Management of Hypertension in the Older Adult Hospitalized With Community-Acquired Pneumonia

Management of hypertension in older adults who are hospitalized is challenging. Many older adults have multiple comorbidities, with hypertension being common. Nurse practitioners are vital in managing hypertension in older adults who are hospitalized with community-acquired pneumonia. The differences in national guidelines for hypertension management and the lack of guidelines for inpatient hypertension management make it difficult to choose the best blood pressure goal for these vulnerable patients. This report addresses the management of hypertension in older adults hospitalized with community-acquired pneumonia.     

Comparison between the world health organization (WHO) and international society of hypertension (ISH) guidelines for hypertension

The global burden of hypertension remains an unsolved problem, especially in low- and middle-income countries (LMICs). For this reason, clinical practice guidelines containing the latest evidence-based recommendations are crucial in the management of hypertension. It is noteworthy that guidelines simply translated from those of high-income countries (HICs) are not the solution to the problem of hypertension in LMICs. Among the numerous guidelines available, those of the World Health Organisation and the International Society of Hypertension are the latest to be published as of the writing of this article. In this review, we conducted both general and specific comparisons between the recommendations supplied by both guidelines. Differences in aspects of hypertension management such as the timing of antihypertensive initiation, assessment of comorbidities and cardiovascular risk factors, pharmacological therapy selection, and blood pressure target and reassessment are explored. Lastly, the implications of the differences found between the two guidelines in both LMICs and HICs are discussed.

Key messages

• Currently, with low treatment and control rates, hypertension remains a burden in low- and middle-income countries (LMICs).
• The lack of customised guidelines for LMICs cannot be solved simply by adopting guidelines from high-income countries.
• The World Health Organisation (WHO) recently published a clinical guideline for the pharmacological management of hypertension in LMICs. We compare select recommendations from the guidelines to those published by the International Society of Hypertension.

     

Treatment of hypertension and adherence to treatment guidelines in clinical practice: An Italian study

Despite the results from clinical trials in patients with hypertension and the development of a long list of guidelines for the management of hypertension, many physicians and other healthcare professionals still manage hypertension using approaches that clearly diverge at least partially from the recommendations of these guidelines. Whatever the underlying reasons for physicians’ failure to adhere to these guidelines, it is one of the main causes of the high percentage of treated patients with uncontrolled hypertension. This article is a report of the out-comes of a project designed to identify specific discrepancies between hypertension guidelines and clinical practice in Italy then guide the physicians to reach a consensus on hypertension management through discussions with their peers. A total of 1120 internists from all 20 regions in Italy were recruited to participate in workshops conducted between June 2002 and July 2004. They were divided into 57 groups to discuss at least 7 key topics, including the blood pressure level at which to start drug therapy, target-organ damage, isolated systolic hypertension, pulse pressure, clinical trials, generic drugs, and fixed combination drug therapy. The project findings confirmed that the vast majority of internists agree with the guidelines but do not adhere to them completely in clinical practice. Through open discussions that allowed them to identify common viewpoints, the participants may have developed a better awareness of and insight into the guidelines for hypertension management. Hopefully this strategy for group participation will lead to improvements in the management of hypertension throughout Italy.     

Treatment of elderly hypertension based on various hypertension management guidelines--comparison between European and American guidelines and Japanese guidelines

In civilized countries blood pressure is increased in association with age. Elderly population is lately increased both in Japan and Western countries and therefore elderly hypertensive patients are expected to increase. Recently, several guidelines and statements for the treatment of hypertension, such as JNC 7, 2003 ESH/ESC, 2003 WHO/ISH, and BSH IV, are reported in Western countries. In Japan, Japanese Society of Hypertension reported guidelines for management of hypertension in 2000 (JSH 2000) and JSH 2000 is now revised and a new version was published at the end of 2004 (JSH 2004). In this article, management of hypertension (when starts the treatment, target blood pressure level, and choice of drugs, etc) in the elderly is described based on these guidelines and statements.     

