l1 Arar Asr Intro and Overview

INTRODUCTION AND
OVERVIEW
DIAGNOSIS & CLASSIFICATION
Coexisting Cardiovascular Risk Factors
for Risk Stratification
• Diabetes Mellitus
• Dyslipidaemia (TC > 6.5mmol/L)
• Smoking status
• Microalbuminuria
• Estimated GFR < 60mL/min/m2 (CKD)
• Family history of premature CV disease
(Male < 55 y/o; Female < 65 y/o)
TARGET ORGAN DAMAGE & COMPLICATIONS
Risk Stratification
Algorithm for the
Management of
Hypertension
CHOICE OF FIRST LINE MONOTHERAPY
Choose monotherapy in patients with

stage 1 hypertension and with no
compelling indications from one of the 5
classes of drugs ( ACEIs, ARBs, Beta
Blockers , CCBs or Diuretics ) based on
patients' individual clinical profile
Antihypertensive agents
Antihypertensive agents
Blood Pressure Targets
CATEGORY BLOOD
PRESSURE
TARGETS
For all < 140/90 mmHg
Diabetic < 140/80 mmHg
High/ very High Risk diabetic, < 130/80 mmHg

Lacunar stroke,
LVH, CKD with Proteinuria > 1g/
day
Choice of Anti- Hypertensive Drugs in
Patients with Concomitant Conditions
Effective Combination Therapy
Effective Combination Therapy Used in
Outcome Trials
RESISTANT HYPERTENSION
If BP is still >140/90 mmHg with combination of 3 drugs (including a diuretic at near
maximal doses) it is by definition Resistant Hypertension
Before labeling a patient as having resistant hypertension exclude

● Inappropriately measured BP
● Non- adherence to medication
● Office Resistant hypertension
● Inappropriate combination and doses of drugs prescribed
● Intake of any substances which may antagonise the hypertensive effects of drugs taken ( eg NSAIDS,
sympathomimetics, liquorice, oral contraceptives, corticosteroids )
RESISTANT HYPERTENSION
Once Resistant Hypertension has been established
● exclude secondary hypertension ( Commonest OSA )

● re emphasise on non pharmacological approaches
● add spironolactone as the 4th drug ( provided renal function is
intact )
● add a 5th drug if is still not controlled on 4 drugs
( Choice of 5th drug include a beta blocker, an alpha
blocker or a centrally acting drug )

REFRACTORY HYPERTENSION
Patients whose BP are not controlled after taking > 5 anti

hypertensives are by definition having
Refractory Hypertension
Both resistant and refractory

hypertensives , are candidates for device-
based intervention
* Hypertensive urgency - If patient has vague symptoms,
grade III / IV retinopathy and proteinuria
* Asymptomatic severe hypertension - If patient has no

symptoms, no TOD (proteinuria, retinopathy): can treat as
outpatient, start combination treatment, TCA one week
Management of Hypertensive Urgency
( Severe hypertension with non-specific symptoms )
Management of Hypertensive Emergency
( Severe hypertension with acute target organ damage )
KEY LEARNING POINTS
2. In 2015, prevalence of HPT in Malaysia

was 44.7% among those > 30 years years
3. HPT is a silent disease , 62.5% of the cases

remained undiagnosed. Therefore BP should be
measured at every chance encounter
5. A SBP of 130-139mmHg and/or DBP of 85-89

mmHg is defined as ' At Risk BP' an should be treated
in certain risk groups
KEY LEARNING POINTS
6. Healthy Living should be recommended for
all individuals with HPT and At Risk BP
8. In patients with newly diagnosed

uncomplicated HPT who have no compelling
indications, choice of first line monotherapy
include ACEIs, ARBs, BBs, CCBs and
Diuretics
9. Only 37.4% of treated patients achieve
target BP
in Stage 2 and some risk category in Stage 1

