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SHAMS Guielines Summary

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Summary of SHAMS-HTN Guidelines

1) Screening Recommendation

  • Screening is recommended annually for adults aged 40 years or older and for those who are at increased risk of high blood pressure including those who have high-normal blood pressure (130–139/85–89 mm Hg) and those who are overweight or obese.
  • Adults aged 18–39 years with normal blood pressure (<130/85 mm Hg) who do not have other risk factors should be re-screened every 3–5 years.

2) Diagnosis of HTN

  • HTN may be diagnosed in the office or out-of-the-office setting (including home and ambulatory). ABPM is preferable if available. HBPM may be used as an alternative, provided it is performed according to the guidelines.
  • Serial office measurements over 3-5 visits can be used if ABPM or home measurement not available.
  • Home BP Series: Two readings taken each morning and evening for 7 days (28 total). Discard first day readings and average the last 6 days.

3) Classification of HTN

CategorySBP (mm Hg)DBP (mm Hg)
Normal<120and<80
Pre-HTN120–139and/or80–89
HTN Grade I140–159and/or90–99
HTN Grade II160–179and/or100–109
HTN Grade III≥180and/or≥110

4) Isolated Systolic Hypertension

  • Persistent high Office SBP ≥140 mm Hg and Office DPB <90 mm Hg.

5) White-coat Hypertension (Isolated Office HTN, Isolated Clinic HTN)

  • White coat HTN is defined as an elevated BP in the office at repeated visits, while it is normal out of the office, using either ABPM or HBPM.
  • Prevalence of white-coat hypertension averages 13%.

6) Masked (Isolated Ambulatory) Hypertension

  • Masked HTN is defined as normal BP in the office at repeated visits and elevated out of the office, either on ABPM or HBPM.
    • Possible causes: anxiety, stress.
    • Prevalence of masked hypertension averages about 13%.
    • CV events are 2 times higher than those in true normo-tension.

Example Scenario

A 40-year-old lady was checked her BP at the clinic three times at different occasions and her BP usually, below 140/90 mmHg. She admitted that she has checked her BP at home many times which shows usually more than 150/95 mmHg. Ambulatory BP measurement also showed around 150/95 mm Hg, but again the clinical BP measurement showed below 140/90 mmHg readings.

What is the terminology used for this type of BP reading?

a. Pre-hypertension b. Masked hypertension c. Borderline hypertension d. White coat hypertension

7) Clinical Evaluation

Aims

  • Establish the diagnosis of HTN
  • Identify secondary HTN
  • Detect additional RFs of CVDs
  • Determine Target Organ Damage and Associated Clinical Conditions

Components

  • History
  • Physical examination
  • BP measurement
  • Basic investigations

9) History

  1. Presence of CV-RFs (DM, dyslipidemia, obesity, etc.) and other concomitant diseases
  2. History or current symptoms suggestive of CVDs (CHD, MI, stroke, CHF, renal disease, and PAD)
  3. Symptoms suggestive of secondary HTN
  4. Lifestyle: smoking, physical inactivity, alcohol intake, sodium intake, and psychosocial stress
  5. Past experience with antihypertensive drugs
  6. Medication history: oral contraceptives, NSAIDs, steroids, etc.
  7. Family history of HTN and associated diseases (DM, dyslipidemia, CAD, stroke, or renal disease).

10) Physical Examination

Physical examination must be thorough enough to detect signs of comorbidity, organ damage, and secondary causes. It must include:

  1. Weight, height, BMI, and waist circumference
  2. Chest exam for rales
  3. Abdominal exam for organomegaly and bruit
  4. Central nervous system: motor or sensory defects
  5. Cardiac: arrhythmia, murmur, rales, peripheral edema
  6. Retina examination for hypertensive changes. However, a dilated fundoscopic examination by an ophthalmologist is recommended afterwards.
  7. Vascular: absent arterial pulses, carotid bruit, radio-femoral delay