Hypertension alone or related to the metabolic syndrome in postmenopausal women

Hypertension treatment and control efforts represent a major component of primary care with dedicated clinical guidelines and recommendations. However, high blood pressure (BP) control rates are complicated with the difficult to treat and resistant hypertensive patients. This category of patient, therefore, affects the development and implementation of the clinical guidelines. The recommendations of specific algorithms for resistant hypertension and difficult-to-treat patients with elevated BPs have been developed in consideration of new therapies and combination drug treatment. Hypertension treatment guidelines include and will continue to grade evidence from randomized clinical trials with detailed strategies on the management of these high-risk patients. Although resistant hypertension affects high BP control rates, the inclusion of refined pharmaceutical and device treatment strategies in evidence-based guidelines will be expected to have a significant impact on the clinical management of this high-risk patient population.     

The Japanese new guideline for the management of hypertension--background of its preparation and characteristics of the new guideline

The Japanese society of hypertension organized guidelines subcommittee for guidelines for the management of hypertension by request of Japanese physicians and people in the Ministry of Health and Welfare in 1998. Professor Masatoshi Fujishima in the School of Medicine, Kyushu University became a chairman in the committee. He had proceeded the preparation smoothly, and in July, 2000 the new guideline for the management of hypertension was published. The Japanese new guideline for the management of hypertension is slightly different from those in other countries, such as JNC-VI or the WHO/ISH guideline. The Japanese new guideline was prepared under the consideration of characteristics of hypertension in Japan, Japanese life style and recent trends in the management of hypertension in Japan. It is desired that Japanese physicians treat hypertensive patients according to this new guideline, and questionable parts in the guideline should be corrected to make it more useful and valuable. Especially the parts peculiar to the Japanese guideline should be ascertained by further studies in Japan.     

Managing hypertension: measurement and prevention

This article describes the incidence of hypertension and its implications in cardiovascular disease. It recommends that patients' blood pressure is regularly monitored and outlines best practice guidelines for diagnosing and treating the condition. The objectives are to promote the prevention of hypertension and cardiovascular disease and increase awareness, detection, treatment and management of blood pressure among patients with hypertension.     

New European, American and International guidelines for hypertension management: agreement and disagreement

Hypertension is a leading cause of morbidity and mortality worldwide and its control rates remain poor. In 2003, several official organizations presented new guidelines for hypertension management. These guidelines were developed using an evidence-based interpretation of the available information. Recommendations on hypertension prevention, diagnosis, patients' evaluation, decision to treat, antihypertensive drug selection and goals of treatment are included. There is considerable agreement among the new guidelines and only a few points of disagreement, that are of minor significance. Emphasis has been placed on the simplicity of recommendations in order for them to be easily applied by primary care physicians. This review focuses on the key messages of the 2003 guidelines and the areas of agreement and disagreement among them.     

New European,American and International guidelines for hypertension management: agreement and disagreement

Hypertension is a leading cause of morbidity and mortality worldwide and its control rates remain poor. In 2003, several official organizations presented new guidelines for hypertension management. These guidelines were developed using an evidence-based interpretation of the available information. Recommendations on hypertension prevention, diagnosis, patients’ evaluation, decision to treat, antihypertensive drug selection and goals of treatment are included. There is considerable agreement among the new guidelines and only a few points of disagreement, that are of minor significance. Emphasis has been placed on the simplicity of recommendations in order for them to be easily applied by primary care physicians. This review focuses on the key messages of the 2003 guidelines and the areas of agreement and disagreement among them.     

Individualized tailoring of antihypertensive therapy]

Despite the publication of guidelines for the management of hypertension, there is still uncertainty among physicians regarding the right antihypertensive drug selection into the right patient. Though there have been great advances in investigating hypertension, there is only a little knowledge of the mechanisms and genetic backgrounds of 'essential hypertension'. Nationwide investigations, such as association studies dealing with a large number of patients and linkage studies using hypertensive pedigrees, are necessary to correct knowledge of individual genetic backgrounds, which influence the response to antihypertensive drug therapy. Progress toward tailoring treatment for essential hypertension and individualizing target genetic background has just started. Guidelines for the management of hypertension including the consideration of individual genetic background will be published in future days.     

