease . 34
Hypertension and Cardiac Disease . 37
Hypertension and Heart Failure . 37Hypertension and Ischemic Heart Disease . 37Hypertension and Surgery . 38Hypertension and Stroke . 39 Women . 43
Men . 45
Seniors . 46
Children And Adolescents . 47
Algorthim 4: Management of Children With Hypertension . 54 Appendices . 55
References . 66
ACEI – angiotensin converting enzyme inhibitors (the ‘ACE inhibitors')AKI – Acute kidney injuryARBs – angiotensin II receptor blockersBB – Beta-blockerBP – Blood pressureCCB – Calcium channel blockerCHF – Congestive heart failureCKD – Chronic kidney diseaseCr – Creatinine DBP – Diastolic blood pressure DM – Diabetes mellitusDM CKD – Diabetes mellitus chronic kidney diseaseED – Erectile dysfunctionESRD – End-stage renal diseaseeGFR/GFR – Glomerular filtration rate HTN – Hypertension K – PotassiumLVH – Left ventricular hypertrophyNDM CKD – Non diabetes mellitus chronic kidney diseaseRAS – Renin-angiotensin systemSBP – Systolic blood pressureSR – Slow-releaseTIA – Transient ischemic attackTIDM – Type 1 Diabetes mellitusT2DM – Type 2 Diabetes mellitustPA – Tissue plasminogen activator The Government of Bermuda is committed to standardize and improve health care for all people in Bermuda. In 2004, a Department of Health Study determined Bermuda's health pri-orities1 and identified heart disease and stroke as the number two health problem for the country. The 2006 Health Survey of Adults and Children in Bermuda revealed that 25% of adults reported they had high blood pressure2. Diseases of the cir-culatory system, of which high blood pressure is a major contributing factor, are the leading cause of death in Bermuda (43.4% of all deaths in 20073).
The 2008 National Health Promotion Strategy, Well Bermuda4, listed Improve Heart Health among the primary health promotion goals for the country. The Improve Heart Health objectives are to: 1. Reduce the proportion of adults with high blood pressure. 2. Reduce the proportion of adults with high total blood cholesterol 3. Increase the proportion of adults with high blood pressure whose blood pressure is under control.
4. Increase the proportion of adults who have had their blood pres- sure measured within the preceding year.
5. Increase the proportion of adults who are aware of the early warning symptoms and signs of a stroke.
To facilitate Government's goal for hypertension (high blood pressure), the then Minister of Health appointed a Task Group of representative stakeholders from Bermuda's health professionals in October 2010. The purpose of the Task Group was to provide a consultative forum to review clinical guidelines from recognized hypertension organizations overseas and to develop guidelines best suited to Bermuda's needs. The following five guidelines were reviewed: 1. Caribbean Health Research Council: Managing Hypertension in primary care in the Caribbean. St. Augustine, Trinidad and To-bago: Caribbean Health Research Council 2007.5 2. Royal College of Physicians (NICE): NICE clinical guidelines 18 (and 34): Hypertension: The management of hypertension in adults in primary care (Quick Reference). London: Royal College of Physicians, 2008.6 3. U.S. Department of Health and Human Services (NIH, NHLBI, NH- BPEP). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 2004.7 4. Central Review Committee of the Evidence-Based Recommen- dations Task Force of the Canadian Hypertension Education Programme: Canadian Hypertension Education Programme Recommendations for Management of Hypertension (CHEP). Hy-pertension Canada. 2010.8 5. National Heart Foundation of Australia (National Blood Pressure and Vascular Disease Advisory Committee).Guide to management of hypertension 2008. Updated August 2009. Web version. 2009.9 The Hypertension Guidelines for Bermuda represent the consensus of the Hypertension Task Group based on collective analysis, evaluation and opinion on the current information available to them. The information included throughout the guidelines is taken largely from the above five guidelines and additional referenced documents. These guidelines are designed to be easy to follow and serve as key tools in improving patient care.
TASK GROUP MEMBERS
1. Dr. Femi Bada – Chairman Bermuda Diabetes Association 2. Myrian Balitian-Dill, RN – Nurse Specialist, Cardiac Care Programme – 3. Simone Barton – Executive Director, Bermuda Heart Foundation 4. Dr. Arlene Basden – Director of the Hospitalist Service – KEMH 5. Gloria Burgess, RN – Public Health Nurse, Maternal Health – Department 6. Dr. Annabel Fountain – Director of Endocrinology – KEMH 7. Mellonie Furbert, RD – Public Health Nutritionist, Department of Health 8. Dr. Carl Levick – Director of Cardiology – KEMH 9. Tracy Marra, Pharm D – Pharmacist 10. Sara McKittrick, RD – Dietitian and Diabetes Educator, Bermuda Diabetes 11. Dr. Katherine Michelmore – BHB Employee Health Physician – KEMH 12. Dr. Fiona Ross – Family Physician representative 13. Dr. Cathy Siddle – Internal Medicine 14. Norma Smith, RN – Vice President – Nursing (Acting), KEMH 15. Dr. Jayalakshmi Thamidela – Medical Officer – Department of Health 16. Dr. Lynette Thomas – Director of Nephrology – KEMH 17. Denise Walls, RN – Clinical Manager Nursing, KEMH 18. Dr. Louise White – Family Physician representative Task Group Coordinator 19. Betsy Baillie, MPH, RD – Public Health Consultant, Department of Health DIAGNOSIS AND CLASSIFICATION
MEASUREMENT OF BLOOD PRESSURE (BP)
Setting and Circumstance

• BP can be measured in the office, clinic, hospital, at home or with an ambulatory BP machine.
• No caffeine/tobacco or exercise 30 minutes prior to measurement.
• Rested for five minutes, seated in comfortable chair.
• Arm at heart level; back supported and feet on ground.
• Arm is bare.
• Room is warm and quiet.
Equipment
• Recommend auscultatory method of BP measurement. • Use mercury sphygmomanometer, or calibrated aneroid, or validat- ed electronic device.
• Ensure appropriate cuff size – with the bladder encircling at least 80% of the circumference and covering 2/3 length of the arm.
• Note, a bladder that is too small may cause falsely high readings.
• Use bell of the stethoscope.
Recommended Dimensions for BP Cuff Bladders
Maximum Arm
Age Range
Width, cm
Length, cm
Small adult
Large adult
*Calculated so that the largest arm would still allow the bladder to encircle arm by at least 80%. Source: The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. 2005. The National Heart, Lung and Blood Institute Informa-tion Center10. Technique
• Wrap cuff smoothly, snugly and evenly around the arm with the middle of the balloon over the brachial artery.
• Palpate radial artery and inflate cuff to 20 mmHg systolic pressure above the point when radial pulse is obliterated. • Deflate bladder 3 mmHg per second, listening with the bell of the stethoscope over the brachial artery for Korotkoff phase I (appear-ance) and phase V (disappearance)—corresponding to systolic and diastolic values respectively.
• In children, Korotkoff phase IV (distinct, abrupt muffling of sounds, becoming soft and blowing in quality) is preferred.
Quality Control
• The nurses and office assistants measuring blood pressure must be trained and regularly re-trained in auscultatory method of BP measurement.
• Non-mercury BP equipment should be validated every six months.
Readings
• Initial readings are taken from both arms, with the higher values used for subsequent measurements.
• Because blood pressure normally varies up to 10 mmHg, it is neces- sary to take three readings to obtain the most accurate present blood pressure. • If the first measurement exceeds 140/90 mmHg*, if practical, take a
second confirmatory reading at the end of the consultation.
Standing BP should be recorded at the initial estimation in the
elderly and diabetic patients.
• A decrease in standing SBP >10 mmHg with associated dizziness and/or fainting is considered positive for postural hypotension and should be monitored in subsequent visits using upright position.
• In patients with symptoms or documented postural hypotension
(fall in systolic BP when standing of 20 mmHg or more) consider
referral to a specialist.

• Record the BP reading, patient position, and arm and cuff size in • All readings are recorded to the nearest 2 mmHg, not rounded to the
CLASSIFICATION AND DIAGNOSIS OF HYPERTENSION
Classification of Hypertension
Systolic
Diastolic
Optimal BP
Normal BP
130 – 139
Stage 1 hypertension (mild)
Stage 2 hypertension (moderate)
Stage 3 hypertension (severe)
**Isolated systolic hypertension 1
**Isolated systolic hypertension 2
• Pre-hypertension is not a disease category. It is a designation chosen to identify individuals at high risk of developing hypertension, so
that both patients and physicians are alerted to this risk, and are
encouraged to intervene and prevent or delay the disease from devel-
oping.
** Isolated systolic hypertension
• There is impressive evidence which has accumulated to warrant greater attention to the importance of isolated systolic hyperten-
sion
as a major risk for cardiovascular diseases.
• BP changes occur with increasing age; the rise in systolic BP con- tinues throughout life in contrast to diastolic BP, which rises until approximately the age of 50, and then tends to level off over the next decade, and may remain the same or even fall thereafter.
• Diastolic hypertension predominates before age 50 either alone or in combination with systolic hypertension. The prevalence of systolic hypertension increases with age, and above age 50, it represents the most common form of hypertension.
• Before the age of 50, DBP is a more potent cardiovascular system (CVS) risk factor than SBP; thereafter, SBP is more important. Clini-
cal trials have shown that control of isolated systolic hypertension
reduces total mortality, CVS mortality, stroke, and HF events.
• Poor SBP control is largely responsible for the unacceptable low rates of overall BP control.
ALGORITHM 1:
FOR SCREENING AND IDENTIFYING HYPERTENSION

Screen & Identify elevated
BP ≥ 140/90
This algorithm is based on an See section
Confirm elevated BP
"confirm
Initial encounter elevated BP"
is defined as an ICD-9 code 401.1 ("Elevated blood pressure reading without diagnosis of Complete initial
hypertension. Note: assessment: evaluate
this category is to accurate stage, complete
be used to record an episode of elevated blood pressure in a patient in whom no formal diagnosis of hypertension has been made, or as an incidental finding").
Order additional
This guideline en-courages increased Consider phone
Is secondary cause
use of this 401.1 consult to
ICD-9 code because specialist or
referral if
pressure without hypertension is cur-rently believed to be underreported. Lifestyle modification; +/-
drug therapy
Adapted from: Health Care Guidelines: Hypertension Diagnosis and Treatment, Institute for Clinical Systems Improvement, 13th edition, November 201011 Confirm High Blood Pressure
• Confirmation is based on the initial visit, plus one or more follow-up visits with at least three blood pressure readings at each visit.
• Follow up recommendations based on JNC VII schedule (see next • Use ambulatory BP monitoring to assist with equivocal findings.
• Document stage of hypertension based on classification: Normal, Pre-hypertensive, Stage 1, Stage 2 or Stage 3. Recommendations for Follow-up Based on Initial Blood Pressure Measurements for
Adults without Acute End Organ Damage

