Brief summary of NICE recommendations
Lifestyle interventions to reduce blood pressure
•Ask patients about their diet and exercise patterns, and offer guidance and written or audiovisual information.
•Ask about alcohol consumption and encourage patients to cut down if they drink excessively.
•Discourage excessive consumption of coffee and other caffeine-rich products.
•Encourage patients to reduce their salt intake or use a substitute.
•Offer smokers advice and help to stop smoking.
•Tell patients about local initiatives (for example, run by healthcare teams or patient organisations) that provide support and promote lifestyle change.
Assess risk factors
•Urine test for protein (using test strip)
•Plasma glucose, electrolytes, creatinine, serum total cholesterol and HDL cholesterol.
•Offer drug therapy to patients with:
o persistent high blood pressure of 160/100 mmHg or more
o persistent blood pressure above 140/90 mmHg and raised cardiovascular risk (1 0-year risk of cardiovascular disease of at least 20%, existing cardiovascular disease or target organ damage).
•See flow chart below for choice of drugs.
•Aim to reduce blood pressure to 140/90 mmHg or less, adding more drugs as needed, until further treatment is inappropriate or declined.
•A = ACE inhibitor
(consider angiotensin-II receptor antagonist if ACE intolerant)
•C = calcium-channel blocker
•D = thiazide-type diuretic
This NICE guideline provides recommendations for the primary care management of raised blood pressure (BP).
Hypertension is a major but modifiable contributory factor in cardiovascular diseases (CVD) such as stroke and coronary heart disease (CHD). The objective of this guideline is to decrease cardiovascular morbidity and mortality resulting from these diseases. It is important to assess risk in people before CVD develops and monitoring for persistently raised BP is one aspect of CV risk assessment.
This guideline makes recommendations on primary care management of hypertension. It includes recommendations on approaches to identifying patients with persistently raised BP, and managing hypertension (including lifestyle advice and use of BP-lowering drugs).
This guideline does not address screening for hypertension, management of hypertension in pregnancy or the specialist management of secondary hypertension (where renal or pulmonary disease, endocrine complications or other disease underlie raised blood pressure). Patients with existing coronary heart disease or diabetes should be managed in line with current national guidance for these conditions.
Why a NICE guideline on hypertension?
This NICE guideline on the management of hypertension is based on the best available evidence. A multidisciplinary Guideline Development Group carefully considered evidence of both the clinical effectiveness and cost effectiveness of treatment and care in developing these recommendations. The draft guideline was then modified in the light of two rounds of extensive consultation with the relevant stakeholder groups, including NHS organisations, healthcare professionals, patient/carer groups and manufacturers.
This guideline offers best practice advice on the care of adults with hypertension.
Treatment and care should take into account patients’ individual needs and preferences. People with hypertension should have the opportunity to make informed decisions about their care and treatment. Where patients do not have the capacity to make decisions, healthcare professionals should follow the Department of Health guidelines – ‘Reference guide to consent for examination or treatment’ (2001) (available from www.dh.gov.uk).
Good communication between healthcare professionals and patients is essential. It should be supported by the provision of evidence-based information offered in a form that is tailored to the needs of the individual patient. The treatment, care and information provided should be culturally appropriate and in a form that is accessible to people who have additional needs, such as people with physical, cognitive or sensory disabilities, and people who do not speak or read English.
Unless specifically excluded by the patient, carers and relatives should have the opportunity to be involved in decisions about the patient’s care and treatment.
Carers and relatives should also be provided with the information and support they need.
Key priorities for implementation
The following recommendations have been identified as priorities for implementation.
Measuring blood pressure
•To identify hypertension (persistent raised blood pressure above 140/90 mmHg), ask the patient to return for at least two subsequent clinics where blood pressure is assessed from two readings under the best conditions available.
•Routine use of automated ambulatory blood pressure monitoring or home monitoring devices in primary care is not currently recommended because their value has not been adequately established; appropriate use in primary care remains an issue for further research.
•Lifestyle advice should be offered initially and then periodically to patients undergoing assessment or treatment for hypertension.
•If raised blood pressure persists and the patient does not have established cardiovascular disease, discuss with them the need to formally assess their cardiovascular risk. Tests may help identify diabetes, evidence of hypertensive damage to the heart and kidneys, and secondary causes of hypertension such as kidney disease.
•Consider the need for specialist investigation of patients with signs and symptoms suggesting a secondary cause of hypertension. Accelerated (malignant) hypertension and suspected phaeochromocytoma require immediate referral.
•Drug therapy reduces the risk of cardiovascular disease and death. Offer drug therapy to:
patients with persistent high blood pressure of 160/100 mmHg or more
patients at raised cardiovascular risk (10 year risk of CVD of 20% or more, or existing CVD or target organ damage) with persistent blood pressure of more than 140/90 mmHg.
•In hypertensive patients aged 55 or older or black patients of any age, the first choice for initial therapy should be either a calcium-channel blocker or a thiazide-type diuretic. For this recommendation, black patients are considered to be those of African or Caribbean descent, not mixed-race, Asian or Chinese.
•In hypertensive patients younger than 55, the first choice for initial therapy should be an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated).
•Provide an annual review of care to monitor blood pressure, provide patients with support and discuss their lifestyle, symptoms and medication.
•Patients may become motivated to make lifestyle changes and want to stop using antihypertensive drugs. If at low cardiovascular risk and with well controlled blood pressure, these patients should be offered a trial reduction or withdrawal of therapy with appropriate lifestyle guidance and ongoing review.
The following guidance is evidence based. The evidence supporting each recommendation is provided in the full guideline (see Section 5). Recommendations are classified according to the type of evidence they are based on (see appendix A).
1.1 Measuring blood pressure
1.1.1 Healthcare professionals taking blood pressure measurements need adequate initial training and periodic review of their performance. D
1.1.2 Healthcare providers must ensure that devices for measuring blood pressure are properly validated, maintained and regularly recalibrated according to manufacturers’ instructions. D
1.1.3 Where possible, standardise the environment when measuring blood pressure: provide a relaxed, temperate setting, with the patient quiet and seated and with their arm outstretched and supported*. D
* The principles of good technique for measuring blood pressure are presented in box
1.1.4 If the first measurement exceeds 140/90 mmHg*, if practical, take a second confirmatory reading at the end of the consultation. D
* Blood pressure is recorded as systolic/diastolic blood pressure measured in millimetres of mercury (mmHg). Raised blood pressure is noted when either systolic pressure exceeds 140 mmHg or diastolic blood pressure exceeds 90 mmHg.
1.1.5 Measure blood pressure on both of the patient’s arms with the higher value identifying the reference arm for future measurement. D
1.1.6 In patients with symptoms of postural hypotension (falls or postural dizziness) measure blood pressure while patient is standing. In patients with symptoms or documented postural hypotension (fall in systolic BP when standing of 20 mmHg or more) consider referral to a specialist. D
1.1.7 Refer immediately patients with accelerated (malignant) hypertension (BP more than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage) or suspected phaeochromocytoma (possible signs include labile or postural hypotension, headache, palpitations, pallor and diaphoresis). D
1.1.8 To identify hypertension (persistent raised blood pressure, above 140/90 mmHg), ask the patient to return for at least two subsequent clinics where blood pressure is assessed from two readings under the best conditions available. D
1.1.9 Measurements should normally be made at monthly intervals. However, patients with more severe hypertension should be re evaluated more urgently. D
1.1.10 Routine use of automated ambulatory blood pressure monitoring or home monitoring devices in primary care is not currently recommended because their value has not been adequately established; appropriate use in primary care remains an issue for further research. C
•Readings from clinic and ambulatory blood pressure devices, when used side-by-side, may differ from one another and from true arterial pressure because they use different methods and assumptions.
