Changing Strategies Of Treatment Of Hypertension Dr Sunita Dodani Family Medicine Department The Aga Khan University Karachi, Pakistan

Changing Strategies Changing Strategies Of Treatment Of Of Treatment Of

HypertensionHypertension

Dr Sunita DodaniDr Sunita DodaniFamily Medicine DepartmentFamily Medicine Department

The Aga Khan UniversityThe Aga Khan UniversityKarachi, PakistanKarachi, Pakistan

Objectives:Objectives:At the end of this presentation, we should be At the end of this presentation, we should be

able to:able to: Learn about recent guidelines of hypertension Learn about recent guidelines of hypertension

management.management. Define hypertension by the JNC-VI guidelines.Define hypertension by the JNC-VI guidelines. Discuss the management steps recommended by Discuss the management steps recommended by

JNC VI.JNC VI. Define the provider’s role in patient compliance.Define the provider’s role in patient compliance. Controversies of stepped care therapy.Controversies of stepped care therapy.

New Guidelines:New Guidelines: Joint National Committee (JNC) sixth report on Joint National Committee (JNC) sixth report on

prevention, detection, evaluation and treatment of high prevention, detection, evaluation and treatment of high blood pressureblood pressure (JNC-VI) - 1997.(JNC-VI) - 1997.

WHO/International Society of Hypertension (ISH), WHO/International Society of Hypertension (ISH), Guidelines of Hypertension Management for Primary Guidelines of Hypertension Management for Primary Care Physicians - 1999.Care Physicians - 1999.

British Hypertension Society Guidelines for Hypertension British Hypertension Society Guidelines for Hypertension Management - 1999.Management - 1999.

Local:Local: First report of National Task Force on First report of National Task Force on Hypertension, Pakistan Hypertension League - 1998.Hypertension, Pakistan Hypertension League - 1998.

JNC-VI GuidelinesJNC-VI Guidelines:: ((Drawn from consensus and evidence - Drawn from consensus and evidence -

based findings)based findings)

Discuss hypertension treatment in step-wise-Discuss hypertension treatment in step-wise-manner.manner.

Cover treatment strategies in special Cover treatment strategies in special population like Black Americans, pregnancy population like Black Americans, pregnancy and patients with co-morbid conditions.and patients with co-morbid conditions.

Definition:Definition:

Normal pressure into 3 categories.Normal pressure into 3 categories.

Abnormal pressure into 3 stages Abnormal pressure into 3 stages for adults > 18 and older.for adults > 18 and older.

Classification of Blood PressureClassification of Blood Pressurefor Adults Age 18 and Olders:for Adults Age 18 and Olders:

CategoryCategory Systolic Systolic DiastolicDiastolic(mm Hg)(mm Hg) (mm Hg)(mm Hg)

OptimalOptimal <120<120 andand <80<80NormalNormal <130<130 andand <85<85High-normalHigh-normal 130-139130-139 or or 85-8985-89HypertensionHypertension

Stage 1Stage 1 140-159 140-159 oror 90-9990-99Stage 2Stage 2 160-179160-179 oror 100-109100-109Stage 3Stage 3 >> 180 180 oror >> 110 110

Changing Strategies Changing Strategies Of Treatment Of Hypertension Of Treatment Of Hypertension

(Cont’d)(Cont’d)

Elevated BP (>140/90) on 2 or more visits Elevated BP (>140/90) on 2 or more visits with BP taken 2 or more times on each visit with BP taken 2 or more times on each visit and then averaged.and then averaged.

Seated in a chair with arm supported at Seated in a chair with arm supported at heart level.heart level.

Must not smoke or drink caffeine for 30 Must not smoke or drink caffeine for 30 minutes prior to measuring the BP.minutes prior to measuring the BP.

Cuff size should encircle 80% of the patient’s Cuff size should encircle 80% of the patient’s arm.arm.



BP measurements should be attempted BP measurements should be attempted only after 5 minutes of rest.only after 5 minutes of rest.

BP should be at least 2 minutes apart, BP should be at least 2 minutes apart, averaged, and then repeated if 2 averaged, and then repeated if 2 measurements differ by more than 5 measurements differ by more than 5 mmHg.mmHg.

Anxious patient may falsely give high Anxious patient may falsely give high reading (white coat hypertension).reading (white coat hypertension).

