Updated Management of Hypertension in Adults at Primary Care Level

Objectives

Improve prevention and effective management of hypertension to reduce cardiovascular and renal morbidity and mortality, through integrated population-level risk management, effective blood-pressure control and prevention of target-organ damage.[1]Prioritise primordial and primary prevention alongside high-risk secondary and tertiary interventions for cardiovascular disease.[2]

• Reduce modifiable hypertension risks, including obesity, unhealthy diet, diabetes mellitus, excessive alcohol intake, physical inactivity and smoking.[1]
• Promote cardiovascular-protective lifestyles by reducing salt, alcohol and caffeine intake, adopting a prudent high-fibre, low-fat diet, stopping smoking and undertaking regular moderate physical activity.[2][3]
• Maintain total salt consumption below 5 grams daily while ensuring that salt is iodised.[3]
• Achieve blood pressure below 140/90 mmHg for people without co-morbidity and below 130/80 mmHg for those with co-morbidity; apply a target below 120/80 mmHg in congestive heart failure.[4][5]
• Empower patients to participate actively in management of chronic non-communicable conditions through self-care, self-monitoring, treatment adherence, education and cardiovascular risk-factor control.[6][7]
• Establish patient support groups at all facilities, addressing self-care, emotional needs, cultural differences, discrimination, behavioural change and change management.[7][8]

Implementation

Deliver hypertension control through health services and trained health professionals, combining standardised blood-pressure measurement, cardiovascular-risk assessment, lifestyle modification, stepwise pharmacological treatment, patient support and referral to higher levels of care where required.[1][9][4]The guideline was compiled by the Directorate for Chronic Diseases, Disabilities and Geriatrics in the National Department of Health, with contributions from the Guideline Committee, the Southern African Hypertension Society, and national and provincial Department of Health colleagues.[10]

• Identify risk and target-organ damage through medical history, physical examination, vital signs and routine investigations, including assessment of weight, body mass index, abdominal obesity, eye findings, urine abnormalities and microalbuminuria where indicated.[9][2]
• Measure blood pressure with an approved, appropriately sized cuff after adequate rest; record systolic and diastolic readings, measure both arms initially, and use the arm with the higher reading thereafter if readings differ.[7][8]
• Calculate blood pressure as the average of two readings taken one minute apart, take further readings if results differ by 5 mmHg, and diagnose hypertension when readings exceed 140/90 mmHg on three occasions within two months.[8]
• Maintain equipment by servicing and calibrating blood-pressure devices and attachments at least every two years.[8]
• Provide each patient with their blood-pressure reading and treatment goal, encourage them to request measurement at every visit, and ask them to return medicine containers at each appointment.[4][8]
• Educate patients, families and caregivers on hypertension, treatment targets, adherence, side-effects, medicine and food interactions, and lifestyle modification; encourage patients to tell all healthcare providers about their hypertension and medicines.[7][8]
• Initiate management with lifestyle modification and introduce medicines stepwise according to blood pressure, cardiovascular risk, target-organ damage and co-existing disease.[5]Begin eligible patients on low-dose hydrochlorothiazide and add antihypertensive classes, such as beta-adrenergic blocking agents or calcium-channel blockers, where indicated and not contraindicated.[11][5]
• Tailor medicine selection to compelling indications, contraindications and co-morbid disease, and titrate doses or escalate treatment steps when blood pressure remains uncontrolled.[11][5][12]
• Assess adherence and lifestyle factors before diagnosing resistant hypertension, and investigate potential causes including measurement error, volume overload, excess sodium intake, inappropriate therapy, drug interactions, alcohol excess, obesity, chronic kidney disease and secondary conditions.[6][8][13]
• Refer patients for specialist or hospital assessment when hypertension remains uncontrolled after compliant Step 4 treatment, serious adverse effects occur, secondary causes are suspected, target-organ damage cannot be managed at primary level, or resistant hypertension requires investigation.[4][6][7]
• Manage hypertensive emergencies in hospital where possible, using experienced staff and high-care or intensive-care monitoring when parenteral treatment is required; lower diastolic blood pressure slowly over 48 to 72 hours and arrange long-term follow-up.[14][15][6][7]
• Monitor blood-pressure control at every visit, reinforce adherence and lifestyle measures, and undertake six-monthly assessment after target blood pressure has remained stable for one year.[14][7]
• Repeat routine investigations annually when initial results are normal, including creatinine, potassium, glucose, cholesterol assessment where indicated and resting electrocardiography.[4]