•Average ambulatory readings from a series of patients, taken over 24 hours, are commonly lower than clinic readings by between 10/5 and 20/10 mmHg. However, an individual patient may have ambulatory readings higher or lower than clinic readings. Studies comparing clinic and ambulatory measurement vary in their design, setting, conduct of measurement and analysis: estimated differences between ambulatory and clinic values vary with these factors.
•Clinic and ambulatory readings may also differ because of a ‘white coat’ effect − that is, a response to the setting or clinician.
•Epidemiological studies are inconsistent in demonstrating the additional prognostic value of ambulatory blood pressure monitoring to predict cardiovascular disease in unselected patients.
1.1.11 Consider the need for specialist investigation of patients with unusual signs and symptoms, or of those whose management depends critically on the accurate estimation of their blood pressure. D
BOX 1 Estimation of blood pressure by auscultation
1.2 Lifestyle interventions
1.2.1 Ascertain patients’ diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes. B
•Education about lifestyle on its own is unlikely to be effective.
•Healthy, low-calorie diets had a modest effect on blood pressure in overweight individuals with raised blood pressure, reducing systolic and diastolic blood pressure on average by about 5−6 mmHg in trials. However, there is variation in the reduction in blood pressure achieved in trials and it is unclear why. About 40% of patients were estimated to achieve a reduction in systolic blood pressure of 10 mmHg systolic or more in the short term, up to 1 year.
•Taking aerobic exercise (brisk walking, jogging or cycling) for 30–60 minutes, three to five times each week, had a small effect on blood pressure, reducing systolic and diastolic blood pressure on average by about 2–3 mmHg in trials. However, there is variation in the reduction in blood pressure achieved in trials and it is unclear why. About 30% of patients were estimated to achieve a reduction in systolic blood pressure of 10 mmHg or more in the short term, up to 1 year.
•Interventions actively combining exercise and diet were shown to reduce both systolic and diastolic blood pressure by about 4–5 mmHg in trials. About one-quarter of patients receiving multiple lifestyle interventions were estimated to achieve a reduction in systolic blood pressure of 10 mmHg systolic or more in the short term, up to 1 year.
•A healthier lifestyle, by lowering blood pressure and cardiovascular risk, may reduce, delay or remove the need for long-term drug therapy in some patients.
1.2.2 Relaxation therapies* can reduce blood pressure and individual patients may wish to pursue these as part of their treatment. However, routine provision by primary care teams is not currently recommended. B
* Examples include: stress management, meditation, cognitive therapies, muscle relaxation and biofeedback.
•Overall, structured interventions to reduce stress and promote relaxation had a modest effect on blood pressure, reducing systolic and diastolic blood pressure on average by about 3–4 mmHg in trials. There is variation in the reduction in blood pressure achieved in trials and it is unclear why. About one-third of patients receiving relaxation therapies were estimated to achieve a reduction in systolic blood pressure of 10 mmHg systolic or more in the short term, up to 1 year.
•The current cost and feasibility of providing these interventions in primary care has not been assessed and they are unlikely to be routinely provided.
1.2.3 Ascertain patients’ alcohol consumption and encourage a reduced intake if patients drink excessively, because this can reduce blood pressure and has broader health benefits. B
•Excessive alcohol consumption (men: more than 21 units/week; women: more than 14 units/week) is associated with raised blood pressure and poorer cardiovascular and hepatic health.
•Structured interventions to reduce alcohol consumption, or substitute low alcohol alternatives, had a modest effect on blood pressure, reducing systolic and diastolic blood pressure on average by about 3–4 mmHg in trials. Thirty percent of patients were estimated to achieve a reduction in systolic blood pressure of 10 mmHg systolic or more in the short term, up to 1 year.
•Brief interventions by clinicians of 10–15 minutes, assessing intake and providing information and advice as appropriate, have been reported to reduce alcohol consumption by one-quarter in excessive drinkers with or without raised blood pressure, and to be as effective as more specialist interventions.
•Brief interventions have been estimated to cost between £40 and £60 per patient receiving intervention. The structured interventions used in trials of patients with hypertension have not been costed.
1.2.4 Discourage excessive consumption of coffee and other caffeine-rich products. C
•Excessive consumption of coffee (five or more cups per day) is associated with a small increase in blood pressure (2/1 mmHg) in participants with or without raised blood pressure in studies of several months duration.
1.2.5 Encourage patients to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. B
•Advice to reduce dietary salt intake to less than 6.0 g/day (equivalent to 2.4 g/day dietary sodium) was shown to achieve a modest reduction in systolic and diastolic blood pressure of 2–3 mmHg in patients with hypertension, at up to 1 year in trials. About one-quarter of patients were estimated to achieve a reduction in systolic blood pressure of 10 mmHg systolic or more in the short term, up to 1 year.
•Long-term evidence over 2–3 years from studies of normotensive patients shows that reductions in blood pressure tend to diminish over time.
•One trial suggests that reduced sodium salt, when used as a replacement in both cooking and seasoning, is as effective in reducing blood pressure as restricting the use of table salt.
1.2.6 Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. B
•The best current evidence does not show that calcium, magnesium or potassium supplements produce sustained reductions in blood pressure.
•The best current evidence does not show that combinations of potassium, magnesium and calcium supplements reduce blood pressure.
1.2.7 Offer advice and help to smokers to stop smoking. A
•There is no strong direct link between smoking and blood pressure. However, there is overwhelming evidence of the relationship between smoking and cardiovascular and pulmonary diseases, and evidence that smoking cessation strategies are cost effective.
•See: Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation, NICE technology appraisal no. 39, March 2002. www.nice.org.uk/TA039
1.2.8 A common aspect of studies for motivating lifestyle change is the use of group working. Inform patients about local initiatives by, for example, healthcare teams or patient organisations that provide support and promote healthy lifestyle change. D
1.3 Estimating cardiovascular risk
1.3.1 If raised blood pressure persists and the patient does not have established cardiovascular disease, discuss with them the need to formally assess their cardiovascular risk. Tests may help identify diabetes, evidence of hypertensive damage to the heart and kidneys, and secondary causes of hypertension such as kidney disease. D
1.3.2 Test for the presence of protein in the patient’s urine. Take a blood sample to assess plasma glucose, electrolytes, creatinine, serum total cholesterol and HDL cholesterol. Arrange for a 12-lead electrocardiograph to be performed. D
1.3.3 Consider the need for specialist investigation of patients with signs and symptoms suggesting a secondary cause of hypertension. Accelerated (malignant) hypertension and suspected phaeochromocytoma require immediate referral. D
•An identifiable cause of hypertension is more likely when hypertension occurs in younger patients (less than 30 years of age), worsens suddenly, presents as accelerated (malignant) hypertension (BP more than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage) or responds poorly to treatment.