Changing Strategies Changing Strategies Of Treatment Of Of Treatment Of

Hypertension(Cont’d)Hypertension(Cont’d)

BP rises in most people as they age, BP rises in most people as they age, BP BP is not considered a normal part of aging.is not considered a normal part of aging.

Isolated systolic hypertension is Isolated systolic hypertension is considered in patients with systolic BP considered in patients with systolic BP >140 mmHg and diastolic BP <90 mmHg>140 mmHg and diastolic BP <90 mmHg

Management:Management:

Three-pronged approach:Three-pronged approach: Lifestyle modifications.Lifestyle modifications.

Appropriate medications (based on the Appropriate medications (based on the patient’s demographic and medical profile).patient’s demographic and medical profile).

Professional health care support to foster Professional health care support to foster compliance.compliance.

Life Style Modification:Life Style Modification:

Lifestyle modifications for all Lifestyle modifications for all stages of hypertension and are the stages of hypertension and are the initial recommendations for both initial recommendations for both high normal and stage 1 high normal and stage 1 hypertension.hypertension.

Life Style Modifications (Cont’d):Life Style Modifications (Cont’d):

Weight reductionWeight reduction

also also cholesterol and DM cholesterol and DM

Patients with abdominal obesityPatients with abdominal obesitywaist sizewaist size >34 cms Females>34 cms Females

>39 cms Males>39 cms Males

Hypertension riskHypertension risk

Exercise:Exercise:

Brisk walking.Brisk walking.

30-45 minutes at 40% - 60% of 30-45 minutes at 40% - 60% of maximal activity maximal activity determined by determined by pulse rate (220 - age x 0.4 & 0.6).pulse rate (220 - age x 0.4 & 0.6).

Changing Strategies Changing Strategies Of Treatment Of Hypertension (Cont’d)Of Treatment Of Hypertension (Cont’d)

DASH:DASH: Dietary approaches to stop hypertension. Dietary approaches to stop hypertension.

Like DM diet, DASH diet includes a specific number Like DM diet, DASH diet includes a specific number of servings and the weight of servings.of servings and the weight of servings.

Unlike DM Diet, DASH diet does not offer the Unlike DM Diet, DASH diet does not offer the option of food exchanges.option of food exchanges.

Plant food sourcesPlant food sourcesOnly 2 - 3 animal protein servings/dayOnly 2 - 3 animal protein servings/day



in Dietary sodium.in Dietary sodium. Esp. for African Esp. for African

AmericansAmericans ElderlyElderly DMDM

75 meq/day of dietary sodium or less (75 meq/day of dietary sodium or less ( 5 mmHg 5 mmHg systolic & 2.6 mm diastolic).systolic & 2.6 mm diastolic).

Cessation of smoking.Cessation of smoking. alcohol intake.alcohol intake.

<< 10 oz wine 10 oz wine << 2 oz whisky 2 oz whisky << 24 oz beer 24 oz beer

Initial Drug Therapy:Initial Drug Therapy:

Step-wise approach:Step-wise approach:1.1. First line -First line - Diuretic or Diuretic or -blocker.-blocker.

2.2. New agentsNew agents - Ca channel blocker, ACE - Ca channel blocker, ACE inhibitor, vasodilator etc. should be inhibitor, vasodilator etc. should be considered if patient is not responsive to considered if patient is not responsive to initial therapy or has co-morbid conditions.initial therapy or has co-morbid conditions.

3.3. Adrenergic agents should only be used as a Adrenergic agents should only be used as a last choice b/c of their side effect profile.last choice b/c of their side effect profile.

Choosing the right medication forChoosing the right medication foryour patient:your patient:

Choice of the treatment regimen Choice of the treatment regimen depends on:depends on:

Degree of BP elevation.Degree of BP elevation. Number of associated & concurrent risk Number of associated & concurrent risk

factors.factors. Presence of TOD.Presence of TOD. Clinical CVD or associated clinical Clinical CVD or associated clinical

conditions (ACC).conditions (ACC).