合并腹腔高压重症患者肠内营养期间误吸预防的证据总结

目的:评价并整合合并腹腔高压的重症患者肠内营养期间预防误吸的证据。方法:检索BMJBestPractice、UpToDate、国际指南协作网(GIN)、美国国立指南库(NGC)、CochraneLibrary、PubMed、WebofScience、中国知网、万方、维普等数据库关于重症患者合并腹腔高压期间肠内营养误吸预防的所有证据,包括指南、证据总结、临床决策、专家共识、系统评价及原始研究。由两名研究者对纳入的文献进行质量评析,并对提取的证据级别进行评定。结果:共纳入文章17篇,其中系统评价8篇,指南3篇,最佳证据总结2篇,临床决策4篇。总结出20条误吸预防的证据,包括腹腔高压及误吸的危险因素的识别、肠内营养的管理、腹腔高压的管理、气道的管理、药物管理以及临床监测等。结论:建议在使用此证据时还应结合科室患者的具体情况进行个体化调整,并且此证据在临床使用过程中,若发现问题应及时改进,以提升护理质量,保证安全,提高患者满意度。     

重症患者腹内高压预防与管理的最佳证据总结

目的 检索、评价并总结重症患者腹内高压的相关证据,为临床护理人员预防和管理重症患者腹内高压提供参考依据。方法 系统检索UpToDate、BMJ Best Practice、英国国家卫生与临床优化研究所网站、国际指南协作网、加拿大安大略护士协会网站、苏格兰院际间指南网、乔安娜布里格斯研究所循证卫生保健中心数据库、WHO官网、中国医脉通指南网、世界腹腔间隔室综合征学会网站、Cochrane Library、PubMed、Embase、CINAHL、中国知网、万方数据库等,关于重症患者腹内高压的证据,包括指南、推荐实践、证据总结、专家共识、系统评价、随机对照试验、最佳实践信息手册等,检索时限为建库至2021年12月。由2名研究者独立进行文献质量评价和资料提取。结果 共纳入证据15篇,包括指南5篇、专家推荐1篇、专家共识2篇、最佳实践1篇、系统评价6篇,汇总、提取21条最佳证据,包括评估、监测管理、治疗管理、体位管理、肠内营养管理、容量复苏和液体管理6类。结论 该研究总结的重症患者腹内高压预防和管理的最佳证据具有科学性和全面性,为医护人员规范化监测、管理重症患者腹内高压提供了循证依据。     

Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations

Objective Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. In the absence of consensus definitions and treatment guidelines the diagnosis and management of IAH and ACS remains variable from institution to institution. Design An international consensus group of multidisciplinary critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to develop practice guidelines for the diagnosis, management, and prevention of IAH and ACS. Methods Prior to the conference the authors developed a blueprint for consensus definitions and treatment guidelines which were refined both during and after the conference. The present article is the second installment of the final report from the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of the Abdominal Compartment Syndrome. Results The prevalence and etiological factors for IAH and ACS are reviewed. Evidence-based medicine treatment guidelines are presented to facilitate the diagnosis and management of IAH and ACS. Recommendations to guide future studies are proposed. Conclusions These definitions, guidelines, and recommendations, based upon current best evidence and expert opinion are proposed to assist clinicians in the management of IAH and ACS as well as serve as a reference for future clinical and basic science research.     

Lowering the systolic blood pressure target in hypertensive patients: current controversies and future outlook

ABSTRACT

Introduction: Randomized controlled trials and meta-analyses have established the benefits of blood pressure (BP) lowering. The 2017 American Heart Association/American College of Cardiology (AHA/ACC) guidelines for the management of hypertension established 130/80 mmHg as the threshold for the diagnosis- and treatment-target BP level.

Area covered: The global trends are thought to be heading toward intensive BP-lowering management. In this paper, authors summarize the evidence on lowering the BP target in hypertensive patients with a focus on the 2017 AHA/ACC guidelines.

Expert commentary: According to the results of clinical research, meta-analyses and the 2017 AHA/ACC guidelines, the target systolic BP may change from less than 140/80 mmHg to 130/80 mmHg in any other international hypertension guidelines. However, this direction of intensive BP control is still controversial.     

Hypertension: a review for clinicians

Despite the existence of a variety of consistent hypertension guidelines,the issue of inadequate management of the condition persists. The challenge for health care professionals is not only to understand and adopt the guidelines but also to take a holistic approach to patient care. In addition, clinicians need to encourage adherence to medication protocols, which will hopefully lead to an overall reduction in morbidity and mortality associated with hypertension. It is the clinician's professional responsibility to be cognizant of the emerging research on vasoactive substances as new drugs are being developed that will effect endothelial receptors. It is important that clinicians are trained appropriately in blood pressure measurement and risk factor identification and intervention.     

