Kijabe OPD Guidelines

Hypertension
Key Facts:
• Hypertension is de-ined as a BP in clinic persistently elevated above 140/90

Diagnosis High Risk Patients

• Patients need at least 3 blood pressures on 3
separate occasions >140/90 to diagnose
hypertension.
• Consider home monitoring if patient has
appropriate resources
• Patient with the following conditions are at
higher risk of complications.
o Diabetes; Coronary Artery Disease;
Cerebrovascular Disease; Peripheral
vascular disease Chronic Kidney
disease or Cardiovascular risk >20%

Investigations:
• Clinical examination to look for signs of end organ damage and secondary causes of
hypertension (i.e. renal disease, or endocrine disorders). To be done at each review.
• Creatinine and urine dip – excluding renal causes/complications. To be done annually
• HBA1c – exclude diabetes. To be done annually
Management
• Assess if patient needs consultant review – see below.
• Offer all patients lifestyle advice – diet, salt reduction, exercise and ideal weight.
• Target BP for most patients is <140/90.
• If elderly patients (>75 yrs) the bene-it of BP control needs to be balanced with drug side
effects and risk. Consider higher target of 150/90
• Review patients after 2-4 weeks to check on: Drug tolerance; BP; Creatinine if started or
changed dose of ACEi and Electrolytes if on diuretic.
• Once BP is in target range review every 6 months.

Extras
Patient Diagnosed
Hypertensive * Target BP for most patients is <140/90
* Target for CKD patients is lower as per
CKD guideline
* For most patients dual therapy at lower
BP>140/90 BP >160/100 drug doses will be more effective and better
tolerated than maximising monotherapy.
* Use fixed dose combination drugs if
availble and affordable.
* There is rarely clinical benefit of increasing
Lifetsyle Advice for 3 months
HCTZ beyond 12.5mg.
Commence Calcium Channel
(If Risk Factors consider missing
Blocker AND HCTZ 12.5mg
this step) The following patients should deviate from
the pathway. Discuss with consultant if doubt.
NOT CONTROLLED? NOT CONTROLLED? 1. Chronic Kindey DIsease - ACEi/ARB is
first line drug (as monotherapy or as part of
Start HCTZ 12.5mg OD Add in ACEi or ARB combination therapy)
(Consider CCB if funds allow)
2. Diabetes - ACEi/ARB is first line drug (as
NOT CONTROLLED? NOT CONTROLLED? monotherapy or as part of combination
therapy)
Add CCB 3. Heart Failure - CCBs should generally be
Consultant Review
(HCTZ if CCB preiously used)
avoided. Start with HCTZ and/or ACEi/ARB
NOT CONTROLLED? 4. HIV - Some older ARVs can interact with
CCB's. Check for drug interactions prior to
Add in ACEi or ARB NOT CONTROLED? starting.
Drug Starting Dose Usual Dose Maximum Dose
HCTZ 12.5mg OD 12.5mg OD 25mg OD
CCB - Amlodipine 5mg OD 5-10mg OD 10mg OD
CCB - Nifedipine 20mg BD 20mg BD 40mg BD
ACEi - Enalapril 5mg OD 5-20mg daily (in 1-2 20mg daily
divided doses)
ARB - Losartan 50mg OD 50-100mg OD 100mg OD

Consultant review if any of the following: Hypertensive Emergency.

• Age <30 • Blood pressure >180/110 with
• Unable to control BP on 3 agents concerns regarding end organ damage.
• Pregnancy o Renal
• Concerns regarding hypertensive o Cardiac
emergency o Neurological
o Visual

References:
• WHO Guidelines: https://apps.who.int/iris/bitstream/handle/
10665/344424/9789240033986-eng.pdf
• Kenya MOH Guidelines 2017 - https://www.health.go.ke/wp-content/uploads/2018/06/
Cardiovascular-guidelines-2018_A4_Final.pdf