Risk Stratification:Risk Stratification:Risk Factors for

Cardiovascular DiseasesTarget Organ Damage

(TOD)Associated ClinicalConditions (ACC)

1. Used for riskstratification: Levels of systolic anddiastolic BP

(Stages 1-3) Men > 55 years Women > 65 years Smoking Total Cholestrol > 6.5mmol/L

Diabetes FH of premature CVD

LVH (ECG, Echo, XR)

Proteinuria & / or slightelevation of plasmacreatinine 1 . 2 – 2

mg/dl (106- 177 mmol/L)

Ultrasound orradiological evidenceof atheroscleroticplaques

(carotid, illiac & f emoral arteries, aorta)

CerebrovascularDiseaseIschemic strokeCerebral hemorhageTransient ischemic attack

Heart Disease:Myocardial InfarctionAngina PectorisCoronary revascularization

Congestive Heart failure

Risk Stratification (Cont’d):Risk Stratification (Cont’d):Risk Factors For

Cardiovascular DiseasesTarget Organ Damage

(TOD)

Associated ClinicalConditions (ACC)

2. Other factorsadversely

influencingthe prognosis

Reduced HDL Raised LDLMicroalbuminuria indiabetes

Impaired GTT Obesity Sedentary life style Raised fibrinogen High risksocioeconomic &ethnic group High risk geographicregion

Generalized or focalnarrowing of the retinalarteries ( retinopathy)

Renal Diseases: Diabetic nephropathy

Dosage & Combination TherapyDosage & Combination Therapy

Single daily dose Single daily dose interval of 4 - 6 weeks to observe the full interval of 4 - 6 weeks to observe the full response, unless it is necessary to lower BP more urgently.response, unless it is necessary to lower BP more urgently.

If drug well tolerated but response is small, If drug well tolerated but response is small, the dose or add the dose or add drugs stepwise until BP control is attained.drugs stepwise until BP control is attained.

Treatment can be stepped down later if BP falls substantially Treatment can be stepped down later if BP falls substantially below the optimal level.below the optimal level.

Most hypertensives require a combinations of Most hypertensives require a combinations of antihypertensive therapy to achieve optimal control.antihypertensive therapy to achieve optimal control.

Drugs from different classes generally have additive effect on Drugs from different classes generally have additive effect on BP.BP.

Submaximal doses of 2 drugs results in larger response of BP Submaximal doses of 2 drugs results in larger response of BP & fewer side effects& fewer side effects

eg:eg: Diuretic + B-blockerDiuretic + B-blocker

Diuretic + ACE inhibitorDiuretic + ACE inhibitor

Ca-channel blocker + ACE inhibitorCa-channel blocker + ACE inhibitor Fixed dose combination may be convenient and are Fixed dose combination may be convenient and are

acceptable when monotherapy is ineffectiveacceptable when monotherapy is ineffective

Dosage & Combination TherapyDosage & Combination Therapy (Cont’d):(Cont’d):

Dosage & Combination TherapyDosage & Combination Therapy (Cont’d)(Cont’d)

In Elderly:In Elderly:

1.1. Initial drug therapy:Initial drug therapy:

DiureticsDiuretics

Ca channel blockersCa channel blockers

Specific Medication Specific Medication Recommendations For Recommendations For

Concurrent Medical Problems:Concurrent Medical Problems:ConcurrentConditions/Charactersticks

RecommendedDrug Therapy

IntermediateDrug Therapy

Usually NotUsed orContra-indicatedMedications

Diabetes withproteinuria

ACE InhibitorsCa antagonists(both types)

ACE InhibitorsAngiotensinReceptor Blockers

Diuretics with careB Blockers

Heart Failure ACE InhibitorsDiureticsCarvadilolLosartin

B BlockersCa Antagonists

Isolated SystolicHypertension

DiureticsCa Antagonists(non-DHP centraleffects), longacting forms

ACE InhibitorsAngiotensinReceptor Blockers

B Blockers

Specific Medication Specific Medication Recommendations For Concurrent Recommendations For Concurrent

Medical Problems:Medical Problems:ConcurrentConditions/Characteristics



Usually NotContraindicated

MyocardialInfarction

B Blockers (non-ISA)ACE Inhibitors;reduce mortalityafter MI

DiureticsACE InhibitorsReceptor BlockersNon DHP,CaAntago-nists, (Diltiazem,Verapamil)

DHP CaAntagonists egnifedipine(immediaterelease can

worsen myocardialischemia)

AfricanAmerican race

DiureticsCalcium Antagonists(both types)

AngiotensinReceptor Blockers

B BlockersACE Inhibitors

AtrialTachycardia/Fibrillation

B BlockersCa Antagonists(Both Types)