Monitoring & Evaluation

Monitoring centres on standardised clinical measurement, risk assessment, treatment response and follow-up for people with hypertension. The guideline does not establish a formal programme-level evaluation framework, routine reporting system, surveillance architecture, named performance indicators, audit process or accountability mechanism beyond these clinical requirements.[1][9][4][2][3][11][5][12][14][15][6][7][8][13][10][16]

• Measure blood pressure using an approved and maintained device, appropriate cuff size and patient positioning, after adequate rest; record systolic and diastolic readings and assess standing blood pressure for specified older people, people with diabetes and others at risk of postural hypotension.[7][8]
• Measure blood pressure in both arms at the first consultation and subsequently use the arm with the higher reading where readings differ.[8]
• Calculate blood pressure as the average of two readings taken one minute apart, take further readings if the first two differ by 5 mmHg, and confirm hypertension only when blood pressure exceeds 140/90 mmHg on three occasions within two months.[8]
• Service and calibrate blood-pressure devices and attachments at least every two years.[8]
• Assess weight, body mass index, abdominal obesity or waist measures, blood pressure, eye findings and urine abnormalities as part of routine assessment; assess microalbuminuria where indicated.[9]
• Undertake initial investigations and repeat them annually when normal, including creatinine, potassium, glucose, cholesterol assessment where indicated and resting electrocardiography.[4]
• Identify cardiovascular risk, target-organ damage and established disease through medical history, physical examination, vital signs and routine investigations, and manage or refer identified complications appropriately.[4][2]
• Monitor blood pressure against treatment targets and assess treatment response at specified intervals of one to three months, depending on the treatment step.[11][5]
• Monitor blood-pressure control at every visit while reinforcing lifestyle modification and adherence to the management protocol.[7]
• Check treatment adherence before classifying hypertension as resistant, including whether blood pressure remains above the specified threshold despite rational triple therapy that includes a diuretic.[6]
• Review drug containers, including empty containers, at every visit as a measure supporting adherence assessment.[8]
• Perform medical follow-up every six months after target blood pressure has been maintained for one year.[4][14]
• Check postural symptoms and standing systolic blood pressure when considering dose reduction for possible postural hypotension.[14]
• Conduct frequent blood-pressure and calcium-channel-blocker dosage checks for people receiving antiretroviral therapy, because antiretroviral medicines may alter calcium-channel-blocker metabolism and blood levels.[15]
• Use intensive-care or high-care monitoring with experienced staff and modern monitoring facilities for hypertensive emergencies requiring parenteral treatment.[14][15]
• Apply clinical blood-pressure thresholds and goals, which vary by co-morbidity and clinical context, including targets below 130/80 mmHg for people with co-morbidity and below 120/80 mmHg in congestive heart failure.[1][9][4]

Costing & Financing

No costing, budget, financing arrangement, funding source, resource-mobilisation mechanism, funding gap or economic assumption is specified.[1][9][4][2][3][11][5][12][14][15][6][7][8][13][10][16]

• Require clinical resources including approved blood-pressure devices, periodic device servicing and calibration, routine laboratory investigations, electrocardiography where indicated, referral capacity and high-care or intensive-care monitoring for hypertensive emergencies; however, no associated costs or funding allocations are provided.[4][14][15][7][8]
• Support patient education and support groups at all facilities, but the document does not specify the financial resources, implementing budget or funding source required.[7][8]