الفهرس 
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Abstract
Hypertension is a worldwide common health problem with lifetime risk approaching 90%. The reported prevalence of hypertension varied around the world from 3.4% in men in rural India as the lowest to 72.5% in elderly women in Poland as the highest. It constitutes a major – but preventable - risk factor for coronary heart disease and stroke. Most hypertensives are managed in primary care which is the leading reason for office visits. Despite the availability of a wide range of antihypertensive drugs, blood pressure is still poorly controlled. The economic constraints and the cost-effectiveness aspects should be considered in this chronic disease with life-long therapy. However, there are few audit studies concerned with the process, outcome and struc¬tures for hypertension care. The objective of this essay is to review the evidence for management of hypertension in Primary Health Care.
A systematic literature search was conducted reviewing research studies, published from 2000 until March 2012. The keywords and search terms were determined according to the study objectives, with definition of the inclusion and exclusion criteria. These terms were used in various combinations with utilization of various Boolean commands. The sources used included PubMed, Web of Science, Evidence-Based Medicine Reviews, Stat!REF, ToxNet, Up-To-Date, and MD Consult. The retrieved articles were grouped according to the main areas of focus in the present study. The collected materials were classified according to the specific objectives of the review. Critical appraisal of the articles was done to identify the level of evidence, and any methodological problems. Then, synthesis of the evidence was done for each area of the study, followed by editing.
According to the reviewed literature, the definition of hypertension is based on the potential of blood pressure to become a risk for cardiovascular events. The classification of its grades is important for the sake of management and research. The American Heart Association classification is the most widely used, with a category of prehypertension. The risk of cardiovascular disease increases progressively above 115/75 mmHg.
The measurement of blood pressure must be accurate as it is the cornerstone of appropriate diagnosis and treatment. Current guidelines recommend that family physicians take at least 2 BP readings at each patient visit and note the averaged result, both verbally to patients and in writing in patients’ charts. The sphygmomanometer remains the basic tool with the palpatory and auscultatory methods. Other new techniques include oscillometric methods, Finger Cuff Method of Penaz, Ultrasound techniques, and tonometry, in addition to the invasive methods in very special circumstances. Home monitoring may be used to improve hypertension management and avoid the white-coat effect.
There is a significant relation of hypertension with advancing age. Females in many Arab and Moslem countries show higher prevalence than males. Illiterate and highly educated, unemployed and subjects doing house duties tend to have significantly higher hypertension prevalence. The wide geographic variations, besides the different risk factors related to the individual’s genetic core, personal characteristics, socio-economic level, and lifestyle should be taken into account when primary care physicians deal with their clients in order to early detect hypertension among them.
Historically, hypertension guidelines focused on blood pressure values as the only or main variables determining the need and the type of treatment. The current approach emphasizes that diagnosis and management of hypertension should be related to quantification of total or global cardiovascular risk. Tables are developed to calculate cardiovascular risk such as the SCORE, ASSIGN, and QRISK.
The treatment of hypertension itself is based on prevention measures, non-pharmacological measures, and pharmacological treatment. The preventive actions concern habits and lifestyle monitoring as reduction in salt intake, prevention of obesity, increased exercise, stopping smoking, and limiting alcohol intake.
The pharmacological treatment involves five main classes: beta-blockers, diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors (ACEI), and angiotensin receptor blockers (ARB). The first four are on the essential drug list. Other drugs included those with Central Sympatholytic Action as methyldopa, arteriolar dilators as Hydralazine and minoxidil, and peripheral sympathetic inhibitors as reserpine. Statins should be more widely used as they can significantly improve outcomes. Apart from the weight of evidence for beneficial effects on clinical outcomes, the safety and tolerability of the drug, its cost, demographic differences in response, concomitant medical conditions, and lifestyle issues must be considered in drug selection.
Most surveys evaluating the prescribing behaviors of practicing physicians revealed that monotherapy is less preferred than polypharmacy. The initial use of low-dose combinations allows faster blood pressure reduction without substantially higher intolerance rates and is likely to be better accepted by patients. In diabetic patients, three or four drugs are usually required to reduce systolic blood pressure to <140 mmHg. The goal is blood pressure <130/80 mmHg in patients with chronic kidney disease; renal function and electrolytes should be monitored carefully after introduction of ACE inhibitors.
The selection of the first-line drug remains debatable. There is good evidence that antihypertensive therapy with diuretics and β-blockers has a major beneficial effect on a broad spectrum of cardiovascular outcomes. Most large clinical trials in unselected patients failed to show a difference between newer agents - such as ACE inhibitors, calcium channel blockers, and ARBs - and the older diuretics and β-blockers with regard to survival, myocardial infarction, and stroke. Therefore, experts recommend diuretics as the first-line treatment of most older patients with hypertension because these agents are less expensive than the newer agents. However, other views claim that β-blockers should no longer be considered ideal first-line drugs in the treatment of hypertension without compelling indications for their use.
An optimal treatment regimen divided drugs into two groups easily remembered as AB and CD. A and B refer to drugs that interrupt the renin-angiotensin system (ACE /ARB and β-blockers) and C and D refer to those that do not (calcium channel blockers and thiazide diuretics). Combinations of drugs between these groups are likely to be more potent in lowering blood pressure than combinations within a group. Drugs A/B are more effective in young, white persons, in whom renins tend to be higher, and drugs C/D are more effective in old or black persons, in whom renin levels are generally lower.
The suboptimal control of hypertension witnessed in many settings may be due to lack of provider and/or client compliance. from the side of the providers, the adherence of physicians to guidelines has been shown to be negatively related to longer experience years, which may be related to overestimation of own effectiveness, and lack of education and training. The factors underlying poor patient compliance include therapeutic adhesion, age, lifestyle, body-mass index, number of visits to the doctor during the past year and the understanding of their condition. Additionally, there is a high prevalence of lack of motivation for follow-up.
Therefore, appropriate information and reinforcement could prevent many problems in the treatment of hypertension. Interventions to improve hypertensive patient management provide an optimistic development which will enhance the management of hypertension. Such interventions include reminder systems, use of medical assistants, community-wide cardiovascular health awareness programs, and educational and organizational initiatives. Another approach is the use of a team-oriented approach to measuring BP and managing hypertensive patients. Finally, initiatives to encourage self-management of hypertension are to be encouraged.