•An elevated creatinine level may indicate renal disease. Labile or postural hypotension, headache, palpitations, pallor and diaphoresis are potential signs of phaeochromocytoma. Hypokalaemia, abdominal or flank bruits, or a significant rise in serum creatinine when starting an ACE-inhibitor may indicate renovascular hypertension. Isolated hypokalaemia may be due to hyperaldosteronism. Potential signs of Cushing syndrome include osteoporosis, truncal obesity, moon face, purple striae, muscle weakness, easy bruising, hirsutism, hyperglycaemia, hypokalaemia and hyperlipidaemia.
1.3.4 Use the cardiovascular risk assessment to discuss prognosis and healthcare options with patients, both for raised blood pressure and other modifiable risk factors. D
•Risk models provide a useful prognostic tool for clinicians and patients in primary care. They reinforce the need to offer treatment to patients based on their profile of cardiovascular risk rather than focusing on blood pressure in isolation.
•Most risk models derive from the Framingham Heart Study: a cohort of over 5000 men and women aged 30–62 years from Framingham, Massachusetts followed up from 1971 to assess the determinants of cardiovascular disease.
•Limitations of commonly used risk models include poor validation in UK ethnic minorities and younger populations.
•Framingham risk calculator computer programmes currently provide the best assessment of risk of coronary heart disease and stroke over 10 years. The latest version developed by the Joint British Societies* gives the risk of a cardiovascular event over 10 years (a combined score including the risk of coronary heart disease and stroke).
•Risk charts may be relatively imprecise, placing patients in bands of risks, although the visual presentation may be helpful to some patients. Evidence suggests the Joint British Societies chart adheres most closely to Framingham risk calculators.
•When only the CHD risk score is known, CVD risk score can be approximated by multiplying by 4/3. When CHD and stroke risk are reported, the CVD risk can be approximated by adding these two scores together.
* Joint British Societies Cardiovascular Risk Charts are available from the British National Formulary.
1.4 Pharmacological interventions
For this updated guideline issued by NICE and the British Hypertension Society (www.bhsoc.org), new studies published since July 2004 were appraised and the data considered together with those from the earlier studies, using meta-analysis where appropriate. The Guideline Development Group (GDG) considered this evidence in the context of other available evidence. Adverse events data and issues of patient concordance were particularly noted, and the GDG also had access to a detailed health economic analysis comparing the cost-effectiveness of the main drug classes. Consideration was also given to the pathogenesis of hypertension and the mechanism of action of the different classes of drugs used to lower blood pressure, taking age and ethnicity into account. Finally, where the evidence did not prove definitive, the GDG took into account existing guidelines and constructed recommendations most compatible with current good practice.
In formulating its recommendations, the GDG has assumed a ’drug class effect’ unless there was clear evidence to the contrary. However, clinical-outcome trials involving thiazide-type diuretics have used a variety of different drugs at different doses. Moreover, the GDG felt that the benefits from ACE inhibitors and angiotensin-II receptor antagonists were closely correlated and that they should be treated as equal in terms of efficacy (although, because of cost differences, ACE inhibitors should be initiated first).
One class of drugs that caused particular debate was the beta-blockers. In head-to-head trials, beta-blockers were usually less effective than a comparator drug at reducing major cardiovascular events, in particular stroke. Atenolol was the beta-blocker used in most of these studies and, in the absence of substantial data on other agents, it is unclear whether this conclusion applies to all beta-blockers.
The evidence showed calcium-channel blockers or thiazide-type diuretics to be the drugs most likely to confer benefit as first-line treatment for most patients. The health economic model slightly favoured calcium-channel blockers, with thiazide-type diuretics as the next most cost-effective option. On balance, the GDG decided that calcium-channel blockers and thiazide-type diuretics should be offered as equal alternatives for clinicians and patients to consider as initial treatment. Consideration should be given to the patient’s risk of adverse effects and preferences.
This conclusion is less certain for younger patients (defined pragmatically as those younger than 55, who were often not included in the clinical trials reviewed). In the absence of clinical outcomes data in younger patients, the GDG considered that for pragmatic reasons it was essential to make a recommendation, and considered blood pressure lowering as the most suitable surrogate for clinical outcomes. What data there are suggest that initial therapy with a beta-blocker or an ACE inhibitor may provide superior initial blood pressure lowering compared with a calcium-channel blocker or a thiazide-type diuretic. The studies suggesting beta-blockers are generally an inferior choice have already been covered. Consequently, for patients younger than 55, an ACE inhibitor (or an angiotensin-II receptor antagonist if an ACE-inhibitor is not tolerated) is a better choice as initial therapy.
Many patients will require more than one drug to achieve adequate blood pressure control. An algorithm is provided on page 45. Pathophysiological reasoning suggests that adding an ACE inhibitor to a calcium-channel blocker or a diuretic (or vice versa in the younger group – that is, adding either a calcium-channel blocker or a diuretic to an ACE inhibitor) are logical combinations. In addition, these combinations have been commonly used at step 2 in clinical trials. Beyond this point there is even less evidence to guide practice, but the GDG concluded that the most straightforward choice is to recommend combining the three drug classes that have been used at steps 1 and 2 in treatment – that is, offering a three-drug combination of an ACE inhibitor (or angiotensin-II receptor antagonist) plus a calcium-channel blocker plus a thiazide-type diuretic.
The GDG was also concerned by the higher risk of patients developing diabetes, particularly when treated with the combination of a beta-blocker and a thiazide-type diuretic. Omitting beta-blockers from the routine treatment algorithm was therefore justified. Nevertheless, the GDG noted that there are certain compelling indications for beta-blockers and these have been specified.
Recommendations beyond a three-drug combination are based on consensus rather than hard evidence, but it was felt that practitioners would appreciate some guidance. The GDG also felt that if three drugs in combination were failing to provide adequate blood pressure control, a practitioner might consider seeking expert advice.
The recommendations below should be read in conjunction with the algorithms on pages 44 and 45.
1.4.1 Drug therapy reduces the risk of cardiovascular disease and death. Offer drug therapy to: A
•patients with persistent high blood pressure of 160/100 mmHg or more
•patients at raised cardiovascular risk (10 year risk of CVD of 20% or more, or existing cardiovascular disease or target organ damage) with persistent blood pressure of more than 140/90 mmHg.
•In placebo-controlled trials, blood pressure management beginning with a low-dose thiazide-type diuretic or beta-blocker has been shown to reduce mortality, myocardial infarction and stroke (relative risk reductions of 8%, 15% and 25%, respectively).
1.4.2 Provide appropriate guidance and materials about the benefits of drugs and the unwanted side effects sometimes experienced in order to help patients make informed choices. D
1.4.3 Offer drug therapy, adding different drugs if necessary, to achieve a target of 140/90 mmHg, or until further treatment is inappropriate or declined. Titrate drug doses as described in the ‘British national formulary’ noting any cautions and contraindications. A
•In trials aiming to reduce blood pressure to below 140/90 mmHg using stepped medication regimens, between one-half and three-quarters of patients achieved target blood pressure.
•In these trials about one-half of patients needed treatment with more than one drug.