DiureticsACE InhibitorsAngiotensin.Receptor Blockers

Specific Medication Specific Medication Recommendations For Recommendations For

Concurrent Medical Problems:Concurrent Medical Problems:ConcurrentConditions/Characteristics



Usually NotUsed orContraindicatedMedications

Angina B BlockersCa Antagonists(both types)

DiureticsACE InhibitorsAngiotensinReceptor Blockers

DiabetesMellitus

Low dose diuretics(carefulmonitoring)

ACE InhibitorsReceptor BlockersCa antagonists(both types)

B Blockers

Dyslipidemia AngiotensinReceptor Blockers

ACE InhibitorsCa Antagonists(both types)Diuretics with care

B Blockers


Medical ProblemsMedical Problems (Cont’d): (Cont’d):

ConcurrentConditions/Characteristics


Intermediate Drug Therapy

Usually notusedContraindicatedMedications

Essential orsenile tremors

B Blockers ACE InhibitorsReceptor BlockerCa AntagonistsDiuretics

HyperthyroidismB Blockers

Migraine B Blockers (NonISA)

CalciumAntagonist(non DHP)

DiureticsACE InhibitorsReceptor BlockerDHP CalciumAntagonists


Medical Problems (Cont’d):Medical Problems (Cont’d):ConcurrentConditions/Characteristics


IntermediateDrug

Therapy

Usually Not Used/

ContraindicatedMedications

Osteoporosis Thiazides

Pre-operativeHypertension

B Blockers

Prostatism AngiotensinReceptorBlockers

DiureticsACE Inhibitors

( can’t be givenwith severe renal

impairment)

RenalInsufficiency

AngiotensinReceptorBlockers

Ca Antagonists(both types)

B Blockers

WHO/ISH Guidelines for WHO/ISH Guidelines for Hypertension ManagementHypertension Management

Summary Points:Summary Points: Use of Grades rather than stages, otherwise values Use of Grades rather than stages, otherwise values

choosen are same as JNC-VI.choosen are same as JNC-VI. Mild, moderate and severe are not used in the WHO-Mild, moderate and severe are not used in the WHO-

ISH guidelines - they correspond to grades 1,2 & 3.ISH guidelines - they correspond to grades 1,2 & 3. Term borderline hypertension is subgroup of Grade Term borderline hypertension is subgroup of Grade

1 i.e.1 i.e. Systolic 140-149 Systolic 140-149

Diastolic 90-94Diastolic 90-94

British Hypertension Society Guidelines British Hypertension Society Guidelines for Hypertension Management:for Hypertension Management:

Summary Points:Summary Points: Grades rather than stages are used to classify Grades rather than stages are used to classify

hypertension.hypertension. Uses coronary heart disease risk accessors or risk Uses coronary heart disease risk accessors or risk

charts.charts. Isolated systolic hypertension defined as systolic Isolated systolic hypertension defined as systolic >> 160 160

and diastolic and diastolic << 90. 90. Use of aspirin (primary prevention ) in hypertension Use of aspirin (primary prevention ) in hypertension

patients.patients. Use of statins in patients with hypertension.Use of statins in patients with hypertension.

Indications for specialist referral:Indications for specialist referral:

Urgent treatment indicated:Urgent treatment indicated: Malignant Malignant hypertension, impending complications.hypertension, impending complications.

To investigate potential underlying causes of To investigate potential underlying causes of hypertension when initial evaluation suggests this hypertension when initial evaluation suggests this possibility.possibility.

To evaluate therapeutic problems or failures.To evaluate therapeutic problems or failures. Special circumstances: Unusually variable blood Special circumstances: Unusually variable blood

pressure, possible white coat hypertension, pressure, possible white coat hypertension, pregnancy.pregnancy.

New guidelines like JNC-VI, unlike previous New guidelines like JNC-VI, unlike previous guidelines, has introduced the concept of guidelines, has introduced the concept of aggressive blood pressure control at optimal aggressive blood pressure control at optimal levels.levels.

For elderly patients , the achievement of at least For elderly patients , the achievement of at least 140/90 mm Hg or below blood pressure is 140/90 mm Hg or below blood pressure is acceptable.acceptable.

Life style modification alone for those patients at Life style modification alone for those patients at relatively low overall risk for cardiovascular relatively low overall risk for cardiovascular diseases and with drugs for those at higher risk.diseases and with drugs for those at higher risk.