Initial Blood Pressure, mmHg
Follow-up recommended
Normal BP
Re-check in 2 years Re-check in 1 year* Stage 1 hypertension (mild)
Confirm within 2 months.** If still stage 1 and no other risk factors prescribe lifestyle modification and sodium restriction for 6 months. If other risk factors present, treat.
Stage 2 hypertension (moderate)
Evaluate, treat, or refer to source of care within 1 month. Stage 3 hypertension (severe)
For those with high pressures great-er than 180/110 mmHg, evaluate and treat immediately or within one week depending on clinical situation and complications.
* Provide lifestyle modification. If systolic and diastolic categories are different, follow rec-ommendations for the shorter time follow-up (e.g., 160/86 mmHg should be evaluated or referred to source of care within one month).
** Modify the scheduling or follow-up according to reliable information about past BP mea-surements, other cardiovascular risk factors, or target organ disease.
Source: Seventh Report of the Joint National Committee on Prevention, Detection, Evalua-tion, and Treatment of High Blood Pressure. 2004. White-Coat Hypertension
• Is defined as consistently high BP in a medical setting (>140/90) and normal BP at home (<129/84 mmHg).
• It is more common in the elderly, accounting for more than 20% of all patients diagnosed with high blood pressure and is normally benign.
• It requires continued monitoring at home and if measurements are elevated, ambulatory blood pressure monitoring can assist with di-agnosis. Ambulatory BP Monitoring (ABPM)
• This provides detailed BP information over a 24-hour period.
• It is useful if the diagnosis of hypertension is in doubt.
• It provides more information than the office or home measurement especially showing mean daytime and night time values.
• There is an increasing body of evidence suggesting that ABPM values are better predictors of cardiovascular disease (CVD) risk, target or-gan damage, and a better method of assessing treatment effects on blood pressure. EVALUATION AND ASSESSMENT

Risk Assessment
The risk for cardiovascular disease in patients with hypertension is deter-
mined not only by the level of blood pressure, but also by the presence or
absence of target organ damage and other risk factors such as smoking,
dyslipidemia and diabetes, as shown in the Seventh Report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treat-
ment of High Blood Pressure. These factors independently modify the risk
for subsequent cardiovascular disease, and their presence or absence is
determined during the routine evaluation of patients with hypertension
(i.e., history, physical examination, laboratory tests).
Evaluation
• Determine stage of hypertension, specifically looking for secondary • Assess impact of hypertension (end organ damage).
• Estimate overall risk of developing premature cardiovascular dis- History should document:
• A family history of hypertension, cardiovascular disease, cerebrovas- cular disease, diabetes mellitus and dyslipidemia.
• All medications being used including herbal supplements, over-the- counter, prescription and illicit drugs – as many agents may tempo-rarily elevate blood pressure and/or adversely affect antihypertensive medications.
• Symptoms and signs of target organ disease and secondary hyperten- Physical Exam
• General appearance: distribution of body fat, skin lesions, muscle strength, alertness • Fundoscopy • Neck: palpation and auscultation of carotids, thyroid• Heart: size, rhythm, sounds• Lungs: rhonchi, rales • Abdomen: renal masses, bruits over aorta or renal arteries, femoral • Extremities: peripheral pulses, edema• Neurologic assessment Routine Investigations
Initial Pertinent Labs:
Order tests as neces-
sary, especially if not
• Microalbuminuria done within past year.
• Urinalysis• Fasting blood glucose or HbA1c• Hematocrit • Serum sodium• Potassium• Creatinine • Estimated glomerular filtration rate eGFR • Calcium• Lipid profile (total cholesterol, high-density lipo-protein cholesterol, low-density lipoprotein choles-terol and triglycerides) Source: Hypertension Diagnosis and Treatment Clinical Evaluation of Confirmed Hyperten-sion Thirteenth Edition / November 201010 Secondary Causes of Hypertension
• Chronic kidney disease • Obstructive uropathy • Thyroid and parathyroid disease • Drug induced or related causes (prescription, over-the-counter, herb- al supplements, illicit drugs) • Excessive alcohol use • Obstructive sleep apnoea • Primary aldosteronism and other mineralocorticoid excess states • Other glucocorticoid excess states including chronic steroid therapy • Renal artery stenosis • Pheochromocytoma • Cushing's syndrome • Aortic coarctation CARDIOVASCULAR RISK ASSESSMENT

Cardiovascular Risk Factors7

• Gender• Age (older than 55 years for men, 65 years for women)• Hypertension• Diabetes • Elevated cholesterol (total or LDL) or low HDL cholesterol• Estimated glomerular filtration rate <60 mL/min.
• Family history of premature cardiovascular disease• Microalbuminuria• Obesity (BMI ≥30 and waist circumference <40" men and <35" wom- en (see appendix IV)) • Physical inactivity• Cigarette and tobacco use • Evidence of atrial fibrillation (history, examination, electrocardio- Stratification of Risk and Prognosis
Risk Factors (RF) and Stage 1
140 – 159/90 – 99 160 179/100 –109 ≥ 180/110
1 or 2 risk factors
3 or more risk fac-
tors OR target organ
damage
Associated clinical

Source: WHO, ISH Writing Group. 2003 World Health Organization/International Society of Hyperten-sion Statement on Management of Hypertension. Journal of Hypertension 2003. Vol. 21:11 1983 – 199212 Cardiovascular Risk Charts and Calculators
Various cardiovascular risk charts and web-based decision support pro-
grammes are available for assessing cardiovascular risk. CVD risk is es-
timated using epidemiological data such as those generated from the
Framingham Study. Any of the following websites can be used to assess
cardiovascular risk in patients.
1. Interactive Risk Assessment Tool for Estimating 10-year Risk of Devel- oping Hard CHD (Myocardial Infarction and Coronary Death).
http://hp2010.nhlbihin.net/atpiii/calculatorasp?usertype=prof#moreinfo 2. American Heart Association has an interactive "Heart Attack Risk Calculator" for patients to use. At the following website click on "Learn Your Risk". After patients enter their health information they can get a Risk Report and Action Plan to assist them in achieving health goals. http://www.heart.org/HEARTORG/Conditions/HeartAttack/HeartAt-tackToolsResources/Heart-Attack-Risk-Assessment_UCM_303944_Ar-ticle.jsp 1. The Joint British Societies Cardiovascular Disease New Risk Assess- ment Charts 2009. 2. The Joint British Societies Cardiovascular Risk Assessor (V01.06) is available to download onto your PC from the HEART U.K. website with the permission of Professor Durrington.
1. National Heart Foundation of Australia – Australia Cardiovascular Risk Charts.
COMPLICATED AND RESISTANT HYPERTENSION
Complicated hypertension is defined as hypertension with end organ damage.
End Organ Damage7