1.4.4 New In hypertensive patients aged 55 or older or black patients of any age, the first choice for initial therapy should either be a calcium-channel blocker or a thiazide-type diuretic. For this recommendation, black patients are considered to be those of African or Caribbean descent, not mixed-race, Asian or Chinese. A*
1.4.5 New In hypertensive patients younger than 55, the first choice for initial therapy should be an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated). C*
1.4.6 New If initial therapy was with a calcium-channel blocker or a thiazide-type diuretic and a second drug is required, add an ACE inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated). If therapy was initiated with an ACE inhibitor (or angiotensin-II receptor antagonist), add a calcium-channel blocker or a thiazide-type diuretic. B*
1.4.7 New If treatment with three drugs is required, the combination of ACE inhibitor (or angiotensin-II receptor antagonist), calcium-channel blocker and thiazide-type diuretic should be used. B*
1.4.8 New If blood pressure remains uncontrolled on adequate doses
of three drugs, consider adding a fourth and/or seeking expert advice. C*
1.4.9 New If a fourth drug is required, one of the following should be considered: C*
•a higher dose of a thiazide-type diuretic or the addition of another diuretic (careful monitoring is recommended) or
1.4.10 New If blood pressure remains uncontrolled on adequate doses of four drugs, and expert advice has not yet been obtained, this should now be sought. C*
1.4.11 New Beta-blockers are not a preferred initial therapy for hypertension. However, beta-blockers may be considered in younger people, particularly: B*
•those with an intolerance or contraindication to ACE inhibitors and angiotensin-II receptor antagonists or
•women of child-bearing potential or
•people with evidence of increased sympathetic drive.
In these circumstances, if therapy is initiated with a beta-blocker and a second drug is required, add a calcium-channel blocker rather than a thiazide-type diuretic to reduce the patient’s risk of developing diabetes. C*
1.4.12 New In patients whose blood pressure is not controlled (that is, above 140/90 mmHg) despite a treatment regimen that includes a beta-blocker, treatment should be revised according to the treatment algorithm on page 45 (see also 1.4.14). C*
1.4.13 New In patients whose blood pressure is well controlled (that is, 140/90 mmHg or below) with a regimen that includes a beta-blocker, long-term management should be considered as part of their routine review. In these patients there is no absolute need to replace the beta-blocker with an alternative agent. C*
1.4.14 New When a beta-blocker is withdrawn, the dose should be stepped down gradually. Beta-blockers should not be withdrawn in patients who have compelling indications for beta-blockade, for example those who have symptomatic angina or who have had a myocardial infarction. C*
1.4.15 Offer patients with isolated systolic hypertension (systolic BP 160 mmHg or more) the same treatment as patients with both raised systolic and diastolic blood pressure. A
•Patients with isolated systolic hypertension received similar benefits from treatment to other patients with raised blood pressure.
1.4.16 Offer patients over 80 years of age the same treatment as other patients over 55, taking account of any comorbidity and their existing burden of drug use. A
•Patients over 80 years of age are poorly represented in clinical trials and the effectiveness of treatment in this group is less certain. However, it is reasonable to assume that older patients will receive worthwhile benefits from drug treatment, particularly in terms of reduced risk of stroke.
1.4.17 Where possible, recommend treatment with drugs taken only once a day. A
•A meta-analysis found that patients adhered to once-daily blood pressure lowering regimens better than to regimens requiring two or more doses a day (91% versus 83%). Similarly, once-daily regimens were better adhered to than twice-daily regimens (93% versus 87%).
1.4.18 Prescribe non-proprietary drugs where these are appropriate and minimise cost. D
•Drug treatment beginning with either a non-proprietary thiazide-type diuretic or beta-blocker minimises cost.
•From a model of lifetime costs and effects, based on the findings of trials, treatment using stepped care including thiazide-type diuretics, beta-blockers, ACE-inhibitors/angiotensin receptor blockers and calcium-channel blockers is estimated to be cost effective.
1.5 Continuing treatment
1.5.1 The aim of medication is to reduce blood pressure to 140/90 mmHg or below. However, patients not achieving this target, or for whom further treatment is inappropriate or declined, will still receive worthwhile benefit from the drug(s) if these lower blood pressure. C
•In trials aiming to reduce blood pressure to below 140/90 mmHg using stepped medication regimens, between one-half and three-quarters of patients achieve target blood pressure.
•In these trials about one-half of patients needed treatment with more than one drug.
1.5.2 Patients may become motivated to make lifestyle changes and want to reduce or stop using antihypertensive drugs. If at low cardiovascular risk and with well controlled blood pressure, these patients should be offered a trial reduction or withdrawal of therapy with appropriate lifestyle guidance and ongoing review. B
•When normal blood pressure has been established through drug therapy, the patients most likely to remain normotensive if they stop taking drugs are those who are relatively young, with lower on-treatment blood pressure, taking only one drug and who adopt lifestyle changes.
•Withdrawal of antihypertensive drugs has a much better chance of being successful when supported by structured interventions to encourage patients to restrict their salt intake and to lose weight if they are overweight.
1.5.3 Patients vary in their attitudes to their hypertension and their experience of treatment. It may be helpful to provide details of patient organisations that provide useful forums to share views and information. D
1.5.4 Provide an annual review of care to monitor blood pressure, provide patients with support and discuss their lifestyle, symptoms and medication. D
•Listening to patients’ views about the pros and cons of treatment for hypertension, involving patients in each stage of the management of their condition and providing clearly written supportive information is good clinical practice.
2 Notes on the scope of the guidance
All NICE guidelines are developed in accordance with a scope document that defines what the guideline will and will not cover. The scope of this guideline was established, after a period of consultation, at the start of the guideline development process; it is available from www.nice.org.uk/CG034
This guideline provides recommendations for the care of patients with raised blood pressure. It does not address screening for hypertension, management of hypertension in pregnancy or the specialist management of secondary hypertension (where renal or pulmonary disease, endocrine complications or other disease underlie raised blood pressure). The updated recommendations exclude people with significant comorbidities, people who are unconscious and older people in long-term care facilities.
3 Implementation in the NHS
The Healthcare Commission assesses the performance of NHS organisations in meeting core and developmental standards set by the Department of Health in ‘Standards for better health’ issued in July 2004. Implementation of clinical guidelines forms part of the developmental standard D2. Core standard C5 says that national agreed guidance should be taken into account when NHS organisations are planning and delivering care.
NICE has developed costing tools to help organisations implement this guidance (listed below). These tools include:
•a costing report to estimate the national savings and costs associated with implementation
•a costing template to estimate the local costs and savings involved.
These are available on our website (www.nice.org.uk/CG034).
Suggested audit criteria based on the key priorities for implementation are listed in appendix D of this document (see page 38), and can be used to audit practice locally.
The Guideline Development Groups have made the following recommendations for research, on the basis of their reviews of the evidence. The Groups regard these recommendations as the most important research areas to improve NICE guidance and patient care in the future. The Guideline Development Groups’ full sets of research recommendations are detailed in the full guideline (see section 4).
•The role of ambulatory and home blood pressure monitoring devices in improving patient care and health outcomes. The consequences for resource use (reflecting equipment purchase, maintenance, recalibration, staff, training and medication costs), patient participation in treatment and quality of life. The appropriate use of these devices either as a routine strategy or in self-selecting patients.
•The long-term value of table salt substitutes in lowering blood pressure.
•The long-term value of pragmatic multifaceted lifestyle interventions, including diet, exercise and relaxation, that could be supported by the NHS and other government agencies.
•The validity of cardiovascular risk prediction models in British patient populations, particularly in young people and in ethnic minority groups.
