Diagnosis and Management of Hypertension
PHL-PCS Guidelines are more focused, evidenced based,
contain local and regional data - Dr. Maqbool Jafary
Beta Blockers are very helpful in Heart Failure while ACEIs and ARBs are much more effective with least side effects - Prof. Azhar MA Farooqui

KARACHI: Pakistan Cardiac Society and Pakistan Hypertension League organized a joint meeting to promote the PHL-PCS guidelines on Diagnosis and Management of Hypertension at Karachi recently. The session was chaired by Prof. Azhar M. A.Farooqui while the expert’s panel consisted of Dr. Fatema Jawad consultant diabetologist, Prof. Shaukat Ali Prof.of Neurology at JPMC, Dr. Tariq Aziz consultant ophthalmologist, Prof Waris Qidwai Prof of Family Medicine at AKU, Dr. Imran Ahmad Consultant Cardiologist from ZMU. Dr. Maqbool H. Jafary Chairperson of the committee which had prepared these guidelines and Dr. Aamir Hameed were the guest speakers. Dr. A. Rashid Khan consultant cardiologist at ASH and Secretary of PCS Karachi Chapter was the moderator of the session.
Speaking at the occasion Dr. Maqbool H. Jafary said that in this computer age, there is lot of information and it is not possible for healthcare professionals to look at all this. There is large data available on the net and all this may not be authentic and trustworthy. There are guidelines by JNC, WHO-ISH, ESC-ESH, NICE-BSH and our own national guidelines. All this may not be in agreement with each other. The busy practitioners are confused. That is why the Pakistan Cardiac Society and Pakistan Hypertension League felt the need to have National Guidelines and I was entrusted this responsibility. These guidelines are more focused, evidenced based, carry a consensus of opinion and have flexibility of updating them periodically.

Pakistan Cardiac Society and Pakistan Hypertension League organized a meeting to promote the National Guidelines jointly prepared by PCS and PHL at Karachi recently. Picture taken on the occasion shows sitting on the dais from (L to R) Prof. Waris Qidwai,  Prof. Tariq Aziz, Dr. Aamir Hameed, Dr. Maqbool H. Jafary, Prof.Azhar MA Farooqui, Prof.Shaukat Ali, Dr.Fatema Jawad and Dr. Imran Ahmad.

These guidelines Dr. Maqbool Jafary further stated offer concise approach to diagnosis and management thus it is time saving and can serve as a quick reference guide. While formulating these guidelines we had kept in mind the local culture and habits as well. This has lot of regional and local country specific data. These are the efforts of collaborative group with multidisciplinary representation including local data on hypertension. It also includes indigenous data on non-pharmacological approached. However, nothing is perfect and there may be some deficiencies which can be rectified, Dr. Jafary remarked. He thanked Pfizer for publishing the guidelines and sponsoring the meeting.
Dr. Aamir Hameed who had prepared the first draft of these guidelines in his presentation on applying knowledge to patients said that hypertension has become an infectious disease in SAARC countries which is an important risk factor for coronary artery disease. An AKU study had showed that 57% of the studied population had metabolic syndrome. Over 60% of the patients will need two antihypertensive drugs and 30% will require more than three drugs. About 15-20% patients have glucose intolerance hence in them thiazide diuretics and beta blocker combination is not considered good in view of new onset diabetes mellitus. A Meta analysis of twelve studies has shown that there is 22% increased risk of new onset diabetes with beta blockers.
Speaking about first line of therapy in non-pharmacological treatment, he mentioned diet, salt restriction, regular exercise and weight loss. Second line therapy consists of nutrients like Vitamin C and fish oil as well as garlic. In drug therapy, one must choose the drugs which reduce blood pressure, are safe and well tolerated. Therapy must be tailor made for individual patients. ARBs do not have a bad side effects profile and they are also best tolerated. In Pakistan most patients can afford diuretics and beta blockers combination. If after life style modifications the BP is not controlled start the patient on two antihypertensive drugs in case the BP is 20 mmHg above the target level. In case the BP still persists at 140/90 with the use of even four drugs, then expert advice is required. Usually in fifty five years plus patients use CCBs plus thiazide diuretics. There is diabesity epidemic (metabolic syndrome) if the patient loses weight it will also reduce the requirements of antihypertensive drugs. It is better to achieve better control at community level.
Prof. Waris Qidwai said that life style modifications play an important role. Family Physicians must keep themselves update and practice appropriate referral of complicated patients. Smoking cessation is also very important. Dr. Imran Ahmad felt that life style modifications should be prescribed to the patients to ensure that it is practiced. Responding to a question from Dr. Tariq Aziz regarding new onset of diabetes mellitus with beta blockers, Dr. Fatema Jawad said that we use ARBs and ACE Inhibitors in patients with diabetic retinopathy since they are also renoprotective or we use selective beta blockers. There is lot of Vitamin D deficiency and patients must be educated to use healthy balanced diet. Prof. Shaukat Ali remarked that beta blockers are not protective as regards stroke. Prof. Azhar Farooqui felt it was surprising to note that in a country with so much sunshine, we have so many patients with Vitamin D deficiency. Prof. Tariq Aziz said that if the physicians look at the arteries and vessels in eye during fundoscopy examination, one can see the early indications of stroke and other problems. Dr. Imran Ahmad said that hypertension is not a stand alone disease. There is lot of data on beta blockers regarding their efficacy in heart failure. Reports regarding decrease in libido are more psychological rather than drug related. Even otherwise it is the diuretics which are more to blame than the beta blockers as regards erectile dysfunction. Beta blockers are certainly not out of fashion.
Summing up the discussion Prof. Azhar M.A. Farooqui said that it is important to reduce blood pressure. Beta blockers have remained under clouds for sometime but they are very useful in IHD and they are very good in heart failure as well. At the same time we now have much more effective drugs like ACE Inhibitors and ARBs as regards protection against stroke. The Family Physicians were advised to use these guidelines. To promote them small group discussion, workshops for Family Physicians, seminars etc., would be organized from time to time in different parts of the country. The speakers also thanked M/s Pfizer for their valuable contribution in publication of these guidelines.