11) Signs Suggesting Secondary HTN

  • Age of HTN diagnosis <20–30 or >55–60 years
  • Family history of premature CV disease (<55 years)
  • Early TOD
  • Symptoms & signs suggestive of 2ry HTN (Table 2)

Which one of the following sign or symptom is suggesting secondary HTN

A. Being male gender B. Presence of early TOD C. Age of HTN diagnosis >60 year D. No Family history of premature CV disease

Table 2: Symptoms & Signs Suggestive of 2ry Hypertension (P 19)

Standards for BP Measurement

For a reliable and valid BP measurement, it is essential to uphold the following standards:

  1. Patient should have 3–5 minutes of physical rest before measuring BP.
  2. Patient should relax (legs should not be crossed) in a quiet environment (no talking) before measurement.
  3. BP should be measured in sitting position with back support.
  4. BP measurement should be taken in both arms at initial visit. The arm with the higher BP values should be noted in the chart and follow up should be performed on this arm.
  5. Upper arm should not be covered by clothing.
  6. Elbow should be supported and cuffed at heart level.
  7. BP should be measured in standing position, if postural hypotension is suspected (e.g., diabetics and elderly patients).
  8. Patient should avoid nicotine and caffeine one hour before BP measurement.
  9. Patients should avoid BPM while the urinary bladder is distended.

Home Blood Pressure Monitoring (HBPM)

  • HBP may be used for both diagnosis and monitoring of BP.
  • Home SBP values ≥135 mmHg or DBP values ≥85 mmHg should be considered as elevated.
  • Home BPM should be based on duplicate measurements (one minute apart), morning and evening, for an initial 7-day period. First-day home BP values should not be considered.
  • SHMS strongly supports the use of HBPM as adjunctive in hypertension follow-up. It is cost effective and improves adherence and control.

Ambulatory BP Monitoring (ABPM)

  • It is performed by a validated automated device over a period of 24 hours.
  • BP is measured at repeated intervals (every 15–30 mins while awake, and every 30–60 mins during sleep).
  • The patient is instructed to engage in normal activities but to refrain from strenuous exercise and, at the time of cuff inflation, to stop moving and talking and keep the arm still with the cuff at heart level.
  • At least 70% of BPs during daytime and nighttime periods should be satisfactory.
  • ABPM is a more sensitive risk predictor of CV outcome than is office BPM.
  • The incidence of CV events is higher in non-dippers.
  • Normal average daytime BP is <135/85 mm Hg.
  • Nocturnal BP is 10%–20% less than the average daytime BP (<120/75 mm Hg).
  • A 24-hour average value of 130/80 mm Hg corresponds to a 140/90 mm Hg of office value.
  • Possible reasons for the absence of dipping are: sleep disturbance, obstructive sleep apnea (OSA), CKD, and obesity.
  • It is more expensive than self-monitoring.

Indications for ABPM

  1. Suspected white-coat HTN
  2. Confirm diagnosis, if available
  3. Suspected masked HTN
  4. Resistance to drug therapy
  5. Suspicion of nocturnal HTN
  6. Obstructive sleep apnea
  7. Assessing hypertension in children and adolescents
  8. Assessing hypertension in pregnancy
  9. Assessing hypertension in high-risk patients
  10. Suspected drug induced hypotension
  11. Assessment of BP variability
  12. Assessing hypertension in the elderly

Additional Tables and Recommendations

  • Table 4: Clinical indications and diagnostics of secondary hypertension, ESH 2013. P 25.
  • Table 8: Impact of lifestyle therapies on blood pressure in hypertensive patients. P35
  • Summary of Recommendations:
    • Weight reduction to ideal body weight
    • Adopt DASH dietary plan
    • Restrict sodium intake to <1500 mg/day (1/2 to 3/4 teaspoon)
    • Regular moderate-intensity physical activity
    • Smoking cessation
  • Table 9: Recommended lifestyle to prevent cardiovascular risk factors including HTN. P 32
  • Table 15: Antihypertensive Medications: Indications and Contraindications: P 38

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