 • Left ventricular hypertrophy (LVH) • Angina/prior MI • Prior coronary revascularization • Heart failure  • Stroke or transient ischemic attack  • Dementia • Chronic kidney disease (CKD) • Peripheral arterial disease  • Retinopathy The Task Group recommends:  • Referral of patients with significant cardiac dysfunction to a car-  • Referral to a nephrologist for patients with:  • Proteinuria greater than 300 mgs/24 hr., or a  • Rising Creatinine, or a  • GFR less than 60  • Referral of patients with retinal haemorrhages or papilloedema, to hospital as an emergency.
Resistant hypertension is defined as failure to achieve goal blood pres-
sure in patients who are adhering to full doses of an appropriate three
drug regimen that includes a diuretic.
For resistant hypertension, the Task Group recommends first determin-ing adherence, and then if the patient is judged to be adherent, referral to a specialist for evaluation for secondary causes of hypertension (see list on page 11).
In resistant cases of hypertension, also consider other medications (in-
cluding complementary medicines) that patient may be taking that may
increase blood pressure (see table below).
Medications that can increase blood pressure
Caffeine containing products (guanara, cola, green tea) Haemopoietic agents (Epo) Immunomodulators (cyclosporine, tacroli- Oral contraceptives Oral decongestants (pseudoephedrine) Adapted from: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH, NHLBI, NHBPEP • These are defined as situations associated with severe elevations in BP without progressive target organ dysfunction.
• Conditions would include: Upper levels of Stage 2 hypertension asso- ciated with severe headache, shortness of breath, or severe anxiety. These patients present as non-adherent or inadequately treated.
• Some patients with hypertensive urgencies may benefit from treat- ment with an oral, short-acting agent such as captopril, labetolol, or clonidine followed by several hours of observation. There is no evidence to suggest that failure to aggressively lower BP in the ER is associated with any increased short-term risk to the patient who presents with severe hypertension. Such a patient may benefit from adjustment in their antihypertensive therapy, particularly the use of combination drugs.
Note that early triage to establish appropriate therapeutic strategies is critical to limit morbidity and mortality; and also most importantly, ar-range confirmed follow up visit with G.P.
Malignant hypertension is a medical emergency. Diagnosis Criteria:
• BP ≥ 180/110 mmHg PLUS ONE OR MORE of the following: • intracerebral haemorrhage• retinal haemorrhage• papilloedema• haematuria• thrombocytopenia • pulmonary edema • Malignant hypertension requires immediate blood pressure reduc- tion (not necessarily to normal) to prevent or limit organ damage.
• Admit to ICU for continuous monitoring of BP and parenteral ad- ministration of vasodilators (sodium nitroprusside, nicardipine hy-drochloride, nitroglycerin, hydraliazine, enalaprilat) or adrenergic inhibitors (labetolol, esmolol, phentolamine). The goal is to reduce mean arterial BP by no more than 25% (within minutes to one hour), then if stable, to 160/100 –110 mmHg within the next 2 – 6 hours.
• Excessive falls in pressure that may precipitate renal, cerebral, or coronary ischemia should be avoided. For this reason, short acting nifedipine is no longer considered acceptable in the initial treat-ment of hypertensive emergencies or urgencies.
• If this level of BP is well tolerated and the patient is clinically stable, further gradual reduction can be implemented in the next 24 – 48 hours. MANAGEMENT OF HYPERTENSION
Monitoring Schedule for Management of Hypertensive patients
Blood pressure level
Reassess in 3 – 6 months BP 140 – 159/90 – 99 (Stage 1) Reassess within 2 months BP 160 – 179/100 – 109 (Stage Treat, reassess or refer within 1 month2)BP >180/110 (Stage 3) Treat, reassess or refer within 7 days as necessary Treat immediately and reassess within 1 – 3 days as necessary Malignant hypertensive or Refer for in-hospital treatment immedi- emergency patients Isolated systolic hyperten- As for category corresponding to SBP (SBP >140, DBP <90) Isolated systolic hyperten- As for BP >180/110 sion with widened pulse pressure (SBP >160, DBP <70) Adapted from the following Guidelines: 1. National Heart Foundation of Australia (National Blood Pressure and Vascular Disease Advisory Committee). Guide to Management of Hypertension 2008 AND 2. U.S. Department of Health and Human Services Seventh Report of the Joint National Commit- tee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 2004, and 3. Caribbean Health Research Council: Managing Hypertension in primary care in the Carib- bean. St. Augustine, Trinidad and Tobago: Caribbean Health Research Council 2007. Every visit – measure and record:
• BP• Weight (for BMI calculation)• Positive or adverse effects of medications• Healthy lifestyle Annually – measure and record:
• BP• Weight for BMI calculation • Update medical history• Lifestyle management• Laboratory investigation: • Electrolytes glucose • Fasting lipid profile • Microalbuminuria General monitoring
Consider a practice register to assist in the monitoring of patients with
hypertension.
STRATEGIES TO IMPROVE ADHERENCE 7,8,9
• Address emotional stresses, financial and personal concerns.
• Educate patient on diet and lifestyle practices to improve hyperten- • Address alcohol and drug/tobacco use.
• Address any drug interactions and the use of over-the-counter medi- cations that may increase BP.
• Consider white-coat hypertension.
• Dispel myths about hypertension and its treatment by education.
• Address causes of secondary hypertension, i.e., sleep apnoea, chronic • Consider volume overload – excessive salt intake.
• Use of appropriate cuff-size when measuring blood pressure.
• Use of combinations of medications and dosing.
• Review all medications/drugs being taken at each visit – ask specific questions, and give patients permission to tell the truth without fear of reprimand.
• Simplify drug regimens. • Recommend drug dispensing containers, or suggest location of pills to increase compliance.
• Write down a proposed schedule of all medications at each visit.
• Address adherence and the barriers to adherence at each visit.
• Encourage patient to measure home BP.
• Take time to build rapport and educate patient, thus engendering trust of the physician and the chosen mode of treatment.
• Consider out-of-office contact (i.e., phone or e-mail) especially during the first three months of therapy.
• Invite the patient to bring a family member to an early discussion about hypertension, and request their help and support of their loved one.
• Encourage cardiac care, dietitian, physiotherapist or psychologist follow-up when necessary.
• Consider use of incentives, financial or otherwise to increase motiva- LIFESTYLE MANAGEMENT
MANAGEMENT
Adoption of healthy lifestyles by all persons is critical for the prevention
of hypertension and is an indispensible part of the management of those
with hypertension.13
• Observe patients for 3 – 6 months for Stage 1 and 2 Hypertension. Do not hesitate to initiate drug therapy when necessary to meet BP goals.14 • For ongoing support and follow-up15, consider referral to a Lifestyle Modification Programme. See Appendix I for contact information for Lifestyle Modification Programmes offered on the island.
• An outpatient blood pressure clinic is provided by the Department of Health:• Hamilton Clinic – Wednesdays 2 – 4 p.m.
• For Senior Wellness Clinics call 278-6460 or 292-3095 to schedule an appointment. Clinic Times: 2 – 4 p.m.
• Somerset Clinic – 3rd Tuesday of the month• Hamilton Clinic – 2nd and 4th Wednesdays of the month• St. George's – 1st Tuesday of the month • It is recognized that management of hypertension in homeless indi- viduals is an area with many difficulties, refer to free blood pressure clinic and homeless feeding programmes.
REGULAR PHYSICAL ACTIVITY
Prescribe physical activity at moderate intensity, completed in intervals
throughout the day:
• 30 – 60 minutes per day most days of the week for children.10 • ≥30 minutes per day moderate intensity for adults and for those needing to achieve weight reduction.15 • Individuals with Stage 3 Hypertension should be assessed for safety to participate in physical activity programme.15 DIETARY MODIFICATION
Referral to a registered dietitian is advised to assist patient with the rec-
ommended dietary modifications:
• Adherence to the DASH Diet/Vegetarian Diet16 – which may include fruits, vegetables, whole grains, legumes and nuts for a total of 30 – 40 gm fibre / day, lean meats, and low-fat dairy foods.
DASH Diet www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_ • Reduction of sodium intake to: • 2300 mg per day for prevention of hypertension (equivalent to 1 teaspoon of salt). • 1500 mg sodium for hypertensive individuals (equivalent to 2/3 teaspoon of salt). • Strategies to reduce sodium intake include: • Following the DASH diet.
• Avoiding processed canned and fast foods.
• Avoiding adding salt during cooking and at the table.
• Reading food labels to determine sodium content of foods. A food is considered low in sodium if it contains 140 milligrams or less of sodium per serving.
• Food Label www.health.gov.bm (Appendix III).
The following are not recommended: • Supplementation of potassium, calcium and magnesium is not rec- ommended as prevention or treatment of hypertension.8 • There is insufficient evidence to recommend fish oil, supplemental fiber, high protein and low glycemic index diets as a means to lower BP.10 • Hypertensive individuals should be encouraged to reduce their weight to attain a normal BMI <25 (see Appendix IV for BMI Chart). Every 1% reduction in body weight lowers systolic BP by an average of 1 mmHg9.
• Adult BMI can be calculated at http://www.nhlbisupport.com/ • A child and adolescent BMI calculator is available at http://apps.
• Growth charts are available at http://www.cdc.gov/growthcharts • Waist circumference targets are: • <40" men • <35" women (see Appendix IV).
• Refer patient to a registered dietitian. • A multidisciplinary team approach to weight loss is encouraged. Team members should include nurse, dietitian, physiotherapist, and when necessary psychologist/behaviour therapist. The multidisci-plinary team is important in establishing weight maintenance over the long term.17 • Target weight reduction of 10% body weight should be sought through lifestyle behaviour change to: • Reduce calories by decreasing portion sizes and eliminating high calorie beverages. • Limit consumption of high fat foods. • Decrease sedentary activities. • Increase physical activity.
• Reduce age-related weight gain.
• Morbidly obese individuals (BMI >40) may benefit from drug therapy or bariatric surgery.
• Those individuals who undergo bariatric surgery require lifestyle management support post surgery.17 • For more detailed information access the The Practical Guide to the Iden- tification, Evaluation, and Treatment of Overweight and Obesity in Adults an NIH Publication and NHLBI Obesity Education Initiative from www.
nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf PDF file ALCOHOL
Limit drinks to:5,9
• 2 drinks/day men.
• 1 drink/day women.
• 1 drink = 1 oz. liquor, 6 oz. wine, 12 oz. beer.5• Caution should be provided regarding medication/alcohol interac- • Encourage and support a smoke-free environment.
• Advise individual to quit smoking.
• Refer to smoking cessation programme.
• Prescribe nicotine replacement therapy as required.
STRESS MANAGEMENT
In hypertensive clients in whom stress may be contributing to blood pres-
sure elevation, stress management should be considered as an interven-
tion.8 Refer for counselling as required.
The Task Group recognizes that there are a large number of drugs avail-able to reduce blood pressure. Many large-scale trials have confirmed the effectiveness of the different classes of anti-hypertensive agents, but have not confirmed superiority of any particular class. In addition, up to two-thirds of people will need two or more drugs to meet their target blood pressure.6 The British Hypertension Society in collaboration with the National In-stitute for Clinical Excellence has developed a treatment algorithm to inform the better use of logical combinations of drugs.6 These recom-mendations are largely similar to those outlined in other international guidelines, but have the benefit of a straightforward and easily interpret-ed flowchart. The Bermuda Task Group has thus recommended the adop-tion of this algorithm for our local guidelines. These guidelines apply to the ‘uncomplicated' hypertensive patient.
A drug cost comparison including more commonly prescribed anti-hyper-tensive medications available in Bermuda, has been compiled to assist in making drug choices. The Task Group believes that cost implications for the patient, and the impact on health costs for our island should be considered. This list does not include all hypertensive medications that are available. GENERAL POINTS TO CONSIDER WHEN PRESCRIBING DRUGS
• Consideration of ethnicity and age in choice of agent.6 • In hypertensive patients younger than 55, first choice initial therapy should be an angiotensin converting enzyme inhibitors (ACEI) (or an Angiotensin receptor blocker (ARBs) if an ACE inhibitor is not tolerated). • In hypertensive patients aged 55 and over, or black patients* of any age, first choice of initial therapy should be either a calcium channel blocker (CCB) or a thiazide-type diuretic.** • Hypertensive patients of South Asian descent have a higher preva- lence of insulin resistance and type 2 diabetes. These risk factors should be taken into consideration when selecting antihyperten-sives in this group.** *Black patients are those of African or Caribbean descent, and not mixed race, Asian or Chinese patients**Note that thiazides may have a variety of dose-dependent adverse meta- bolic effects, including hypokalaemia, hyperuricemia, mild elevations in the plasma cholesterol and glucose concentrations, and hyperinsulinemia.18 If there is a strong family history of diabetes or if the individual has additional risk factors for diabetes, consideration should be given to choosing an alternative first line treatment or using lowest doses to minimize metabolic abnormalities. • Beta-blockers are not recommended for first line therapy based on evidence that they perform less well than other drugs, particularly in the elderly, and the increasing evidence that suggests that the most frequently used beta-blockers at usual doses carry an increased risk of provoking type 2 diabetes.
• Drugs should be combined according to the algorithm (see Algo- rithm 2 page 26).
• Low dose initial therapy followed by addition of medications from other classes is preferable to increasing to maximum doses of indi-vidual agents. This achieves blood pressure control with a reduced side effect profile.
• Drugs should generally be titrated over four weeks.
• Long acting medications are preferable.
• Combination therapies may be of benefit for some patients but the cost implications should be considered.
• If blood pressure remains uncontrolled on maximum doses of three drugs, consider seeking specialist advice.
ALGORITHM 2:
CHOOSING DRUGS FOR PATIENTS NEWLY DIAGNOSED WITH HYPERTENSION