•The presentation of individual benefits and risks of treatment to patients.
•The influence of class of drug on morbidity and mortality in different age and ethnic groups.
•The relationship between thiazide diuretic/beta-blocker co-treatment and new-onset diabetes. Whether all patients are at increased risk or there are specific high-risk groups.
•Determinants of current patterns of care and use of antihypertensive drugs. Methods to improve uptake where it is shown to be sub-optimal.
•The clinical and cost effectiveness of antihypertensive therapies in people younger than 55.
•The clinical effectiveness of antihypertensive therapies in people from minority ethnic groups, particularly black and Asian people.
•The adoption of quality of life measures within future clinical trial protocols of antihypertensive therapy to allow measures of drug class utility.
•The most effective treatment of hypertension resistant to therapy with three blood pressure lowering drugs.
5 Other versions of this guideline
The previous NICE guidance on hypertension (NICE clinical guideline 18) was developed by the Newcastle Guideline Development and Research Unit. The National Institute for Health and Clinical Excellence commissioned the update of this guidance from the National Collaborating Centre for Chronic Conditions. The Centre established a Guideline Development Group, which reviewed the evidence and developed the recommendations. The members of the Guideline Development Group are listed in appendix B. Information about the independent Guideline Review Panel is given in appendix C.
The booklet ‘The guideline development process – an overview for stakeholders, the public and the NHS’ has more information about the Institute’s guideline development process. It is available from www.nice.org.uk/guidelinesprocess
5.1 Full guideline
The full guideline, ‘Management of hypertension in adults in primary care: partial update’, describes the methods and evidence used for updating section 1.4. For details of the evidence for the other recommendations, see the full version of NICE clinical guideline 18 (www.nice.org.uk/CG018). It is published by the National Collaborating Centre for Chronic Conditions; it is available from www.rcplondon.ac.uk/pubs/books, the NICE website (www.nice.org.uk/CG034fullguideline) and the website of the National Library for Health (www.nlh.nhs.uk).
5.2 Quick reference guide
A quick reference guide for healthcare professionals is also available from the NICE website (www.nice.org.uk/CG034quickrefguide) or from the NHS Response Line (telephone 0870 1555 455; quote reference number N1050).
5.3 Understanding NICE guidance: information for patients and carers
A version of this guideline for people with hypertension and their carers is available from our website (www.nice.org.uk/CG034publicinfo) and the NHS Response Line (telephone 0870 1555 455; quote reference number N1051).
6 Related NICE guidance
Prophylaxis for patients who have experienced a myocardial infarction: drug treatment, cardiac rehabilitation and dietary manipulation. NICE inherited guideline A (2001). Available from www.nice.org.uk/guidelineA
Management of type 2 diabetes – management of blood pressure and blood lipids. NICE inherited guideline H (2002). Available from www.nice.org.uk/guidelineH
Statins for the prevention of cardiovascular events in patients at increased risk of developing cardiovascular disease or those with established cardiovascular disease. NICE technology appraisal no. 94 (2006). Available from www.nice.org.uk/TA094
Cardiovascular risk assessment: the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. NICE clinical guideline. Publication expected December 2007. See www.nice.org.uk/guidelines.inprogress.hyperlipidaemiacardiovascular
7 Review date
The process of reviewing the evidence is expected to begin 4 years after the date of issue of this guideline. Reviewing may begin before this if significant evidence that affects the guideline recommendations is identified sooner. The updated guideline will be available within 2 years of the start of the review process.
Appendix A: Grading scheme
Clinical guideline 18
The grading scheme and hierarchy of evidence used to develop the original NICE clinical guideline (that is, all the recommendations except those in section 1.4) are shown in the table below. Please note the full guideline used a different system for grading of the evidence that was being piloted by the Newcastle Guideline Development and Research Unit.
Hierarchy of evidence
Grade Type of evidence
Ia Evidence from a meta-analysis of randomised controlled trials
Ib Evidence from at least one randomised controlled trial
IIa Evidence from at least one controlled study without randomisation
IIb Evidence from at least one other type of quasi-experimental study
III Evidence from observational studies
IV Evidence from expert committee reports or experts
Grading of recommendation
A Directly based on category I evidence
B Directly based on category II evidence or extrapolated from category I evidence
C Directly based on category III evidence or extrapolated from category I or II evidence
D Directly based on category IV evidence or extrapolated from category I, II or III evidence
Adapted from the Agency for Healthcare Policy and Research (AHCPR) system. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research (1992) Acute pain management: operative or medical procedures and trauma. Rockville MD: Agency for Health Care Policy and Research Publications.
The grading scheme and hierarchy of evidence used in updating section 1.4 are shown in the tables on pages 31 and 32 (the GREG scheme). This system grades evidence from ‘I’ (high) to ’III’ (low) for each type of study (evaluation of treatment, diagnosis or prognosis) according to a series of quality criteria. It also provides a flexible framework for assessing studies that address the process of care (such as patient surveys) and economic analyses. Research provides robust evidence when it has been conducted to exclude bias, to include suitable populations in adequate numbers, and to measure suitable outcomes. Recommendations reflect the evidence, importance and feasibility of defined steps in the provision of healthcare. Grade A* recommendations indicate a clear basis and conditions for providing (or not providing) a pattern of care. Grade B* means there are important uncertainties that need more careful consideration. Grade C* means that key information is unavailable but that the Guideline Development Group has reached a consensus recommendation based on its shared understanding of the issue.
Guideline recommendation and evidence grading (GREG) scheme for assessing evidence and writing recommendations
Evidence statements provide information about disease, diagnosis and treatment, and are used to support recommendations. Each evidence statement is graded by scoring the study design and applying quality corrections.
Design Design scores
Randomised controlled trial 1
Non-randomised controlled study 2
Uncontrolled study 3
Blinded cohort study a 1
Unblinded cohort study 2
Other design 3
Incident cohort study b 1
Other cohort study 2
Population data 1
Representative sample 2
Convenience sample 3
Flawed design, conduct or analysis c +1
Imprecise findings d +1
Lack of consistency or independence e +1
Inadequate relevance f +1
Very strong association g -1
Evidence grade Score
I: High ≤ 1
II: Intermediate 2
III: Low ≥ 3
a Blinding refers to independent interpretation of a test and reference standard.
b An incident cohort is identified and followed in time from a defined point in the progress of disease or care.
c Important flaws may be judged to occur when adequate standards of research are not followed or are unreported in published findings. Potential examples include failure to analyse by intention-to-treat, over-interpretation of secondary analyses, failure to adjust for potential confounding in non-randomised designs. For diagnostic studies this includes the need for an adequate reference standard and to apply different tests in an adequately short timescale.
d Sparse data (too few events or patients) are the most common reason for imprecision. A confidence interval including both no effect and a clinically important effect is an example of an imprecise finding.
e Consistency in design: involves methods, patients, outcome measures; and findings: involves homogeneity of summary estimates. Independence refers to the availability of research from at least two independent sources. Evidence of publication bias also denotes lack of consistency.
f Adequate relevance requires use in studies of a relevant patient-oriented health outcome or a strongly linked surrogate endpoint; and a sufficiently representative and relevant patient group or mix.
g In comparative designs a very strong association can raise the quality score.