ConclusionConclusion::

Diuretics or B-blockers for those as first choice with uncomplicated Diuretics or B-blockers for those as first choice with uncomplicated hypertension.hypertension.

ACE inhibitors for Diabetic patients with proteinuria.ACE inhibitors for Diabetic patients with proteinuria. ACE inhibitors &/ 0r diuretics for patients with heart failure & ACE inhibitors &/ 0r diuretics for patients with heart failure &

systolic dysfunction.systolic dysfunction. Long-acting dihydropyridine Ca antagonist for systolic Long-acting dihydropyridine Ca antagonist for systolic

hypertension in the elderly.hypertension in the elderly. Follow-up during evaluation & stabilization of treatment should be Follow-up during evaluation & stabilization of treatment should be

frequent to monitor BP and other risk factors.frequent to monitor BP and other risk factors. Follow-up is important to establish good relationship with patient Follow-up is important to establish good relationship with patient

and to educate the patient.and to educate the patient.

ConclusionConclusion: : (Contd…)(Contd…)

Life style modification,Reduce wtQuit smoking,Regular exc. , Decrease

sodium and alcohol

Inadequate response

Continue lifestyle modifica-tion,Initiate pharmacotherapy

Inadequate response

Increase daily dose Substitute another drug

Add 2nd drug from diff.class

Inadequate response

Add 2nd or 3rd Drug Inadeq, response

Refer

Figure 1: Stepped Care Algorithm for Figure 1: Stepped Care Algorithm for treatment of Hypertension:treatment of Hypertension:


(Cont’d)(Cont’d) Goal:Goal:

JNC-VI uses a lower goal BP JNC-VI uses a lower goal BP (<140/90 mmHg) for (<140/90 mmHg) for hypertension in the elderly.hypertension in the elderly.


(Cont’d)(Cont’d)Diuretics:Diuretics: plasma volume.plasma volume. cause peripheral vasodilation.cause peripheral vasodilation. potentiate the effect of other anti-hypertensive drugs.potentiate the effect of other anti-hypertensive drugs. Caution:Caution: Renal disease , Gout, DM, Dyslipidemia. Renal disease , Gout, DM, Dyslipidemia. Start low dose.Start low dose.

-blockers:-blockers: 11 selective : start low dose & gradually-increase. selective : start low dose & gradually-increase. Should not be used in COPD, CHF or Should not be used in COPD, CHF or left ventricular function. left ventricular function.

ACE inhibitors:ACE inhibitors: DM with proteinuria.DM with proteinuria. CHF or myocardial infarction.CHF or myocardial infarction.

Stratifying risk and quantifying prognosis:Stratifying risk and quantifying prognosis: Blood Pressure (mm Hg)Other risk

factors and /or CVD

Stage 1SBP 140 - 159DBP 90 - 99

Stage 2SBP 160 - 179DBP 100 - 109

Stage 3SBP > 180DBP > 110

1. No other riskfactors

Low risk Medium risk High risk

2. 1 - 2 risk factors Medium risk Medium risk v. High risk

3. 3 or more riskfactors ordiabetes or TOD

High risk High risk v. High risk

4. ACC v. High risk v. High risk v.High risk

Which Drug treatment should be Which Drug treatment should be used?used?

DyslipidemiaDyslipidemia AthletesAthletes Physically Physically active patientsactive patients Peripheral Peripheral vascular. vascular. diseasedisease

AsthmaAsthma COPDCOPD Heart Heart BlocksBlocks

Heart failureHeart failure PregnancyPregnancy DiabetesDiabetes

AnginaAnginaPost MIPost MITachy-Tachy-arrythmiasarrythmias

B B BlockersBlockers

DyslipidemiasDyslipidemias Sexually Sexually active malesactive males

GoutGoutDiabetesDiabetes

Heart failureHeart failure ElderlyElderly Systolic Systolic HypertensionHypertension

DiureticsDiuretics

Possible Possible

Contra-Contra-indicationsindications

Compelling Compelling contra-contra-indicationsindications

Possible Possible IndicationsIndications

Compelling Compelling IndicationsIndications

Class of Class of DrugDrug

Which Drug treatment should be Which Drug treatment should be usedused

CongestiveCongestive

Heart Heart FailureFailure

Peripheral Peripheral Vascular Vascular DiseaseDisease

AnginaAngina Elderly Elderly Systolic Systolic HypertensionHypertension

CalciumCalciumAntagoniAntagonistssts

PregnancyPregnancy Bilateral Bilateral Renal artery Renal artery StenosisStenosis HyperkalemiaHyperkalemia Heart BlocksHeart Blocks