Younger than
55 years or older or
black patients of any age
A + C or A + D
Add
Further diuretic therapy
• Alpha-blocker • Beta-blocker Consider seeking specialist
Black patients are those of African descent, and NOT A = ACE Inhibitor mixed-race, Asian or Chinese (consider angiotension-II receptor if ACE intolerant) C = calcium-channel blocker D = thiazide-type diuretic • Beta-blockers are no longer preferred as a routine initial therapy for • But consider them for younger people, particularly: • Women of childbearing potential.
• Patients with evidence of increased sympathetic drive.
• Patients with intolerance of or contraindications to ACE inhibi- tors and angiotension-II receptor antagonists.
• If a patient taking a beta-blocker needs a second drug, add a calcium- channel blocker rather than a thiazide-type diuretic, to reduce the patient's risk of developing diabetes.
• If a patient's blood pressure is not controlled by a regime that in- cludes a beta-blocker (that is, it is still above 140/90 mmHg), change their treatment by following the flow chart on the facing page. • If a patient's blood pressure is well controlled (that is,140/90 mmHg) by a regime that includes a beta-blocker, consider long-term manage-ment at their routine review. There is no absolute need to replace the beta-blocker in this case.
• When withdrawing a beta-blocker, step down the dose gradually.
• Beta-blockers should not usually be withdrawn if a patient has a compelling indication for being treated with one, such as symptom-atic angina or a previous myocardial infarction.
Source: NHS, National Institute for Health and Clinical Excellence: NICE clinical guideline 18: Hyper-tension: The management of hypertension in adults in primary care. London: Royal College of Physicians, 20086 KEY TO DRUG PRICE COMPARISON CHART OVERLEAF
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LIFESTYLE MANAGEMENT OF PERSONS WITH DIABETES AND HYPERTENSION:
• Target BP 130/808.
• Lifestyle modification is recommended to include (see Lifestyle Man- agement section page 20): • Regular exercise and increased routine physical activity. • Avoidance of tobacco.
• Moderate alcohol intake.
• Low sodium <2,300 mg or 2.3 g/day.
• All patients with diabetes should be evaluated for albuminuria at least once a year.19 DRUG THERAPY MANAGEMENT
• Most diabetics need two or more drugs for hypertension control in addition to lifestyle change.
• Maximize dose within first month of treatment if BP not at goal.
• Titrate dose to highest tolerated level necessary to achieve goal.
• Use fixed dose combinations wherever possible to improve adher- • Start combination of first line therapies if BP >150/90mmHg at diag- WITH KIDNEY DISEASE OR CO-EXISTANT CCF:5
• Use ACEI or ARB first line with consideration if Cr >260mmol/L.
• If renal impairment/oedema, loop diuretic may be required.
BLACK SUBJECTS – WITHOUT KIDNEY DISEASE
• First Line: Thiazide diuretic. • Second Line: ACEI or ARB • are rarely effective on their own in black subjects.5• are ineffective in older black subjects. • should always be added to a thiazide. • they may delay proteinuria and help to control potassium (K) balance with a thiazide. • ACEI are better for renoprotection than ARBs in T1DM.6 • ACEI is more effective and less expensive than most CCB.5 • ARBs are more effective at reducing CV events compared to • ARBs are better for cardiorenal protection than ACEI in T2DM.
• ARBs can replace ACEI if ACEI ineffective or causes cough.19 • Second Line: Consider Long-acting Dihydropyridine Calcium-channel blocker (felodipine, amlodipine).
• If these drugs are contraindicated or cannot be tolerated, a cardi- oselective BB or non-dihydropyridine CCB (verapamil, diltiazem) may be substituted.
NON-BLACK SUBJECTS WITHOUT KIDNEY DISEASE:
• ACEI• ARB if >55 years with left ventricular hypertrophy (LVH).
or long-acting dihydropyridine CCB (felodipine, amlodipine),• or thiazide diuretic.8• If these drugs are contraindicated or cannot be tolerated, a cardi- oselective BB or non-dihydropyridine CCB (verapamil, diltiazem) may be substituted.
• If BP >20/10 mmHg above target:19
• Start with ACEI or ARB and use combination with CCB or diuretic.
• In patients with risk factors for developing overt diabetes, choice of antihypertensive agent should take this into account. Beta-blockers and thiazide diuretics are associated with an increased risk of devel-oping new-onset type 2 diabetes compared with other agents. The relative risk of being diagnosed with diabetes is between 1.2 to 1.46 in individuals taking thiazides compared to those not taking thia-zides with similar baseline characteristics.20 • Baseline predictors of new onset diabetes during treatment with antihypertensives include increasing age, female sex, minority eth-nicity, body mass index and waist circumference, elevated fasting and post-prandial glucose, low HDL, presence of left ventricular hy-pertrophy and the degree of elevation of both diastolic and systolic blood pressures.
• Thiazide therapy rarely affects glycaemic control at low doses.5
• B-blockers may mask symptoms of hypoglycaemia, have negative im-
pact on lipid and glucose metabolism and compromise peripheral circulation5.
• ACEI, ARBs and CCBs have beneficial or neutral effects on insulin
sensitivity and glycaemic control.19 • ACEI, ARBs and renin inhibitors are contraindicated in pregnancy
and caution is required in prescribing to women of child bearing potential7.
• RAS blockers do not prevent worsening of glycaemic control if given
with Thiazide diuretics to obese patients with IFG.19 • Alpha blockers: • can be used as a 4th or 5th line agent but these cause orthostatic hypotension, which may be very troublesome in diabetics with autonomic neuropathy.
• should be avoided if there is diabetic neuropathy and substantial fall in BP or symptoms when standing.19 • are not recommended as first line agents for the treatment of hypertension in patients with diabetes.8 • Aldosterone Blockade:19
• can be used as 4th line, particularly in obese diabetic patients. • Patients with obstructive sleep apnœa and central obesity have demonstrated major benefits of BP reduction with spironolac-tone. Similar reductions in African-American and Caucasians. • BP-lowering response not predicted by baseline plasma/urine al- dosterone levels or renin activity, not affected by age, sex, smok-ing, diabetes. Care with potassium.
ALGORITHM 3:
TREATMENT ALGORITHM FOR PERSONS WITH DIABETES AND HYPERTENSION

Advise increased routine of physical activity/ exercise Avoid tobacco, moderate alcohol Low sodium intake < 2,300 mg/day WITHOUT KIDNEY DISEASE
WITH KIDNEY DISEASE OR
FIRST LINE
FIRST LINE
ACEI or ARB
FIRST LINE
All patients with DM to be ARB if >55yrs with evaluated for albuminuria at least once a year SECOND LINE
Add ACE inhibi-
tor or ARB
If renal impairment/
ACEI rarely effec- oedema, loop diuretic
tive on their own ARBs can replace may be required
in black subjects, are ineffective in jects and should to a thiazide. They may delay protein- uria and help to control K balance SECOND LINE
pyridine Calcium- SECOND LINE
(Felodipine, amlo- Consider long-acting dipine) or thiazide • Use fixed dose combinations wherever possible to improve blocker (Felodipine, • Start combination of first line therapies if BP >150/90mmHg at diagnosis.
If these drugs are contraindicated or cannot be tolerated, a cardioselective betablocker or non-dihydropyridine CCB (verapomil, diltiazem) may be substituted.
Initial evaluation of the patient with hypertension should include assess-ment for the presence of chronic kidney disease or CKD.21 Patients with an estimated GFR <60 ml/min/1.73 m2 or preserved eGFR with presence of albuminuria (>/=200 mg/g on spot urine albumin or total protein to creatinine ratio for >3 months) are considered to have CKD.7 Progression of CKD to end-stage renal disease (ESRD) is a major public health prob-lem. Hypertension is associated with a more rapid progression to ESRD and thus, this high risk group warrants intensive hypertension manage-ment. Studies have shown that aggressive treatment of hypertension in this group of patients does slow decline in GFR. The goals of therapy in CKD are to lower blood pressure, reduce CVD risk and slow progression of CKD. Goal blood pressure for all patients with CKD is <130/80.21 • Blood pressure should be measured in all CKD patients at each visit. • Serum creatinine and estimated GFR should be measured at initial evaluation and at least yearly. The following website can be used to calculate eGFR: http://nkdep.nih.gov/professionals/gfr_calculators/ • Spot urine total protein (or albumin) to creatinine ratio. • Urine dipstick and microscopic examination.
• Blood pressure should be less than 130/80, unless compelling contrain- dication exists.
• All patients with diabetic CKD and patients with non-diabetic CKD + proteinuria (>/= 200 mg/g on spot urine total protein: creatinine ratio) should be treated with an ACE inhibitor or an ARB unless con-traindicated.21 • Monitor K and Cr carefully in patients with CKD prescribed an ACEI or ARB8. If potassium elevated (>5 mEq/L) review diet and medica-tions, e.g. NSAIDs before initiating ACEI or ARB. • Loop diuretics may enable use of ACEI/ARB. Continue ACEI / ARB if potassium level </= 5.5 meq/L.21 • Continue ACE/ARB or diuretic if GFR decline is less than 30% from baseline over four months.21 • ACEI, ARBs and renin inhibitors are contraindicated in pregnancy. and caution is required in prescribing to women of childbearing po-tential.8 • Referral to nephrologist is indicated in acute renal failure, for full
evaluation of etiology and formulation of management plan. Pa-
tients should be referred to nephrologist for ongoing care when
eGFR is <30 ml/min.

