From the Guidelines
For Indians, the 2020 International Society of Hypertension Global Hypertension Practice Guidelines are recommended, which suggest a standard treatment approach for hypertension management, including lifestyle modifications and pharmacological treatment with a thiazide diuretic, calcium channel blocker, ACE inhibitor, or ARB, with a treatment target of <140/90 mmHg for most patients and <130/80 mmHg for those with diabetes or chronic kidney disease 1.
Classification of Hypertension
The classification of hypertension for Indians is based on the blood pressure levels, with hypertension defined as blood pressure ≥140/90 mmHg. The Indian Guidelines on Hypertension (IGH) categorize hypertension as:
- Grade 1: 140-159/90-99 mmHg
- Grade 2: ≥160/≥100 mmHg
- Isolated Systolic Hypertension: ≥140/<90 mmHg
Management of Hypertension
Management of hypertension in Indians begins with lifestyle modifications, including:
- Salt restriction (<5g/day)
- Weight reduction
- Regular physical activity
- Limited alcohol
- A DASH diet Pharmacological treatment should start with:
- A thiazide diuretic
- Calcium channel blocker (like amlodipine 5-10mg)
- ACE inhibitor (like ramipril 5-10mg)
- ARB (like telmisartan 40-80mg) For most Indians, combination therapy is often needed, with CCB+ARB being particularly effective.
Treatment Targets
Treatment targets for Indians are:
- <140/90 mmHg for most patients
- <130/80 mmHg for those with diabetes or chronic kidney disease Regular monitoring is essential, with home BP monitoring encouraged. Indians have higher salt sensitivity and earlier onset of hypertension-related complications, making aggressive management crucial for preventing cardiovascular disease, which is particularly prevalent in the Indian population 1. Some key points to consider in the management of hypertension in Indians include:
- Morning hypertension and nighttime hypertension are more common in Asia, compared with European populations 1
- South Asian populations originating from the Indian subcontinent have a particularly high risk for cardiovascular and metabolic diseases, including CAD and type 2 DM 1
From the Research
Classification of Hypertension
- The Joint National Committee (JNC) classification is widely used to categorize hypertension, with the following stages: normal, pre-hypertensive, stage I, and stage II 2.
- According to the JNC-8 guidelines, blood pressure categories are defined as follows: normal (less than 120/80 mmHg), pre-hypertensive (120-139/80-89 mmHg), stage I (140-159/90-99 mmHg), and stage II (160 or higher/100 or higher mmHg) 2, 3.
Management of Hypertension in Indians
- The JNC-8 guidelines recommend the use of calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and thiazide-type diuretics as initial therapy for hypertension 2, 4.
- A study conducted in a rural tertiary care Indian hospital found that CCBs were the most prescribed antihypertensive medication, and combination therapy was used in 15.84% of patients 2.
- The American journal of cardiovascular drugs suggests that ACEIs and ARBs play a pivotal role in hypertension management and cardiovascular and renal protection, and should be considered as first-line therapy 5.
Comparison of Guidelines
- The World Health Organization-International Society of Hypertension (WHO-ISH) guidelines and the JNC guidelines have some differences in their recommendations for hypertension management 3.
- The WHO-ISH guidelines suggest continuing monitoring without medication for subjects without other risk factors if pressures are not greater than 150/95 mmHg, while the JNC guidelines recommend drug therapy even in these subjects if blood pressures remain greater than 140/90 mmHg after a 6-12 month period of nonpharmacologic interventions 3.
- The JNC-8 guidelines recommend diuretics or beta-blockers as initial treatment, while the WHO-ISH guidelines indicate that all classes of medication are suitable initial therapy 3, 6.