THE ROLE OF
CHRONIC CARE MODEL
IN HYPERTENSION MANAGEMENT
THE CHRONIC CARE MODEL
6 1
4 2 3 5
24
1. ORGANISATION OF HEALTH CARE
A system seeking to improve
chronic disease care must be
motivated and prepared for
change throughout the
organization from the micro,
meso and macro levels
Create policies and allocate resources with a clear focus to

improve delivery of care for patients with hypertension
2. DELIVERY SYSTEM DESIGN
Utilising multidisciplinary
healthcare team to transform
a system that is essentially
reactive (responding mainly
when a person is sick) to one
that is proactive and focused
on keeping a person as
healthy as possible
Multi-disciplinary practice team with

clear division of labour - planned
management and follow-up
3. DECISION SUPPORT
Promote clinical care that

is consistent with up-to-
date scientific evidence and
patient preferences
Translate evidence based clinical practice guideline

recommendation into daily clinical practice
4. SELF-MANAGEMENT SUPPORT
Emphasize on the patients’
central role as active
partners in managing their
health through
empowerment and
motivation
Empower patients with knowledge and skills to enhance confidence to

self-care. Build quality relationship through effective communication.
5. CLINICAL INFORMATION
SYSTEM
Organize patients and
population data to facilitate
efficient and effective chronic
disease care
Computerized system to remind &

prompt actions; support shared care
among multiple professionals, provide
feedback to healthcare personnel, track
progress and defaulters
6. COMMUNITY RESOURCES
Mobilize community
resources to meet the needs
of patients
Patients & care providers need linkages with community

resources such as home care, exercise program and support
groups.
Decision Support Tool Clinical Informed,
Information Empowered
System Patient
Prepared &
Proactive Productive Interactions
Doctor and
NCD Team
Self-
Management
Support Tool
31
EVIDENCE SUPPORTING THE
CHRONIC CARE MODEL
● CCM has been shown to improve quality of
care and outcomes for various chronic
conditions including hypertension
● Of the 77 papers which met the inclusion
criteria, 75 papers reported improvements to
healthcare practice or health outcomes for
people living with chronic disease.
● The most commonly used elements of the
CCM were self-management support and
delivery system design.
32
CHRONIC CARE MODEL IN
MALAYSIA
33
A cross-sectional survey to assess the feasibility to implement the components of Chronic
Care Model (CCM) in the public primary care clinics
 Majority of the clinics were already equipped with core resources to implement the CCM
 Majority of the clinics have adequate multidisciplinary staff who were willing to be trained
and were committed to improve patient care
 Therefore, implementation of the essential components of the CCM was feasible, despite
various constraints
34
MALAYSIA
35
MALAYSIA
36
KEY PRACTICE POINTS
1. Produce a prepared, proactive health care
team to manage chronic conditions
2. Create effective clinical information

systems e.g. disease registry,
comprehensive medical records
3. Translate CPG recommendations into daily

clinical practice
4. Empower patients to self-manage their

conditions
5. Perform continuous quality improvement activities

e.g. Clinical Audit
THANK YOU

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INTRODUCTION AND

Choose monotherapy in patients with

Diabetic < 140/80 mmHg

High/ very High Risk diabetic, < 130/80 mmHg

Before labeling a patient as having resistant hypertension exclude

● Non- adherence to medication

● Office Resistant hypertension

● Inappropriate combination and doses of drugs prescribed

Once Resistant Hypertension has been established

● exclude secondary hypertension ( Commonest OSA )

blocker or a centrally acting drug )

Patients whose BP are not controlled after taking > 5 anti

Both resistant and refractory

* Asymptomatic severe hypertension - If patient has no

2. In 2015, prevalence of HPT in Malaysia

3. HPT is a silent disease , 62.5% of the cases

5. A SBP of 130-139mmHg and/or DBP of 85-89

8. In patients with newly diagnosed

in Stage 2 and some risk category in Stage 1

Create policies and allocate resources with a clear focus to

Multi-disciplinary practice team with

Promote clinical care that

Translate evidence based clinical practice guideline

Empower patients with knowledge and skills to enhance confidence to

Computerized system to remind &

Patients & care providers need linkages with community

2. Create effective clinical information

3. Translate CPG recommendations into daily

4. Empower patients to self-manage their

5. Perform continuous quality improvement activities

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