Recommendations provide guidance about appropriate care. Ideally, these should be based on clear evidence: a robust understanding of the benefits, tolerability, harms and costs of alternative patterns of care. They also need to be feasible in the healthcare setting addressed. There are three categories, and each recommendation may be positive or negative, conditional or unconditional reflecting current evidence and the understanding of the Guideline Development Group.
A* Recommendation There is robust evidence to recommend a pattern of care.
B* Provisional recommendation On balance of evidence, a pattern of care is recommended with caution.
C* Consensus opinion Evidence being inadequate, a pattern of care is recommended by consensus.
Abu Zubair meriwayatkan dari Jabir bin Abdullah bahwa Nabi Muhammad SAW bersabda:
"Setiap penyakit ada obatnya. Jika obat yang tepat diberikan dengan izin Allah, penyakit itu akan sembuh".
(HR. Muslim, Ahmad dan Hakim).
Sabtu, 18 April 2009
Diposting oleh FX di 04.59
Jumat, 17 April 2009
Hypertension a major risk factor for cardiovascular disease (CVD - cerebrovascular event and ischaemic heart disease) and as such is one of the most important preventable causes of premature morbidity and mortality in developed and developing countries.
Yet studies still show that hypertension remains underdiagnosed, undertreated and poorly controlled in the UK.1 The benefits of antihypertensive therapy in reducing the incidence of CVD and cerebrovascular event depend largely on blood pressure lowering - so achieving stated blood pressure (BP) targets is important.
Taking measurements of blood pressure
* Measure BP in relaxed environment - patient sitting with arm outstretched, and supported.
* Ensure BP equipment is regularly validated and maintained.
* If initial BP >140/90 mm/Hg (or target) repeat later in the consultation if possible.
* If BP is different in both arms - take the higher reading as the reference in future and if there are postural symptoms take a standing BP to measure postural drop.
* Routine use of home monitoring devices or ambulatory BP devices is not recommended.
* Diagnosis - ideally this should require BP >140/90 mm/Hg on at least 3 occasions.
Decision to treat hypertension
Drug treatment is recommended:
* In patients with sustained SBP ≥160 mm Hg or sustained DBP ≥100 mm Hg
* In patients with sustained systolic BP in the range 140-159 mm/Hg, and/or diastolic BP in the range 90-99 mm/Hg with known cardiovascular disease, diabetes, target organ damage (i.e. renal impairment); or an estimated CVD risk of ≥20% over the next 10 years using risk charts or calculator
* Patients with isolated systolic blood pressure or aged >80 should not be treated differently.
* Always take account taken of co-morbidity and other medications (prescribed or otherwise).
* BP treatment targets - titrate the doses of medication to the following targets, adding more drugs as necessary until further treatment is inappropriate or declined:
o BP 140/85 mm/Hg (NICE says140/90 mm/Hg2 - audit standard <150/90 mm/Hg)
o BP 130/80 mm/Hg in patients with established CVD, chronic renal failure or diabetes (strive for optimal glycaemic control - HbA1c <7) NICE says 130/75 mm/Hg - audit standard <140/80 mm/Hg.
Based on JBS2 Guidelines 20053 and NICE.2,4Advise lifestyle measures in hypertensive, borderline hypertensive and patients with high normal BP (130-139/85-89 mm/Hg). Inform about any local initiatives, and supplement advice with leaflets or audiovisual information.
* Patients should stop smoking (offer help ± nicotine replacement therapy).
* Weight reduction should be suggested if necessary, to maintain ideal BMI of 20-25 kg/m2. Offer a diet sheet and/or dietetic appointment. Dietary self-help e.g. dieting clubs, may be appropriate.
* Reduce their salt, total fat, saturated fat and cholesterol intake, while increasing consumption of polyunsaturated, monosaturated fats and oily fish. Encourage fruit, vegetables, legumes and whole grains; and low fat (or zero-fat) dairy, poultry meat, fish and shellfish products (as in the DASH eating plan).5
* Cut alcohol intake to no more than 21 units (male) or 14 units (female) of alcohol per week.
* Encourage regular dynamic exercise tailored to age and capabilities of patient. This may mean three vigorous training sessions per week for a young adult, or brisk walking for ≥30 minutes most days for the older individuals.
* Do not offer supplements of calcium, magnesium or potassium to reduce BP.6
* Relaxation therapy can help (PCT's not recommended to provide them routinely).
* As well as the targets above, strive for a happy, well-informed patient. Remember to look for and treat any underlying cause in your initial assessment (see hypertension article).
Anti-hypertensive therapy choices
In the absence of contraindications or compelling indications for other anti-hypertensive drugs (see table below), follow the guideline algorithm as follows. NB: Black only refers to patients of African or Caribbean descent, not mixed-race, Asian or Chinese3
Initial Drug Choices2
If patient is young (<55) and non-black start with:
* (A) ACE inhibitor or Angiotensin II receptor antagonist (ACE II)
If patient is black or aged ≥55 years use:
* (C) Calcium channel blocker or
* (D) Diuretic (thiazide)
Second Drug Choices
* (A+C) ACE inhibitor or Angiotensin II receptor antagonist with Calcium channel blocker or
* (A+D) ACE inhibitor or Angiotensin II receptor antagonist with Diuretic (thiazide)
Third Drug Choices
* (A+C+D) ACE inhibitor or Angiotensin II receptor antagonist (ACE II) and Calcium channel blocker and Diuretic (thiazide)
* Most hypertensives will need a combination of 2 or 3 drugs to achieve satisfactory control.
* Explain the need for long-term treatment "hypertension treatment should be continued until further notice - usually lifelong. If the patient agrees, enlist the spouse's help with diet and medication. Give clear verbal and written advice, and stress the importance of regular BP checks (± blood tests) and follow-up - including annual review (e.g. in "birthday month").
* Remember that most drugs take 4-8 weeks to produce their maximum effect and don't assess efficacy on the basis of a single clinic blood pressure measurement.
* Beta-blockers are no longer recommended by NICE as first line therapy, as they may be less effective in reducing major cardiovascular events, particularly stroke than other drug combinations.4
o They may be appropriate in younger individuals who cannot tolerate ACEs or ACE IIs.7
o Co-prescribing beta-blocker with CCB is better than a beta-blocker with a thiazide because of increased risk of developing diabetes.
o If this combination is unavoidable, consider screening for diabetes regularly.
o When hypertensive patients on beta-blockers are reviewed, the drug should be continued if there is a compelling indication for their use.
o If the BP is being controlled on betablockers there is no absolute reason to stop them.4
o If the BP is not being controlled the dose should be stepped down and stopped gradually, and replaced with a more appropriate drug as per algorithm above.