Heart FailureHeart Failure LV. LV. DysfunctionDysfunction After MIAfter MI Diabetic Diabetic neph-neph-

ropathyropathy

ACE ACE InhibitorInhibitorss

Possible Possible

Contra-Contra-indicationindicationss

CompellinCompelling contra-g contra-indicationindicationss

Possible Possible IndicationIndicationss

Compelling Compelling IndicationsIndications


Which Drug treatment should be Which Drug treatment should be usedused

Possible Possible

Contra-Contra-indicationsindications

CompellinCompelling contra-g contra-indicationsindications

Possible Possible indicationsindications

CompellinCompelling g IndiacatioIndiacationsns


PregnancyPregnancy Bilateral Bilateral Renal artery Renal artery StenosisStenosis HyperkalemiaHyperkalemia Heart BlocksHeart Blocks

Heart FailureHeart Failure Side Effects Side Effects with other with other drugs e.g. drugs e.g. ACE inhibitors ACE inhibitors (cough)(cough)

AngiotensiAngiotensin IIn II

AntagonistAntagonistss

OrthostaticOrthostatic

hypotensionhypotension

Glucose Glucose IntoleranceIntoleranceDyslipidemiasDyslipidemias

ProstrateProstrate

HypertrophyHypertrophyAlpha Alpha BlockersBlockers

References:References: BMJ 1999 Sep 4; 319:630- 635 - BMJ 1999 Sep 4; 319:630- 635 - British Hypertension Society British Hypertension Society

guidelines for Hypertension management 1999guidelines for Hypertension management 1999; Summary NEW: 9 - ; Summary NEW: 9 - 1313Editorial - British guidelines on managing hypertensionEditorial - British guidelines on managing hypertension

World Health Organization- International Society of Hypertension - World Health Organization- International Society of Hypertension - 1999 WHO-ISH Guidelines for the management of Hypertension - 1999 WHO-ISH Guidelines for the management of Hypertension - Journal of Hypertension (see on line articles, Volume 17, Issue 2, Journal of Hypertension (see on line articles, Volume 17, Issue 2, pages 151 - 183, February 1999).pages 151 - 183, February 1999).

The Sixth Report of the Joint National Committee on the Prevention, The Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure JNC-Detection, Evaluation and Treatment of High Blood Pressure JNC-V1- PDF format from the National Heart, Lung and Blood Institute V1- PDF format from the National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH) NEW updated URL 2-11(NHLBI), National Institutes of Health (NIH) NEW updated URL 2-11

References (Cont’d):References (Cont’d):NHLBL JNC IV References Sheet.NHLBL JNC IV References Sheet.National Guideline Clearing House - Brief Summary NEW: 2 - 11.National Guideline Clearing House - Brief Summary NEW: 2 - 11.Archives of Internal Medicine 1997 Nov 24 BAD LINK -NEW URL -Archives of Internal Medicine 1997 Nov 24 BAD LINK -NEW URL -

waiting for 1997 back issues to be placed on-line ? waiting for 1997 back issues to be placed on-line ? JNC V1: timing is everything Commentary - The Lancet 15 Nov 97.JNC V1: timing is everything Commentary - The Lancet 15 Nov 97. JNC - 6 Guidelines Editorial - American Journal of Kidney JNC - 6 Guidelines Editorial - American Journal of Kidney

Diseases May 1998Diseases May 1998JNC Redux Editorial - American Journal of Kidney Diseases May JNC Redux Editorial - American Journal of Kidney Diseases May

19981998Treatment of hypertension; insights from the JNC V1 report. Am Treatment of hypertension; insights from the JNC V1 report. Am

Fam Physician 1998 Oct 15; 58 (6; 1323 - 30 - PubMed abstract)Fam Physician 1998 Oct 15; 58 (6; 1323 - 30 - PubMed abstract)

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Changing Strategies Of Treatment Of Hypertension Dr Sunita Dodani Family Medicine Department The Aga Khan University Karachi, Pakistan