Know your treatment goals and targets for hypertension.
Hypertension is a common chronic illness where the blood pressure is higher than normal.
Needless to say, the treatment of hypertension involves lowering the blood pressure to expected levels. However, many may not realise that this is not the main goal of treating hypertension. The ultimate goal of treating hypertension is to reduce the chances of dying from what we call "cardiovascular diseases", where hypertension is one of the main risk factors.
According to the Malaysian practice guidelines, hypertension is defined as blood pressure that is persistently elevated to a systolic level of 140mmHg or greater, or diastolic level of 90mmHg or greater.
From our 2006 National Health and Morbidity Survey, nearly half of adults aged 30 and older have hypertension.
There is also a group of adults where the blood pressure is in between the normal and hypertensive level. This is called "pre-hypertension", where the systolic blood pressure is between 120 and 139mmHg, and diastolic blood pressure is between 80 and 89mmHg.
The pre-hypertensive group constitutes one third of adults. They have a greater risk of developing hypertension compared to the normal population. Hence, approximately more than two thirds of our adult population require some attention to their blood pressure.
Ironically, adults with normal blood pressure, where the systolic blood pressure is less than 120mmHg and diastolic, less than 80mmHg, are the minority.
It is an established fact that longstanding and untreated hypertension increases the risk of cardiovascular, cerebrovascular and renal complications. These complications include stroke, ischaemic heart disease (a disease caused by insufficient blood supply to the heart muscle), heart failure and kidney failure.
The commonly known heart attack is part of the spectrum of ischaemic heart disease. This disease has been the main cause of death in Malaysia for many years, and remains likely to be so in the near future, unless appropriate measures are taken.
However, we need to be aware that hypertension is only one of the many risk factors for these complications. Diabetes, smoking and hypercholesterolaemia (high cholesterol level) are among other main risk factors.
Complications of hypertension are contributed by multiple risk factors - not just high blood pressure alone. More importantly, we need to be aware that these risk factors, causing stroke and heart attack, work silently over the years through changes in the blood vessel walls before a sudden occurrence of heart attack or stroke.
Hypertensive kidney disease also develops silently, and may ultimately manifest as kidney failure.
Thus, we need to actively manage these risk factors even when we do not experience any symptoms.
Therefore, the main strategy of treating hypertension is total cardiovascular risk management. There is no doubt that reducing blood pressure to target levels is important. However, we need optimal control of all the other concomitant risk factors - the so-called "total cardiovascular risk management".
It is not an uncommon practice among hypertensive patients to focus on blood pressure readings and take medications accordingly, disregarding other cardiovascular risk factors.
Even then, the target levels for optimal control of hypertension may be different for different individuals. For example, in patients with only hypertension, their target for control is a systolic blood pressure of less than 140mmHg and diastolic of less than 90mmHg. But in patients with concomitant diabetes, the target levels are much lower, with a systolic blood pressure of less than 130mmHg and diastolic blood pressure of less than 80mmHg.
Besides paying attention to blood pressure, screening and monitoring for other cardiovascular risk factors are also needed. These include regular blood testing for fasting blood glucose (or sugar) and fasting serum cholesterol level. The reason for checking blood glucose is obvious; diabetic patients have different treatment targets.
With regards to cholesterol, in particular, raised LDL-cholesterol (bad cholesterol) levels, anything above 3.4mmol/L is associated with increased chances of coronary heart disease. In diabetic patients and patients with established coronary heart disease and kidney disease, the LDL-cholesterol level should be kept to 2.6 mmol/L or less.
Therefore, all hypertensive patients need to know exactly their personal targets for blood pressure control and other cardiovascular risk factors, which depend on individual cardiovascular risk.
There is also a need to speak to your doctor with regards to smoking cessation, optimal exercise and appropriate lifestyle changes. Such personalised management strategies can be managed with your family doctor.
The other strategy for treating hypertension is to have regular assessment of possible early complications. The presence of early complications may need different treatment strategies, such as the use of different classes of medication.
The common complications that need to be monitored include presence of hypertensive heart diseases such as left ventricular hypertrophy and heart failure, and kidney disease.
Left ventricular hypertrophy is the thickening of the left heart muscle. Cardiac assessments such as electrocardiography, chest X-ray and echocardiogram, are able to detect the presence of hypertensive heart disease. Treatment for patients with left ventricular hypertrophy or heart failure should include classes of medications belonging to angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB).
Complications of kidney disease can be detected from urine examination and blood tests (for renal function). Patients with proteinuria - the presence of excessive protein in the urine - are at higher risk of cardiovascular complications. Hence, they need stricter blood pressure control of systolic blood pressure of less than 130mmHg and diastolic of less than 80mmHg. They may even need a lower target level of blood pressure if the degree of proteinuria is high.
Thus, treatment strategies and targets are also different depending on the presence or absence of hypertensive complications.
The goal of treating hypertension is to prevent cardiovascular complications, rather than just getting the blood pressure under controlled. The targets are individualised depending on the cardiovascular risk profile.
Taking all the above facts, setting treatment strategies and targets appears complicated and daunting. However, if you work with your doctor and go for regular and proper assessments in the clinic, arriving at an optimal choice of medication should be easier.