DIABETIC KIDNEY DISEASE (DM-CKD):
• Goal BP is <130/80.21 • Patients with DM-CKD, with or without hypertension, should be treated with an ACEI or an ARB21. ACE inhibitors are more effective than other antihypertensives in slowing progression of kidney dis-ease with macroalbuminuria due to DM-1.21 • Diuretics may potentiate the effects of ACEI and ARBs in diabetic NON-DIABETIC KIDNEY DISEASE (non-DM CKD):
• Multiple antihypertensive agents are usually required to reach tar- get blood pressure.21 CKD with Proteinuria
BP lowering therapy should focus on reducing proteinuria as well as treating BP to target of <130/80.19 Reducing to <125/75 may produce ad-ditional benefit in CKD with proteinuria.6 • ACEI, ARBs and nondihydropyridine CCB have a greater antiprotein- uric effect than other classes in non-DM CKD and should be used. Diuretics may potentiate the beneficial effects of ACEI and ARBs in non-DM CKD.21 • Dihydropyridine CCB should not be used in non-DM CKD with pro- teinuria in the absence of ACEI or ARB therapy.
• ACEI and ARB may be used in combination.
• If CrCl <30 ml/min. a loop diuretic should be substituted for a thia- zide diuretic, particularly if control of volume is desired.8 CKD without Proteinuria
• Goal BP remains <130/80. • Any initial agent may be used for attainment of the goal BP, although a diuretic is a good initial agent, depending on GFR. • In CKD stages 1 – 3, a thiazide, loop or K-sparing diuretic may be • In CKD stages 4 – 5, a loop diuretic is recommended.19 • Combination of ACEI and ARB is not recommended for pts with non- proteinuric CKD.8 Renovascular Disease
• Clinical clues: • Onset of hypertension <30 years old (especially if there is no fam- ily history or risk factors).
• Recent onset of hypertension after age 55.
• Abdominal bruit.
• Accelerated (malignant) or resistant (>4drugs) hypertension.
• Recurrent ‘flash' pulmonary oedema.
• CKD of uncertain etiology (especially if bland urine sediment).
• PMH of ischemic heart disease or peripheral vascular disease. • Large elevation of serum Cr, especially with marked BP reduction by ACEI or ARB (>30% increase of Cr).
• Caution with use of ACEI or ARB due to risk of AKI in bilateral dis- ease or unilateral disease with a solitary kidney. Recommend revas-cularization/stent, if uncontrolled BP or rising Cr.
Renal Transplant patients
• Target blood pressure <130/80.
• No particular class of antihypertensives superior to others. Watch K and Cr with ACEI and ARBs. A >1 mg/dL increase in serum Cr should raise the question of renal artery stenosis.
• Proteinuria after transplantation is a risk factor for graft loss and death. It is reasonable to conclude that control of proteinuria and HTN with ACEI/ARBs may have a favourable outcome on graft sur-vival and mortality.21 • Nocturnal hypertension, reversal of diurnal BP rhythm may be pres- ent so may need 24h BP to evaluate. Still relative salt and water reten-tion after renal transplant as still some renal impairment.
Autosomal dominant Polycystic Kidney Disease (ADPKD):
• Any antihypertensives may be used. No proven benefit of ACEI/ARB has been proven for reno-protection.
HYPERTENSION AND CARDIAC DISEASE
HYPERTENSION AND HEART FAILURE7
Hypertension precedes the development of heart failure in approximately 90% of patients and increases the risk for heart failure by two- to three-fold. Hypertension is especially important in heart failure affecting Afri-can-Americans and elderly persons. Systolic heart failure should generally be treated with an ACE inhibitor. In patients intolerant of ACE inhibitor, angiotensin receptor blockers (ARB) may be used. Carvedilol or metoprolol succinate are also recommended in systolic heart failure, as clinical studies have demonstrated decreased morbidity and mortality plus improvement in heart failure symptoms.
Patients with congestive heart failure (CHF) due to diastolic dysfunction and hypertension should be managed per general guidelines for hyper-tension management. Black patients with systolic heart failure who re-main hypertensive despite a trial of ACE inhibitor and beta-blocker may benefit from adding a combination of hydralazine and nitrates (mortality reduction demonstrated in the "African-American Heart Failure Trial".22 ) Loop diuretics are often necessary to control volume retention but should
be used with care. There is no evidence that diuretics prevent progression
of disease, and diuretics can also increase serum creatinine levels when
used in excess. Aldosterone antagonists may provide additional benefit in
patients with severe left ventricular dysfunction, usually New York Heart
Association class 3 – 4. Studies generally demonstrate reduced mortality
by using Aldosterone antagonist in this situation. Hyperkalemia is a risk
with Aldosterone antagonist, and therefore these agents should be used
only in patients with serum creatinine less than 2.5 mg/dl, with serum
potassium monitored closely in all patients.
Blood pressure targets in heart failure have not been firmly established. Systolic blood pressures are generally lowered to the range 110 – 130. Very low blood pressures (systolic blood pressures less than 100) may be desir-able in some heart failure patients, to maximize after load reduction, as long as lower blood pressures are tolerated from a symptom standpoint. HYPERTENSION AND ISCHEMIC HEART DISEASE7
Hypertensive patients are at increased risk for myocardial infarction or other major coronary events and may be at higher risk for death follow-ing acute myocardial infarction. Lowering both systolic and diastolic blood pressures reduces ischemia in part by reducing myocardial oxygen demand. However, some studies have shown an apparent increase in coro-nary risk at low levels of diastolic blood pressure, generally in the range of 60 ml of mercury or less. Therefore, patients with occlusive coronary disease and or left ventricular hypertrophy should maintain a diastolic blood pressure above 60 mmHg. Systolic blood pressure should be treated to a target of less than 130 mmHg.
Unless contraindicated, pharmacologic therapy should be initiated with a beta-blocker. Beta-blockers will lower blood pressure, reduce symptoms of angina, improve mortality, and reduce myocardial oxygen demand. If blood pressure or anginal symptoms are not controlled by beta-blocker therapy alone, or beta-blockers are not tolerated, as in the presence of reactive airway disease, severe peripheral arterial disease, or high degree AV block, either long-acting dihydropyridine (amlodipine, nifedipine SR, felodipine SR) or non-dihydropyridine type calcium channel blockers (diltiazem and verapamil) may be used. Diltiazem or verapamil, in com-bination with a beta-blocker, can cause bradycardia or high degree AV block. Therefore, amlodipine, nifedipine SR, felodipine SR are preferred for combination therapy with beta-blockers. Nitrates may be added as a third agent.
Short-acting nifedipine should not be used because of demonstrated po-tential to increase mortality, particularly in the setting of an acute myo-cardial infarction.
HYPERTENSION AND SURGERY
Uncontrolled hypertension is associated with wider fluctuations of BP during induction of anesthesia and intubation, and may increase the risk for peri-operative ischemic events. The Task Group recommends that: • Sustained hypertension should be controlled prior to elective opera- tive procedures.
• Surgical candidates with controlled hypertension should be main- tained on their medications up until the time of surgery.
• Antihypertensive medication should be reinstated as soon as pos- • Hypokalaemia should be corrected in advance of surgery.
• For older patients, consideration should be given to treatment with beta-1 selective beta-blockers before and during the peri-operative period.
Hypertension is very common in the early post-operative period and may be related to increased sympathetic tone and vascular resistance. The Task Group recommends that in the post-operative setting: • Consideration is given to factors such as pain and increased intravas- cular volume.
• If resumption of oral treatment must be interrupted, periodic dos- ing with intravenous enalapril or transdermal clonidine hydrochlo-ride may be useful.
HYPERTENSION AND STROKE
Primary Prevention
Increased blood pressure is the most significant and treatable risk factor
for primary stroke and recurrence of stroke even in the very elderly. All
five major classes of antihypertensive agents are effective in preventing
first ever stroke and can be considered, depending on cost, adverse effect
profiles and co morbidities.6,7,9
Secondary Prevention
There is well established evidence that BP-lowering therapy is effective
in preventing recurrent stroke and other major vascular events in people
with an established history of stroke or TIA.
Even those with BP initially less than 140/90 mmHg benefit from antihy-pertensive therapy. The benefits appear to be greater in those with a his-tory of intracerebral haemorrhage than in other stroke subtypes.
Antihypertensive therapy should be initiated with caution in the very old or frail, in patients with severe carotid stenosis, and in those with initial BP levels less than 120 mmHg systolic. 6,7,8, 9 The most direct available evidence for effective secondary prevention of stroke comes from studies using diuretics or combination of ACE inhibi-tors and diuretics.6,7,8, 9 Acute Stroke
Following acute stroke, BP is often raised and falls spontaneously over the
next few days. Both high and low blood pressure levels immediately post
stroke are associated with an adverse prognosis.
The American Stroke Association has issued guidelines suggesting that in patients with recent ischemic stroke with systolic >220 or diastolic 120 – 140, cautious reduction of BP by 10 – 15% is suggested.
In situations where thrombolytic agents are to be used, BP needs to be controlled. Systolic BPs >185 or diastolic >110 contraindicate the use of tPA.
The KEMH utilizes the stroke guidelines of the Massachusetts General Hospital (MGH) to treat BP for ischemic stroke and hemorrhagic stroke. Note that the guidelines below for ischemic stroke do not pertain to pa-tients eligible for or undergoing tPA treatment.
MGH ischemic stroke BP management guidelines:
• Systolic less than or ≤ 220 OR diastolic less than or ≤ 120 • Observe unless other end-organ involvement (e.g., aortic dissec- tion, acute myocardial infarction, pulmonary edema, hyperten-sive encephalopathy).' • Treat other symptoms of stroke (e.g., headache, pain, agitation, nausea, vomiting). • Treat other acute complications of stroke, including hypoxia, in- creased intracranial pressure, seizures, or hypoglycemia. • Systolic >220 OR diastolic 121 – 140. Two options: • Labetalol 10 – 20 mg IV for 1 – 2 min. • May repeat or double every 10 min. (max. dose 300 mg) • Nicardipine 5 mg/h IV infusion as initial dose; titrate to de- sired effect by increasing 2.5 mg/h every 5 min. to max. of 15 mg/h. • Aim for a 10% – 15% reduction in blood pressure. • Diastolic >140: • Nitroprusside 0.5 mcg/kg/min. IV infusion as initial dose with continuous blood pressure monitoring. • Aim for a 10% – 15% reduction in blood pressure. MGH hemorrhagic stroke guidelines
• Blood pressure should be managed according to American Heart Association 2007 Guidelines for the Management of Intracerebral Hemor-rhage. All patients who require treatment with continuous intrave-nous antihypertensive therapy should undergo urgent placement of an intra-arterial catheter for blood pressure monitoring and central venous catheter for central venous pressure monitoring as well as administration of IV antihypertensive medications. Once a physician determines that a patient requires treatment with IV antihyperten-sive therapy, he/she must designate an individual who will remain at the bedside and monitor effectiveness of therapy until blood pres-sure is controlled. • Elevated blood pressure (suggested medications in approximate or- der of preference): • Labetalol: 5 – 100 mg/hr. by intermittent bolus doses of 10 – 40 mg or continuous drip (2 – 8 mg/min.) • Nicardipine: 5 mg/hr. increased by 2.5 mg/hr. q15 minutes to max. • Esmolol: 250 mcg/kg as a load; maintenance use, 25 – 300 mcg/kg/ • Enalapril: 0.625 – 5 mg IV Q6h. • Hydralazine: 5 – 20 mg IV Q30 min. • Nitroprusside: 0.1 – 10 mcg/kg/min. • The following suggested algorithm is adapted from the AHA 2007 Guidelines for ICH: • If SBP is >200 mmHg or MAP is greater than 150 mmHg, then consider aggressive reduction of blood pressure with continuous intravenous infusion, with frequent blood pressure monitoring every five minutes. • If SBP is >180 mmHg or MAP is greater than 130 mmHg and there is evidence of or suspicion of elevated ICP, then consider moni-toring ICP and reducing blood pressure using intermittent or continuous intravenous medications to keep cerebral perfusion pressure greater than 60 to 80 mmHg. • If SBP is >180 mmHg or MAP is greater than 130 mmHg and there is not evidence of or suspicion of elevated ICP, then consider a modest reduction of blood pressure (e.g., MAP of 110 mmHg or target blood pressure of 160/90 mmHg) using intermittent or con-tinuous intravenous medications to control blood pressure. • Any clinical deterioration in association with reduction of BP should prompt reconsideration of ongoing BP management strategy. • The etiology of hypotension must be established. Volume replen- ishment is the first approach. Isotonic saline or colloids can be used and monitored with central venous pressure. If CVP is nor-mal or elevated in the setting of hypotension, then a pulmonary artery catheter should be placed to monitor pulmonary artery pressures. If hypotension persists after correction of volume defi-cit, continuous infusions of vasopressors should be considered, particularly for low systolic blood pressure such as less than 90 mmHg. • Phenylephrine: 2 – 10 mcg/kg/min. • Dopamine: 2 – 20 mcg/kg/min. • Norepinephrine: 0.05 – 0.2 mcg/kg/min. Treating hypertensive women leads to a greater reduction in CVD as com-pared to men. A recently published study indicates that lowering systolic pressure by 15 mmHg in hypertensive women, reduced CVD by 40 per cent in women compared to 20 per cent in men.23 There are additional factors to consider with regard to blood pressure in certain groups of women.
Oral Contraceptives6, 7
• Monitor BP prior to usage then six monthly as combined oral contra- ceptives can raise BP levels.
• If already hypertensive, use POP (Progesterone Only Pill).
• Women over 35 years with other coexistent risk factors, e.g. smoking and migraine should not use the combined oral contraceptive.
• For women with stage 1 hypertension who wish to continue oral contraception, monitor BP, recommend salt restriction, and use an-tihypertensives. Combined oral contraceptives are contraindicated in women with Stage 2 hypertension.
Women on Hormone Replacement Therapy (HRT)6,7
• HRT does not cause BP to rise so women with hypertension should not be denied access.
PREGNANT WOMEN6,7,24
The following conditions do not necessarily follow a specific order. For ex-
ample a pregnant woman can have pre-eclampsia and end up with HEELP
or have pre-eclampsia and end up with eclampsia. Additionally, HELLP
can occur after delivery.
• Chronic hypertension is defined as BP >140/90 before the 20th week
of pregnancy, or if only measured after 20 weeks gestation, persist-ing six weeks post-partum.
• Gestational hypertension is defined as the development of hyper-
tension in pregnancy without other signs of pre-eclampsia.
• Pre-eclampsia is usually diagnosed on the basis of hypertension
with proteinuria. Proteinuria is defined as 300 mg/l protein, or 30 mg/mmol creatinine in a random specimen, or an excretion of 300 mg per 24 hr. Hypertension is defined as SBP >140 mmHg or DBP >90 mmHg after 20 weeks in a pregnant woman who was normotensive before 20 weeks gestation.
• Pre-eclampsia superimposed on chronic hypertension is regarded
as highly likely in women with known hypertension who develop new proteinuria or in women with known hypertension and protein-uria who have sudden increases in BP or proteinuria, thrombocyto-penia, or increases in hepatocellular enzymes.
• HELLP Syndrome (hemolysis, elevated liver enzymes, low platelet
count). Symptoms are headache, nausea and vomiting that gets con-tinuously worse, upper abdominal pain and vision problems.
• Eclampsia is often preceded by premonitory signs including head-
ache, visual disturbances, and epigastric pain, constricting sensa-tions in the thorax, apprehension, excitability, and hyperflexia. However, convulsions can occur suddenly and without warning in a seemingly stable patient with no apparent or only minimal eleva-tions of BP.
Pregnant women with pre-eclampsia and hypertension should
have their urine checked for protein in addition to vital signs per-
formed at their visits. These patients should be monitored closely
with the advice of an obstetrician.