Drug Indications and Contraindications
Drug Class Indications (compelling and possible) Cautions and Contraindications
ACE inhibitors Compelling Indications
* Heart failure8
* LV dysfunction
* Type 1 diabetes with nephropathy
* IHD ± Post MI
* Previous stroke/CVE
* Proteinuria and non-diabetic nephropathy;
* Chronic renal diseasea
* Type 2 diabetic nephropathy
* Renovascular disease
* Renal impairmenta
Angiotensin II receptor antagonists (ARBs, ACE IIs) Compelling Indications
* Cough on ACE
* Heart failure 9 intolerant of ACEs
* Type 2 diabetic nephropathy
* Diabetic microalbuminuria
* Renovascular disease
* Renal impairment
Beta-Blockers Compelling Indications
* Symptomatic angina10
* Post MI
* Patients with evidence of increased sympathetic drive.4
* Heart block
* Heart failurec
* Diabetes (except if CHD)
* Athletes and physically active patients
Calcium channel blockers (dihydropyridine)
(eg nifedipine S/R) Compelling Indications
* Elderly ISH
* Elderly Angina
* Congestive Cardiac Failure
Other calcium channel blockers
(rate limiting) Compelling Indications
* Myocardial Infarction
* Heart block
* Heart failure
* Combination with beta-blockers
Thiazides Compelling Indications
* Elderly including ISH
* Hypertensives of African origin
* Heart failure
* Previous Stroke
Diuretics (anti-aldosterone) Compelling Indications
* Post MI
* Renal failure
Alpha blockers Compelling Indications
* Prostatic hyperplasia (BPH)
* Urinary incontinence
* Orthostatic hypotension
* Congestive heart failured
1. ACE-inhibitors may be beneficial in chronic renal failure but should only be used with caution, close supervision and specialist advice are needed when there is established and significant renal impairment.
2. Caution with ACE inhibitors and angiotensin II receptor antagonists in peripheral vascular disease because of association with renovascular disease.
3. Beta-blockers may worsen heart failure, but in specialist hands may be used to treat heart failure (titrate dose carefully).
4. When used as monotherapy
Adapted from Williams B et al; BMJ. 2004 Mar 13;328(7440):634-40.11
CVE=Cerebrovascular Episode; COPD=chronic obstructive pulmonary disease; ISH=Isolated systolic hypertension; PVD=peripheral vascular disease.
Drugs to further reduce CVD risk
* Unless contraindicated, the guideline suggests prescribing low-dose aspirin and a statin for all people with IHD, and hypertensive patients aged >50 years who have a 10-year CVD risk ≥20% once BP is under control.3
* Also aim (in this group) to lower total cholesterol by 25% or LDL-cholesterol by 30% or achieve a total cholesterol of <4.0 mmol/l or LDL-cholesterol of <2.0 mmol/l, whichever is the greatest reduction.3
* Hypertension in the elderly: The absolute benefit of treatment is greater in the elderly. Patients tolerate BP treatment as well as younger age groups, so studies suggest optimum BP levels should be similar.
o Beware older people show greater BP variability so more readings may be necessary (including standing BP) and titrate therapy to standing levels.
o Isolated systolic hypertension should certainly be treated, although in borderline cases (140-159/<90 mm/Hg) without cardiovascular or target organ damage, resource and quality of life issues come to the fore.
o Follow the drug choices as above, starting with calcium channel blocker or thiazide.
o Benefits in those aged >80 have not been proven, but is the subject of current research (HYpertension in the Very Elderly Trial (HYVET) trial).
* Hypertension in the young: Always consider a secondary cause for hypertension (e.g. renal artery stenosis), particularly if difficult to control (consider consultant referral). Framingham risk data is not valid <32 years, and it is extremely unlikely that their CVD 10 year risk will be ≥20%. Balance long term risk with inconvenience of early treatment.
* Idiopathic hypertension in pregnancy: Methyldopa remains the first-line choice, with calcium antagonists (nifedipine) and hydralazine commonly used as second-line. Labetolol is often used for resistant third trimester hypertension. Avoid ACE-inhibitors and thiazides.12
* Hypertension and oral contraceptives: Generally patients with OCP induced hypertension or pre-existing hypertension should use non hormonal contraception, especially if there is co-existent migraine or CVD. If this is unacceptable, switching to the POP with careful BP monitoring is recommended.
* HRT and hypertension: HRT use is not generally associated with increasing BP, and HRT should not be denied to hypertensive women as long as BP can be controlled.
* Hypertension and ethnic groups: Black African-Caribbeans frequently have severe hypertension which often responds to salt restriction. They are sensitive to diuretics and calcium antagonists, but ACEs and β-blockers are often ineffective as monotherapy - unless used with diuretics, CCB or alpha blockers.6,11
* At least every 6 months, frequency of visits depending on degree of control, complexity of therapy and compliance. Annual urinalysis for protein, blood for glucose, creatinine and electrolytes (± total and HDL cholesterol) and evaluation of CHD/CVD risk recommended: with routine visits to measure weight, BP and to enquire about general health, side-effects, treatment problems and to re-inforce non-drug measures. A robust call/recall system is essential.
* It may be possible to gradually titrate down or stop medication in patients who successfully modify their lifestyle (as long as appropriate BP and other targets are achieved, in patients with low cardiovascular risk).
* In order to improve the effectiveness of healthcare, most GP practices now have "practice protocols" for hypertension, asthma, diabetes, etc.. Local adaption and hence "ownership" of these is essential for their full implementation and effectiveness.
* All of the primary health care team should be involved in the initial design, with review dates and regular audits built in
* Guidelines should act as a catalyst for the practice's individual protocol.
Hypertensive care lends itself well to audit. The Quality and outcomes framework (QOF) quality indicators for hypertension are currently as follows (2006-7):
Reference Criterion Target