Prise en charge diagnostique et thérapeutique de l'hypertension artérielle pulmonaire

Pulmonary hypertension is a rare disease related to increased resistance in the pulmonary vascular bed. The disease leads spontaneously to right heart failure and death. A pathophysiological classification taking into account possible causal factors is available. Diagnosis rests on right heart catheterisation when clinical and paraclinical data suggest the diagnosis. To date, guidelines are available for severe forms of the disease. ICU management may be required for right heart failure. Despite the lack of consensus, management of patients with pulmonary hypertension resembles to this of patients with severe pulmonary embolism with right heart failure and the need for inotropic support.     

Delphi panel study of current hypertension treatment patterns

OBJECTIVE: The purpose of this study was to assess whether, and to what extent, usual practice in the management of patients with mild to moderate hypertension differs from that recommended in the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI). The results were used as input for a clinical decision analytic model to assess the cost-effectiveness of a new treatment for hypertension. METHODS: A Delphi panel survey of general practitioners and cardiologists in the United States was conducted to determine current strategies for the treatment of mild to moderate uncomplicated hypertension. The purpose of the panel survey was to reach consensus on 3 key facets of the JNC-VI guidelines and how they relate to the respondents' clinical practices: (1) the definition of mild to moderate hypertension, (2) the treatment that adult patients with uncomplicated mild to moderate hypertension should receive, and (3) the management of patient follow-up. RESULTS: Of the 20 physicians contacted for the survey, 10 responded to both rounds of the questionnaire. There was considerable variation in the responses for defining the ranges of healthy, acceptable, unacceptable, and serious blood pressure. In general, the Delphi panel respondents cited higher limits than stated in the JNC-VI guidelines. Physicians followed the guidelines approximately 60% of the time. Primary determinants of initial drug choice among the panelists were comorbid conditions and the severity of hypertension; patients' age, race, and sex were secondary determinants. Follow-up typically occurred 1 month after therapy initiation. Panelists reported titrating the dose of new therapies upward once or twice before discontinuing the drug for lack of efficacy. Once adequate blood pressure control was achieved, patient follow-up was reported to occur every 3 to 4 months. CONCLUSIONS: This Delphi panel study highlights the differences between clinical practice and the JNC-VI guidelines in the treatment of hypertension. The results were used as a basis for defining a structure for a cost-effectiveness model and provided the management practice and prescribing practice patterns required by the model.     

Management of hypertension in diabetic patients: outstanding issues

Cardiovascular disease is the leading cause of premature mortality in Type 2 diabetes mellitus; consequently, good management of all risk factors is vital. The recent reappraisal of the European Society of Hypertension guidelines on hypertension management reset the blood pressure goal for Type 2 diabetic patients to blood pressure <140/90 mmHg. Although this recommendation is based on the best available evidence, further data are still required to provide a better understanding of the natural history of Type 2 diabetes in order to establish blood pressure goals throughout the natural history of the diabetic patient with hypertension.     

Management of hypertension in diabetic patients: outstanding issues

Cardiovascular disease is the leading cause of premature mortality in Type 2 diabetes mellitus; consequently, good management of all risk factors is vital. The recent reappraisal of the European Society of Hypertension guidelines on hypertension management reset the blood pressure goal for Type 2 diabetic patients to blood pressure <140/90 mmHg. Although this recommendation is based on the best available evidence, further data are still required to provide a better understanding of the natural history of Type 2 diabetes in order to establish blood pressure goals throughout the natural history of the diabetic patient with hypertension.     

Primary care management of childhood and adolescent hypertension

Purpose: To educate advance practice nurses on the diagnosis, pharmacologic, and nonpharmacologic management of hypertension in children and adolescents.
Data sources: Information was collected through a search of published literature and clinical practice guidelines.
Conclusions: Increasing rates of hypertension in children and adolescents are correlated to risk for coronary artery disease in adulthood. Nonpharmacologic management includes lifestyle modifications addressing weight reduction, physical activity, and dietary modification. Pharmacologic management is typically reserved for patients with severe hypertension or those who do not respond to lifestyle modifications. Early intervention is critical for preventing target-organ damage and complications of long-term hypertension.
Implications for practice: Nurse practitioners must identify and address elevated blood pressure levels in children and adolescents. Many children and adolescents can successfully lower blood pressure readings through nonpharmacologic lifestyle changes. Education about lifestyle modification strategies should focus on family-based changes in order to increase likelihood of successful implementation.