Treatment
The following drugs are commonly used to treat hypertension in preg-
nancy:
• Methyldopa first choice. • CCB's (nifedipine/labetolol) are second choice in resistant hyperten- sion especially in third trimester.
• Beta-blockers are not used because of the risk of intrauterine growth • Thiazides are avoided due to potential to reduce circulatory blood • ACEI are avoided and discontinued in women who are planning • Magnesium sulphate for pre-eclampsia/eclampsia.
• Low-dose aspirin for prevention is controversial. • Erectile dysfunction (ED) is increasingly more common in men over 50 and even more common if those who are hypertensive. • Screen for ED annually or more frequently as required (Appendix V) • A lower risk of ED was reported among men who were physically active, not obese, and non-smokers. Therefore, lifestyle modification should be encouraged to prevent ED. • If ED appears after institution of antihypertensive drug therapy, the offending agent should be discontinued and treatment restarted with another agent.7 • There is broad agreement that postural hypertension is far more prevalent in this population. To this end the following recommen-dations:• Lying, sitting and standing BP measurements are to be taken.
• Treatment should be titrated to the standing value.
• Restrict alcohol use.
• Isolated Systolic Hypertension is more prevalent in the elderly and should be treated to reduce risk of stroke.
• SBP should be the target for diagnosis and management of HTN in the elderly.
• Comorbidities are common; therefore poly-pharmacy is an impor- tant factor to consider. Watch for: • Adverse drug reactions.
• Drug interactions (e.g., NSAIDS).
CHILDREN AND ADOLESCENTS
In children and adolescents BP is determined by body size and age. BP standards based on gender, age, and height provide a precise classifica-tion of BP according to body size. This approach avoids misclassifying chil-dren who are very tall or very short. The information in this section is taken largely from The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.10 DEFINITION
Hypertension is defined as average SBP and/or diastolic BP (DBP) that is
≥95th percentile for gender, age, and height on ≥3 occasions.10
Blood Pressure Category
<90th percentile 90th – 95th percentile or >120/80 mmHg 95th – 99th percentile + 5 mmHg > 99th percentile + 5 mmHg White-coat hypertension95% at physician office and normotensive outside clini-cal setting MEASUREMENT OF BP IN CHILDREN
All children >3 years old who are seen in a medical setting should have
their BP measured.10
• The preferred method is auscultation. • Appropriate cuff size – the width of cuff bladder should be ¾ of the length of upper arm. If high blood pressure obtained always verify the width of the cuff in relation to the length of upper arm by direct measurement. Also see the referred table. • Use standard clinical sphygmomanometer, with bell of stethoscope placed over the brachial artery pulse, proximal and medial to the antecubital fossa, below the bottom edge of the cuff . • Child should be in comfortable, relaxed position, and seated with his or her back supported, feet on the floor and right arm supported, and at the level of heart. • Fifth Korotkoff sound defines diastolic BP.
• The right arm is preferred because of the possibility of coarctation of Conditions under Which Children <3 Years Old Should Have BP Measured10
• History of prematurity, very low birth weight, or other neonatal complication requiring intensive care.
• Hypertension of placement of any indwelling umbilical catheters.
• Congenital heart disease (repaired or non-repaired).
• Recurrent urinary tract infections, haematuria, or proteinuria.
• Renal disease or urologic malformations.
• Solid-organ transplant.
• Malignancy or bone marrow transplant.
• Treatment with drugs known to raise BP.
• Other systemic illnesses associated with hypertension (neurofibro- matosis, tuberous sclerosis, etc).
• Evidence of elevated intracranial pressure.
Recommended Dimensions for BP Cuff Bladders
Maximum Arm
Age Range
Width, cm
Length, cm
Small adult
*Calculated so that the largest arm would still allow the bladder to encircle arm by at least 80%.
Source: The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pres-sure in Children and Adolescents. 2005. The National Heart, Lung and Blood Institute Information Center. Blood Pressure Tables
To accurately assess blood pressures in boys and girls it is recommended
to use Tables 3 and 4 from the Fourth Report on the Diagnosis, Evaluation,
and Treatment of High Blood Pressure in Children and Adolescents
(2005). These
tables enable assessment of blood pressure levels by age and height per-
centile for boy and girls. The tables can be found in Appendices VI and VII
(pages 62 – 65).
Using the BP Tables10
1. Use the standard height charts to determine the height percen- 2. Measure and record the child's SBP and DBP. 3. Use the correct gender table for SBP and DBP. 4. Find the child's age on the left side of the table. Follow the age row horizontally across the table to the intersection of the line for the height percentile (vertical column). 5. There, find the 50th, 90th, 95th, and 99th percentiles for SBP in the left columns and for DBP in the right columns. Classification of Hypertension in Children and Adolescents, with Measurement
Frequency and Therapy Recommendation
macologic
based on indications apeutic Lif
ysical activity and diet ysical activity and diet ysical activity and diet uency of BP Measure
e-check at next scheduled e-check in 1–2 w additional occasions, e mation Centor SBP or DBP
ung and Blood Institut Clinical Evaluation of Confirmed Hypertension
Study or Procedure
Evaluation for identifiable causes
History:
including sleep,
History and physical All children with persis- family, risk factors, diet, examination help tent BP ≥95th percentile and Habits: smoking and
focus subsequent drinking alcohol; Physical examination
BUN, creatinine, electro-
R/O renal disease lytes, urinalysis, and urine and chronic pyelone-culture R/O anemia, consis-tent with chronic renal disease R/O renal scar, con-genital anomaly, or disparate renal size Evaluation for comorbidity
Fasting lipid panel
Identify hyperlipid- • Overweight patients emia, identify meta- with BP at 90th – 94th bolic abnormalities • All patients with BP ≥95th percentile • Family history of hyper- • Child with chronic Identify substances History suggestive of that might cause possible contribution by substances or drugs Identify sleep disor- History of loud, frequent der in association with hypertension Adapted from: The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. 2005. The National Heart, Lung and Blood Institute Informa-tion Center. Study or Procedure
Evaluation for target-organ damage
Echocardiogram
Identify LVH and • Patients with comorbid other indications of risk factors* and BP cardiac involvement. 90th – 94th percentile The presence of LVH • All patients with BP is an indication to ≥95th percentile initiate or inten-sify antihypertensive therapy Identify retinal vas-cular changes Additional evaluation as indicated
ABPM
Identify white-coat • Patients in whom white-coat hyperten- abnormal diurnal BP sion is suspected • When other informa- tion on BP pattern is needed Plasma renin determina- Identify low renin, • Young children with suggesting miner- stage 1 hypertension alocorticoid-related • Any child or adolescent with stage 2 hyperten- Renovascular imaging Identify renovascular • Isotopic scintigraphy • Positive family history of severe hypertension • MRA• Duplex Doppler flow • 3-Dimensional CT• Arteriography: DSA or Plasma and urine steroid Identify steroid-medi- ated hypertension Plasma and urine catechol- Identify catechol-amines Source: The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pres-sure in Children and Adolescents. 2005. The National Heart, Lung and Blood Institute Information Center. Indications for Antihypertensive Drug Therapy in Children10
• Symptomatic hypertension• Secondary hypertension• Hypertensive target-organ damage• Diabetes (types 1 and 2)• Persistent hypertension despite non-pharmacologic measures PHARMACOLOGIC THERAPY OF CHILDHOOD HYPERTENSION10
The goal for antihypertensive treatment is reduction of BP to <95th per-centile unless concurrent conditions are present, in which case BP should be lowered to <90th percentile.10 • Antihypertensive medications used are similar to adults but smaller • ACE-inhibitors and ARBs are used only in children with diabetes, mi- croalbuminuria, and proteinuric renal disease. • ACE-inhibitors and ARBs should not be used during pregnancy and extreme caution should be taken in teenage girls with effective birth control methods.
• BBs and CCBs are used for children with hypertension and migraine • If control is not achieved with 2-drugs consider secondary hyperten- • Children should not be restricted from physical activity.
ALGORTHIM 4:
MANAGEMENT OF CHILDREN WITH HYPERTENSION

Measure BP and height and calculate BMI
Determine BP category for gender, age and height Educate on heart Over 3 visits healthy lifestyle for family Diagnostic workup Diagnostic workup include evaluation for in 6 months for target-organ damage Secondary Primary Consider diagnostic workup Consider referral & evaluation for target-organ To provide with expertise damage (if overweight or in pediatric Appendix I
Adoption of healthy lifestyles by all persons is critical for the prevention of hypertension and is an indispensible part of the management of those with hypertension.13 For ongoing support and follow-up, consider referral to a lifestyle mod-
ification programme such as:

• Bermuda Heart Foundation/CORE Centre 87 Front Street (Entry off Chancery Lane) Hamilton, HM 12232-7812 or 232-CORE www.mybermudaheart.bm • CHIP (Coronary Health Improvement Program)/Lifestyle Medicine In- stitute, Inc., Loma Linda CA.
Bermuda Directors:Pembroke – Pamela Greyson 236-8771 pgreyson@logic.bmSomerset – Chirleen Williams 238-3691 lou@ibl.bmHamilton Parish – Mellonie Furbert 293-5168 melhoney@logic.bm For support of patients who have undergone angioplasty, or bypass, or
have had a heart attack refer to Cardiac Care Programme:

• The Cardiac Care Programme, KEMH is a nurse-managed programme to assist patients in managing their heart disease at home. It is also a programme to help address risk factors associated with heart disease. Patients who have undergone angioplasty, or bypass, or have had a heart attack should be referred by their physician. Patients with no known heart disease but have risk factors for heart disease will also be accommodated. The Cardiac Care Programme work very closely with the Day Hospitals' Cardiac Exercise Programme to provide a complete Cardiac Rehabilitation Service. Call Myrian Balitian-Dill, RN, MN, CCN(C) at 239-1219 for more informa-tion or e-mail us at myrian.bakitian-dill@bhb.bm Appendix II
DASH diet: Guide to recommended servings
The Dietary Approaches to Stop Hypertension (DASH) diet can help you control your blood pressure. The DASH diet is rich in grains, fruits, veg-etables and low-fat dairy products. It limits fat, saturated fat and choles-terol and provides plenty of fibre, potassium, calcium and magnesium. The DASH diet also limits sodium to between 2,300 milligrams and 1,500 milligrams a day. Here are the types and amounts of foods recommended in the DASH diet, along with specific examples of serving sizes. Use these details as you plan your own menus. Servings for a
Servings for
Examples of 1 serving
6 to 8 a day
1 slice whole wheat bread 1 ounce (oz.) dry cereal ½ cup cooked cereal ½ cup cooked rice or pasta ½ English muffin or small bagel (2 oz.) 4 to 5 a day
½ cup (4 fluid oz.) 100% fruit juice 1 medium fruit ½ cup fresh, frozen or canned fruit 1/4 cup dried fruit Vegetables
4 to 5 a day
3 to 4 a day
½ cup (4 fluid oz.) low-sodium vegetable juice 1 cup raw leafy green vegetables ½ cup cooked vegetables 1 small potato 1 sweet potato 2 to 3 a day
2 to 3 a day
1 cup (8 fluid oz.) milk (low-fat or
6 or fewer a
3 to 6 a day
1 oz. cooked lean meat, skinless 1 egg (no more than 4 a week) 4 to 5 a week
1/3 cup (1.5 oz.) nuts seeds and
2 tablespoons peanut butter dry beans
2 tablespoons (½ oz.) seeds ½ cup cooked dry beans or peas 2 to 3 a day
1 teaspoon soft margarine 1 tablespoon low-fat mayonnaise 2 tablespoons light salad dressing 1 teaspoon vegetable oil 5 or fewer a
1 tablespoon sugar 1 tablespoon jelly or jam ½ cup sorbet 1 cup (8 fluid oz.) sugar-sweet-ened lemonade This plan is based on Your Guide to Lowering Your Blood Pressure with DASH by the National Heart, Lung, and Blood Institute. http://www.nhlbi.
nih.gov/health/public/heart/hbp/dash/new_dash.pdf. This information was accessed 18 March 2010 and adapted by Mayo Foundation for Medical Education and Research. Ministry of Health Department of Health
67 Victoria Street P.O. Box HM 1195, Hamilton HM EX, Bermuda Phone: (+1 441) 278-6467/68 • Fax: (+1 441) 292-7627 E-mail: mlbfurbert@gov.bm Appendix III
Check your food labels
low fat dair
Also exempted: lean meats,
of dietar
hoose foods with 3g or more
heck how much is a ser
hoose 0g tr
y fibre per ser
y products and
Appendix IV
HEALTHY LIVING GUIDE YOUR WAIST SIZE
By measuring your waist circumference you can check if you have excess fat around your waist that can put your health at risk. Measure your waist size to see if you are within the recommended range.
To measure your waist size, place a tape measure around the narrowest point of your waist (between your lower ribs and your hip HIGH RISK
bone), breathe out and measure the circumference.
Ideal to be below Greatest risk if above Speak to your doctor if you have any concerns
BODY MASS INDEX (BMI) Body Mass Index (BMI) is a quick way to check if you have a However, BMI may not be accurate if you are an athlete or very healthy body weight for height. Check your BMI in the graph muscular (muscle weighs more than fat.). Use BMI together below, and speak to your doctor if you have any concerns.
with waist circumference to calculate your risk.
If your weight is in the orange to red range, your health may be at risk.
Weight in kilograms 40 50 60 70 80 90 100 110 120 130 140 150 CLINICALLY
eet and inches 5'8" 84 98 112 126 140 154 168 182 196 210 224 238 252 268 282 298 312 326 340 352 For personalised information go to • www.cdc.gov/nccdpphp/dnpa/bmi Want personalised information ? If you want more information to build a personal healthy living plan, try these reliable web sites: www.mypyramid.gov • www.eatwell.gov.uk • www.nhsdirect.nhs.uk/magazine/interactive/calories www.thecaloriecounter.com • www.webmd.com Appendix V
SEXUAL HEALTH INVENTORY FOR MEN (SHIM)

PATIENT NAME: TODAY'S DATE:

PATIENT INSTRUCTIONS
Sexual health is an important part of an individual's overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is one type of very common medical condition affecting sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, you may choose to discuss treatment options with your doctor.
Each question has several possible responses. Circle the number of the response that best describes your own
situation. Please be sure that you select one and only one response for each question.

OVER THE PAST 6 MONTHS:
1. How do you rate your
MODERATE
VERY HIGH
confidence that you could get and keep an A FEW TIMES
MOST TIMES
2. When you had
SOMETIMES
ALMOST NEVER (MUCH LESS
(MUCH MORE
erections with sexual (ABOUT HALF
ALWAYS OR
THAN HALF THE
THAN, HALF THE
stimulation, how often THE TIME)
were your erections hard enough for penetration (entering your partner)? 3. During sexual
A FEW TIMES
MOST TIMES
SOMETIMES
intercourse, how often ALMOST NEVER (MUCH LESS
(MUCH MORE
(ABOUT HALF
ALWAYS OR
were you able to THAN HALF THE
THAN, HALF THE
NTERCOURSE
THE TIME)
maintain your erection after you had penetrated (entered) your partner? 4. During sexual
EXTREMELY
intercourse, how difficult DIFFICULT
DIFFICULT
DIFFICULT
SLIGHTLY
DIFFICULT
NOT DIFFICULT
NTERCOURSE
was it to maintain your erection to completion of A FEW TIMES
MOST TIMES
SOMETIMES
5. When you attempted
ALMOST NEVER (MUCH LESS
(MUCH MORE
(ABOUT HALF
ALWAYS OR
sexual intercourse, how THAN HALF THE
THAN, HALF THE
NTERCOURSE
THE TIME)
often was it satisfactory
Add the numbers corresponding to questions 1-5. TOTAL:

The Sexual Health Inventory for Men further classifies ED severity with the following breakpoints:

1-7 Severe ED 8-11 Moderate ED 12-16 Mild to Moderate ED 17-21 Mild ED

Appendix VI
Blood Pressure Levels for Boys by Age and Height Percentile
Systolic BP (mmHg)
Diastolic BP (mmHg)
Í Percentile of Height Î
Í Percentile of Height Î
5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th
90th 94 95 97 99 100 102 103 95th 98 99 101 103 104 106 106 54 54 55 56 57 58 58 99th 105 106 108 110 112 113 114 61 62 63 64 65 66 66 90th 97 99 100 102 104 105 106 54 55 56 57 58 58 59 95th 101 102 104 106 108 109 110 59 59 60 61 62 63 63 99th 109 110 111 113 115 117 117 66 67 68 69 70 71 71 90th 100 101 103 105 107 108 109 59 59 60 61 62 63 63 95th 104 105 107 109 110 112 113 63 63 64 65 66 67 67 99th 111 112 114 116 118 119 120 71 71 72 73 74 75 75 90th 102 103 105 107 109 110 111 62 63 64 65 66 66 67 95th 106 107 109 111 112 114 115 66 67 68 69 70 71 71 99th 113 114 116 118 120 121 122 74 75 76 77 78 78 79 90th 104 105 106 108 110 111 112 65 66 67 68 95th 108 109 110 112 114 115 116 69 70 71 72 73 74 74 99th 115 116 118 120 121 123 123 77 78 79 80 81 81 82 90th 105 106 108 110 111 113 113 68 68 69 70 71 72 72 95th 109 110 112 114 115 117 117 72 72 73 74 75 76 76 99th 116 117 119 121 123 124 125 80 80 81 82 83 84 84 90th 106 107 109 111 113 114 115 70 70 71 72 73 74 74 95th 110 111 113 115 117 118 119 74 74 75 76 77 78 78 99th 117 118 120 122 124 125 126 82 82 83 84 85 86 86 8 50th 94 95 97 99 100 102 102 90th 107 109 110 112 114 115 116 71 72 72 73 74 75 76 95th 111 112 114 116 118 119 120 75 76 77 78 79 79 80 99th 119 120 122 123 125 127 127 83 84 85 86 87 87 88 9 50th 95 96 98 100 102 103 104 90th 109 110 112 114 115 117 118 72 73 74 75 76 76 77 95th 113 114 116 118 119 121 121 76 77 78 79 80 81 81 99th 120 121 123 125 127 128 129 84 85 86 87 88 88 89 50th 97 98 100 102 103 105 106 58 59 60 61 61 62 63 90th 111 112 114 115 117 119 119 73 73 74 75 76 77 78 95th 115 116 117 119 121 122 123 77 78 79 80 81 81 82 99th 122 123 125 127 128 130 130 85 86 86 88 88 89 90 Blood Pressure Levels for Boys by Age and Height Percentile (Continued)
Systolic BP (mmHg)
Diastolic BP (mmHg)
Í Percentile of Height Î
Í Percentile of Height Î
5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th
100 102 104 105 107 114 115 117 119 120 118 119 121 123 124 125 127 129 130 132 102 104 106 108 109 116 118 120 121 123 120 122 123 125 127 127 129 131 133 134 105 106 108 110 111 118 120 122 124 125 95th 121 122 124 126 128 129 130 79 79 80 130 131 133 135 136 107 109 111 113 114 121 123 125 126 128 125 127 128 130 132 132 134 136 138 139 110 112 113 115 117 124 125 127 129 130 127 129 131 133 134 135 136 138 140 142 112 114 116 118 119 126 128 130 131 133 130 132 134 135 137 137 139 141 143 144 115 116 118 120 121 128 130 132 134 135 132 134 136 138 139 140 141 143 145 146 BP, blood pressure * The 90th percentile is 1.28 SD, 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean. For research purposes, the standard deviations in Appendix Table B–1 allow one to compute BP Z-scores and percentiles for boys with height percentiles given in Table 3 (i.e., the 5th,10th, 25th, 50th, 75th, 90th, and 95th percentiles). These height percentiles must be converted to height Z-scores given by (5% = -1.645; 10% = -1.28; 25% = -0.68; 50% = 0; 75% = 0.68; 90% = 1.28%; 95% = 1.645) and then computed according to the methodology in steps 2–4 described in Appendix B. For children with height percentiles other than these, follow steps 1–4 as described in Appendix B. Appendix VII
Blood Pressure Levels for Girls by Age and Height Percentile
Systolic BP (mmHg)
Diastolic BP (mmHg)
Í Percentile of Height Î
Í Percentile of Height Î
5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th
90th 97 97 98 100 101 102 103 95th 100 101 102 104 105 106 107 56 57 57 58 59 59 60 99th 108 108 109 111 112 113 114 64 64 65 65 66 67 67 90th 98 99 100 101 103 104 105 57 58 58 59 60 61 61 95th 102 103 104 105 107 108 109 61 62 62 63 64 65 65 99th 109 110 111 112 114 115 116 69 69 70 70 71 72 72 90th 100 100 102 103 104 106 106 61 62 62 63 64 64 65 95th 104 104 105 107 108 109 110 65 66 66 67 68 68 69 99th 111 111 113 114 115 116 117 73 73 74 74 75 76 76 90th 101 102 103 104 106 107 108 64 64 65 66 67 67 68 95th 105 106 107 108 110 111 112 68 68 69 70 71 71 72 99th 112 113 114 115 117 118 119 76 76 76 77 78 79 79 90th 103 103 105 106 107 109 109 66 67 67 68 69 69 70 95th 107 107 108 110 111 112 113 70 71 71 72 73 73 74 99th 114 114 116 117 118 120 120 78 78 79 79 80 81 81 90th 104 105 106 108 109 110 111 68 68 69 70 70 71 72 95th 108 109 110 111 113 114 115 72 72 73 74 74 75 76 99th 115 116 117 119 120 121 122 80 80 80 81 82 83 83 90th 106 107 108 109 111 112 113 69 70 70 71 72 72 73 95th 110 111 112 113 115 116 116 73 74 74 75 76 76 77 99th 117 118 119 120 122 123 124 81 81 82 82 83 84 84 90th 108 109 110 111 113 114 114 71 71 71 72 73 74 74 95th 112 112 114 115 116 118 118 75 75 75 76 77 78 78 99th 119 120 121 122 123 125 125 82 82 83 83 84 85 86 9 50th 96 97 98 100 101 102 103 90th 110 110 112 113 114 116 116 72 72 72 73 74 75 75 95th 114 114 115 117 118 119 120 76 76 76 77 78 79 79 99th 121 121 123 124 125 127 127 83 83 84 84 85 86 87 50th 98 99 100 102 103 104 105 59 59 59 60 61 62 62 90th 112 112 114 115 116 118 118 73 73 73 74 75 76 76 95th 116 116 117 119 120 121 122 77 77 77 78 79 80 80 99th 123 123 125 126 127 129 129 84 84 85 86 86 87 88 Blood Pressure Levels for Girls by Age and Height Percentile (Continued)
Systolic BP (mmHg)
Diastolic BP (mmHg)
Í Percentile of Height Î
Í Percentile of Height Î
5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th
50th 100 101 102 103 105 106 107 60 60 60 61 62 63 63 90th 114 114 116 117 118 119 120 74 74 74 75 76 77 77 95th 118 118 119 121 122 123 124 78 78 78 79 80 81 81 99th 125 125 126 128 129 130 131 85 85 86 87 87 88 89 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64 90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78 95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82 99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90 50th 104 105 106 107 109 110 110 62 62 62 63 64 65 65 90th 117 118 119 121 122 123 124 76 76 76 77 78 79 79 95th 121 122 123 124 126 127 128 80 80 80 81 82 83 83 99th 128 129 130 132 133 134 135 87 87 88 89 89 90 91 50th 106 106 107 109 110 111 112 63 63 63 64 65 66 66 90th 119 120 121 122 124 125 125 77 77 77 78 79 80 80 95th 123 123 125 126 127 129 129 81 81 81 82 83 84 84 99th 130 131 132 133 135 136 136 88 88 89 90 90 91 92 50th 107 108 109 110 111 113 113 64 64 64 65 66 67 67 90th 120 121 122 123 125 126 127 78 78 78 79 80 81 81 95th 124 125 126 127 129 130 131 82 82 82 83 84 85 85 99th 131 132 133 134 136 137 138 89 89 90 91 91 92 93 50th 108 108 110 111 112 114 114 64 64 65 66 66 67 68 90th 121 122 123 124 126 127 128 78 78 79 80 81 81 82 95th 125 126 127 128 130 131 132 82 82 83 84 85 85 86 99th 132 133 134 135 137 138 139 90 90 90 91 92 93 93 50th 108 109 110 111 113 114 115 64 65 65 66 67 67 68 90th 122 122 123 125 126 127 128 78 79 79 80 81 81 82 95th 125 126 127 129 130 131 132 82 83 83 84 85 85 86 99th 133 133 134 136 137 138 139 90 90 91 91 92 93 93 BP, blood pressure * The 90th percentile is 1.28 SD, 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean. For research purposes, the standard deviations in Appendix Table B–1 allow one to compute BP Z-scores and percentiles for girls with height percentiles given in Table 4 (i.e., the 5th,10th, 25th, 50th, 75th, 90th, and 95th percentiles). These height percentiles must be converted to height Z-scores given by (5% = -1.645; 10% = -1.28; 25% = -0.68; 50% = 0; 75% = 0.68; 90% = 1.28%; 95% = 1.645) and then computed according to the methodology in steps 2–4 described in Appendix B. For children with height percentiles other than these, follow steps 1–4 as described in Appendix B. 1Department of Health. Health Priorities Report. Government of Bermuda. 2Attride-Stirling, J., Boney, C., Trott, C., and DeRoza, D. Health Survey of Adults and Children in Bermuda 2006. Government of Bermuda: Department of Health 2007 3Department of Health: Causes of Death 2007, Epidemiology and Surveil- lance Unit: Government of Bermuda 4Attride-Stirling, J. Well Bermuda: A National Health Promotion Strategy. Gov- ernment of Bermuda: Department of Health. 2006 5 Caribbean Health Research Council: Managing Hypertension in primary care in the Caribbean. St. Augustine, Trinidad and Tobago: Caribbean Health Research Council 2007.
6Royal College of Physicians: NICE clinical guideline 18: Hypertension: The management of hypertension in adults in primary care. London: Roy-al College of Physicians, 2008. Retrieved 1 September 2010 from http://www.nice.org.uk/nicemedia/live/10986/48385/48385.pdf 7U.S. Department of Health and Human Services (NIH, NHLBI, NHBPEP). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 2004. U.S.A.: Author Retrieved 1 September 2010 from http://www.nhlbi.nih.gov/guide-lines/hypertension/jnc7full.pdf 8Central Review Committee of the Evidence-Based Recommendations Task Force of the Canadian Hypertension Education Programme: 2010 Canadian Hypertension Education Programme Recommenda-tions (CHEP). Hypertension Canada. 2010. Retrieved 1 September 2010 http://hypertension.ca/chep/wp-ontent/uploads/2010/03/Scientific-Summary2010EN.pdf 9National Heart Foundation of Australia (National Blood Pressure and Vascular Disease Advisory Committee). Guide to management of hypertension 2008. Updated August 2009. Web version. 2009. Re-trieved 5 October 2010 from http://www.heartfoundation.org.au/SiteCollectionDocuments/A_Hypert_Guidelines2008_2009Update_FI-NAL.pdf 10National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Chil-dren and Adolescents. 2004. National Heart Lung and Blood Institute, National Institute of Health. Retrieved 10 December 2010 from http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf 11Institute for Clinical Systems Improvement. Health Care Guidelines: Hyper- tension Diagnosis and Treatment, Institute for Clinical Systems Improvement, 13th edition, November 2010. Retrieved 10 January 2011 from http://www.icsi.org/hypertension_4/hypertension_diagnosis_and_treat-ment_4.html 12WHO, ISH Writing Group. 2003 World Health Organization/Internation- al Society of Hypertension Statement on Management of Hyperten-sion. Journal of Hypertension 2003. Vol. 21:11 1983 – 1992. Retrieved 1 September 2010 from http://www.who.int/cardiovascular_diseases/guidelines/hypertension_guidelines.pdf 13 Whelton, P.K., He J., Appel, L.J., Cutler, J.A., Havas, S,, Kotchen, T.A., et al. Primary prevention of hypertension: Clinical and Public Health Ad-visory from The National High Blood Pressure Education Program. JAMA 2002; 288:1882-8. Retrieved 17 January 2011 from http://www.
nhlbi.nih.gov/health/prof/heart/hbp/pphbp.pdf 14B. Williams, et al. Guidelines for Management of Hypertension: Report of the Fourth Working Party of the British Hypertension Society 2004-BHS IV. BMJ:328: 13 March 2004: 634-640. Retrieved 8 November 2010 from http://www.bhsoc.org/pdfs/Summary%20Guidelines%202004.pdf 15N. Huang, et al. Guide to Management of Hypertension. Australian Pre- scriber: 2008; 31:150 – 3. Retrieved 5 October 2010 from http://www.
australianprescriber.com/upload/pdf/articles/986.pdf 16L. Appel. American Society of Hypertension Position Paper: Dietary Ap- proaches to Lower Blood Pressure. The Journal of Clinical Hypertension 2009; 7:358–365. Retrieved 1 September 2010 from http://www.ash-us.
org/assets-new/pub/pdf_files/DietaryApproachesLowerBP.pdf 17U.S. Department of Health and Human Services (NIH, NHLBI, NHBPEP). The Practical Guide to the Identification, Evaluation and Treatment of Over-weight and Obesity in Adults. 2000. U.S.A.: Author. Retrieved 17 January 2011 from http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf 18 Zillich, A.J., Garg J., Basu, S., et al. Thiazide diuretics, potassium, and the development of diabetes: a quantitative review. Hypertension. 2006 Aug; 48(2):198 – 200.
19 Bakris, G.L., Sowers, J.R. ASH position paper: treatment of hypertension in patients with diabetes—an update. J Clin Hypertens (Greenwich) 2008;10:707 – 13 20 Taylor, E.N., Hu, F.B., Curhan, G.C. Antihypertensive Medications and the Risk of Incident Type 2 Diabetes. Diabetes Care May 2006 Vol. 29 no. 5 1065 – 1070 21 National Kidney Foundation – Kidney Disease Outcomes Quality Initia- tive KDOQI Clinical Practice Guidelines on Hypertension and Antihy-pertensive Agents in Chronic Kidney Disease. 2004 NKF KDOQI www.
kidney.org 22 Franciosa, J.A., et al. African-American Heart Failure Trial. New England Journal of Medicine 2004. 351: pp. 249 – 257 23 Boggia, et al. Ambulatory Blood Pressure Monitoring in 9357 Sub- jects From 11 Populations Highlights Missed Opportunities for Cardiovascular Prevention in Women. Hypertension. 2011; 0: HYPERTENSIONAHA.110.156828v1 Retrieved 17 January 2011 from http://hyper.ahajournals.org/cgi/con-tent/abstract/HYPERTENSIONAHA.110.156828v1 24 Marshall, D., Lindheimer, M.D., Taler, S.J., M.D. Hypertension in Preg- nancy. Journal of the American Society of Hypertension, Vol. 2, Issue 6, pp. 484 – 494, November 2008. Retrieved 5 October 2010 from http://download.journals.elsevierhealth.com/pdfs/journals/1933-1711/PI-IS193317110800185X.pdf

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Price Adjustment at Multiproduct Retailers Department of Economics Emory University Atlanta GA 30322 Department of Marketing School of Business Administration University of Southern California Los Angeles, CA 90089-1421 Dept. of Logistics and Marketing Mgmt University of Minnesota Minneapolis, MN 55455 Robert W. Baird & Co. Last Revision: December 30, 1997

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