BP 1. The practice can produce a register of patients with established hypertension
BP 4. The percentage of patients with hypertension in whom there is a record of the blood pressure in the previous nine months. 40–90%
BP 5. The percentage of patients with hypertension in whom the last blood pressure (measured previous nine months) is 150/90 or less. 40–70%
Diposting oleh FX di 19.24
The Holy Al-Qur'an (English version)
- Surah 1 - Al Fatiha THE OPENING
- Surah 2 - Al Baqarah THE HEIFER
- Surah 3 - Ali 'Imran - THE FAMILY OF 'IMRAN
- Surah 4 - Al-Nisa' THE WOMEN
- Surah 5 - Al Ma'idah THE REPAST
- Surah 6 - Al An'am THE CATTLE
- Surah 7 - Al A'raf THE HEIGHTS
- Surah 8 - Al Anfal THE SPOILS OF WAR
- Surah 9 - Al Tawbah THE REPENTANCE
- Surah 10 - Yunus JONAH
- Surah 11 - Hud THE PROPHET HUD
- Surah 12 - Yusuf JOSEPH
- Surah 13 - Al Ra'd THE THUNDER
- Surah 14 - Ibrahim ABRAHAM
- Surah 15 - Al Hijr THE ROCKY TRACT
- Surah 16 - Al Nahl BEES
- Surah 17 - Al Isra' THE NIGHT JOURNEY
- Surah 18 - Al Kahf THE CAVE
- Surah 19 - Maryam MARY
- Surah 20 - TA HA
- Surah 21 - Al Anbiya THE PROPHETS
- Surah 22 - Al Hajj THE PILGRIMAGE
- Surah 23 - Al Mu'minun THE BELIEVERS
- Surah 24 - Al Nur THE LIGHT
- Surah 25 - Al Furqan THE CRITERION
- Surah 26 - Al Shu'ara' THE POETS
- Surah 27 - Al Naml THE ANTS
- Surah 28 - Al Qasas THE NARRATIONS
- Surah 29 - Al 'Ankabut THE SPIDER
- Surah 30 - Al Rum THE ROMANS
- Surah 31 - Luqman LUQMAN
- Surah 32 - Al Sajdah THE PROSTRATION
- Surah 33 - Al Ahzab THE CONFEDERATES
- Surah 34 - Saba' SHEBA
- Surah 35 - Fatir THE ORIGINATOR OF CREATION
- Surah 36 - Ya Sin YA SIN
- Surah 37 - Al Saffat THOSE RANGED IN RANKS
- Surah 38 - Sad SAD
- Surah 39 - Al Zumar CROWDS
- Surah 40 - Ghafir FORGIVER
- Surah 41 - Fussilat EXPOUNDED
- Surah 42 - Al Shura CONSULTATION
- Surah 43 - Al Zukhruf THE GOLD ADORNMENTS
- Surah 44 - Al Dukhan THE SMOKE
- Surah 45 - Al Jathiyah THE KNEELING DOWN
- Surah 46 - Al Ahqaf WINDING SAND-TRACTS
- Surah 47 - Muhammad MUHAMMAD
- Surah 48 - Al Fath THE VICTORY
- Surah 49 - Al Hujurat THE CHAMBERS
- Surah 50 - Qaf QAF
- Surah 51 - Al Dhariyat THE WINDS THAT SCATTER
- Surah 52 - Al Tur THE MOUNT
- Surah 53 - Al Najm THE STAR
- Surah 54 - Al Qamar THE MOON
- Surah 55 - Al Rahman THE MOST GRACIOUS
- Surah 56 - Al Waq'iah THE INEVITABLE
- Surah 57 - Al Hadid IRON
- Surah 58 - Al Mujadilah THE WOMAN WHO PLEADS
- Surah 59 - Al Hashr THE MUSTERING
- Surah 60 - Al Mumtahinah THAT WHICH EXAMINES
- Surah 61 - Al Saff THE BATTLE ARRAY
- Surah 62 - Al Jumu'ah FRIDAY
- Surah 63 - Al Munafiqun THE HYPOCRITES
- Surah 64 - Al Taghabun THE MUTUAL LOSS AND GAIN
- Surah 65 - Al Talaq DIVORCE
- Surah 66 - Al Tahrim PROHIBITION
- Surah 67 - Al Mulk THE DOMINION
- Surah 68 - Al Qalam THE PEN
- Surah 69 - Al Haqqah THE SURE REALITY
- Surah 70 - Al Ma'arij THE WAYS OF ASCENT
- Surah 71 - Nuh NOAH
- Surah 72 - Al Jinn THE SPIRITS
- Surah 73 - Al Muzzammil THE ENFOLDED ONE
- Surah 74 - Al Muddaththir THE ONE WRAPPED UP
- Surah 75 - Al Qiyamah THE RESURRECTION
- Surah 76 - Al Insan MAN
- Surah 77 - Al Mursalat THOSE SENT FORTH
- Surah 78 - Al Naba' THE GREAT NEWS
- Surah 79 - Al Nazi'at THOSE WHO TEAR OUT
- Surah 80 - 'Abasa HE FROWNED
- Surah 81 - Al Takwir THE FOLDING UP
- Surah 82 - Al Infitar THE CLEAVING ASUNDER
- Surah 83 - Al Mutaffifin THE DEALERS IN FRAUD
- Surah 84 - Al Inshiqaq THE RENDING ASUNDER
- Surah 85 - Al Buruj THE CONSTELLATIONS
- Surah 86 - Al Tariq THE NIGHT STAR
- Surah 87 - Al A'la THE MOST HIGH
- Surah 88 - Al Ghashiyah THE OVERWHELMING EVENT
- Surah 89 - Al Fajr THE DAWN
- Surah 90 - Al Balad THE CITY
- Surah 91 - Al Shams THE SUN
- Surah 92 - Al Layl THE NIGHT
- Surah 93 - Al Duha THE GLORIOUS MORNING LIGHT
- Surah 94 - Al Sharh THE EXPANSION OF THE BREAST
- Surah 95 - Al Tin THE FIG
- Surah 96 - Al Alaq THE CLINGING CLOT
- Surah 97 - Al Qadr THE NIGHT OF POWER
- Surah 98 - Al Bayyinah THE CLEAR EVIDENCE
- Surah 99 - Al Zalzalah THE EARTHQUAKE
- Surah 100 - Al 'Adiyat THOSE THAT RUN
- Surah 101 - Al Qari'ah THE GREAT CALAMITY
- Surah 102 - Al Takathur THE PILING UP
- Surah 103 - Al 'Asr TIME THROUGH THE AGES
- Surah 104 - Al Humazah THE SCANDALMONGER
- Surah 105 - Al Fil THE ELEPHANT
- Surah 106 - Quraysh THE TRIBE OF QURAYSH
- Surah 107 - Al Ma'un THE NEIGHBOURLY ASSISTANCE
- Surah 108 - Al Kawthar THE ABUNDANCE
- Surah 109 - Al Kafirun THOSE WHO REJECT FAITH
- Surah 110 - Al Nasr THE HELP
- Surah 111 - Al Masad THE PLAITED ROPE
- Surah 112 - Al Ikhlas THE PURITY OF FAITH
- Surah 113 - Al Falaq THE DAYBREAK
- Surah 114 - Al Nas MANKIND
- Acute Coronary Syndromes
- Angina Pectoris
- Anomalous Left Coronary Artery From the Pulmonary Artery
- Aortic Coarctation
- Aortic Dissection
- Aortic Regurgitation
- Aortic Stenosis
- Aortic Stenosis, Subaortic
- Aortic Stenosis, Supravalvar
- Ashman Phenomenon
- Atrial Fibrillation
- Atrial Flutter
- Atrial Myxoma
- Atrial Septal Defect
- Atrial Tachycardia
- Atrioventricular Block
- Atrioventricular Dissociation
- Atrioventricular Nodal Reentry Tachycardia (AVNRT)
- Benign Cardiac Tumors
- Brugada Syndrome
- Complications of Myocardial Infarction
- Coronary Artery Atherosclerosis
- Coronary Artery Vasospasm
- Digitalis Toxicity
- Dissection, Aortic
- Ebstein Anomaly
- Eisenmenger Syndrome
- First-Degree Atrioventricular Block
- HACEK Group Infections (Infective Endocarditis)
- Heart Failure - Decompensatio Cordis
- Holiday Heart Syndrome
- Hypertensive Heart Disease
- Junctional Rhythm
- Loeffler Endocarditis
- Long QT Syndrome
- Lutembacher Syndrome
- Mitral Regurgitation
- Mitral Stenosis
- Mitral Valve Prolapse
- Myocardial Infarction
- Myocardial Rupture
- Paroxysmal Supraventricular Tachycardia
- Patent Ductus Arteriosus
- Patent Foramen Ovale
- Pericardial Effusion
- Pericarditis Acute
- Pericarditis, Constrictive
- Pericarditis, Constrictive-Effusive
- Pulmonic Regurgitation
- Pulmonic Stenosis
- Right Ventricular Infarction
- Saphenous Vein Graft Aneurysms
- Second-Degree Atrioventricular Block
- Sinus of Valsalva Aneurysm
- Sudden Cardiac Death
- Tetralogy of Fallot
- Third-Degree Atrioventricular Block
- Torsade de Pointes
- Tricuspid Regurgitation
- Tricuspid Stenosis
- Unstable Angina
- Ventricular Fibrillation
- Ventricular Septal Defect
- Ventricular Tachycardia
- Wolff-Parkinson-White Syndrome