Complication

prevention
for patients with hypertension
A noncommunicable disease education manual for primary health care professionals and patients
Complication
prevention
for patients with hypertension
A noncommunicable disease education manual for primary health care professionals and patients
The Noncommunicable Disease Education Manual for Primary Health Care Professionals and Patients results from the contributions and hard work of many
people. Its development was led by Dr Hai-Rim Shin, Coordinator, and Dr Warrick Junsuk Kim, Medical Officer, of the Noncommunicable Diseases and Health
Promotion unit at the WHO Regional Office for the Western Pacific (WHO/WPRO/NCD) in Manila, Philippines.

WHO graciously acknowledges the intellectual contributions of Dr Jung-jin Cho, Co-director, Community-based Primary Care Project Committee and Professor,
Department of Family Medicine, Hallym University Sacred Heart Dongtan Hospital, Republic of Korea; Dr Hyejin Lee, Volunteer, WHO/WPRO/NCD (currently
PhD candidate, Department of Family Medicine, Seoul National University, Republic of Korea); Ms Saki Narita, Volunteer, WHO/WPRO/NCD (currently PhD
candidate, Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Japan); and Mr Byung Ki Kwon, Technical Officer,
WHO/WPRO/NCD (currently Director, Division of Health Promotion, Ministry of Health and Welfare, Republic of Korea).

Many thanks to Dr Albert Domingo, Dr Sonia McCarthy, Ms Marie Clem Carlos, Dr Katrin Engelhardt, Mr Kelvin Khow Chuan Heng and Dr Roberto Andres Ruiz
from the WHO Regional Office for the Western Pacific and Dr Ma. Charina Benedicto, Physician-in-Charge, Bagong Barangay Health Center & Lying-in Clinic,
Pandacan, Manila, Philippines for reviewing the draft publication.

Financial support for this publication was received from the Korea Centers for Disease Control and Prevention, Republic of

Korea. No conflict of interest was declared.

This is a translation of a manual published by the Ministry of Health and Welfare and Community-based Primary Care Project Committee in the Republic of
Korea. Some of the content has been adapted, with permission, to align with current WHO recommendations and policies. However, the views expressed in the
manual do not necessarily reflect the policies of the World Health Organization. The source publication was developed under the leadership of Dr Jung-jin Cho
(also mentioned above); Mr Hyunjun Kim, Co-director, Community-based Primary Care Project Committee and Director General, Bureau of Health Policy,
Ministry of Health and Welfare, Republic of Korea; and Dr Sunghoon Jung, Deputy Director, Division of Health Policy, Ministry of Health and Welfare, Republic of
Korea.

All illustrations were provided by the source publication.

Photo credits
©Shutterstock: pages 3, 4, 7-14, 19-22

ISBN 978 92 9061 803 4

© World Health Organization 2017
Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO
licence.
 Noncommunicable disease education manual
for primary health care professionals and patients

Part 1 Prevention and management of hypertension

Module 1 Diagnosis and management
Module 2 Healthy lifestyles
Module 3 Healthy eating habits
Module 4 Low-salt diet
Module 5 Physical activity
Module 6 Medication and
management of
Module 7 Complication prevention ◄ YOU ARE HERE
associated diseases
Part 2 Prevention and management of diabetes
Module 1 Diagnosis and management
Module 2 Healthy lifestyles
Module 3 Healthy eating habits 1
Module 4 Healthy eating habits
Module 5 2 Physical activity
Module 6 Taking care of yourself in daily life
Module 7 Complication prevention

Part 3 Quit smoking

 How to use this manual
This book is one of fifteen modules of the “Noncommunicable disease education manual for primary health
care professionals and patients”. This manual is intended to provide health information on the prevention and
control of hypertension and diabetes.

This will be used in the form of a flip chart for health professionals to educate their patients with either
hypertension or diabetes.

Diagnosis and management for patients with hypertension

FOR PATIENTS
Blood pressure target
On one side of the flip chart is the ‘For patients’ page. This side has simple
Systolic blood
pressure
Diastolic blood
pressure
images and key messages that are easy to understand. However, health
professionals may need to provide education for patients to fully understand the
content.
Under Under

140
m mH g
90
mmHg

* Age m or e than 80: blood pr ess ure to be contr olled below 150/90 m m H g

11 FOR PATIENTS

Diagnosis and management for patients with hypertension

FOR PHYSICIANS
Blood pressure target
Patient education Professional information
On the other side of the flip chart is the ‘For physicians’ page. This side
•

•
B lood pr essur e below 140/ 90 m m H g is
generally advised t o pr event complications.
Howev er, bl ood pressur e tar get s c an be
Tar get blood pr es sure

• Accordi ng to the Ei ght h Joint National

includes information that the health professional can read out to the patient
during counselling. Professional information is also provided for further
adjusted according to age, number and type of Com mit tee (J NC8) , those over age 80 are
r isk factor s, and associated diseases. advised t hat t heir target blood pr ess ure should
be below 150/90 m m Hg .
• Ther efor e, if you have hypertension, y ou shoul d
consult y our physician to set a tar get after • Tar get blood pr ess ur e should be below 140/90

understanding. A small image of the ‘For patients’ side is included so that the
evaluating your cur rent health s tat us and ri sk m m H g for hyper tension c om bi ned with
f act ors .
c er ebrovasc ular diseas e and ather osclerosis.
Systolic blood Diastolic blood • For those under age 80 maint ain bel ow 140/90
pressure pressure

health professional is aware of what the patient is looking at.

m m H g; those ov er age 80 mai ntai n below
150/90 m m H g.
Un d er Un d er

140
mmH g
90
mmH g

*Age more than 80: blood pressure to be controlled below 150/90 mmHg

REFERENC E:
James, Paul A., et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
JAMA, 2014, 311.5: 507-520.

12 FOR PHYSICIANS

This publication is intended to serve as a template to be adapted to national context. Images and graphs
that have been watermarked should be replaced with images or graphs that represent the national
situation. If assistance is required, or if you have any questions related to the publication, please contact
the Noncommunicable Diseases and Health Promotion unit at WHO Regional Office for the Western Pacific
(wproncd@who.int).
 Table of contents
Module 7
Complication prevention for patients with hypertension

1 Complications – overview (1)

3 Complications – overview (2)
5 Complications – overview (3)
7 Importance of blood pressure control: complication prevention
9 Complications: stroke
11 Complications: myocardial infarction
13 Complications: chronic kidney disease
15 Hypertensive emergency
17 In case of emergency
19 Regular check-ups for hypertension
21 Possible causes of uncontrolled blood pressure
23 Take-home message
 Complication prevention for patients with hypertension

Complications – overview (1)

Stroke

Hypertensive Angina
retinopathy Myocardial
Infarction
Heart Failure

Chronic Kidney
Disease
Hypertension (Renal
Failure)

Sexual
Dysfunction

Heart Disease
Stroke
Kidney Disease

1 FOR PATIENTS
 Complication prevention for patients with hypertension

Complications – overview (1)

Patient education
• High blood pressure causes severe vessel-
related complications if not properly controlled. Stroke

• Narrower and less flexible vessels cause

atherosclerosis. Hypertensive Angina
retinopathy Myocardial
• If the aorta dilates, it can cause an aortic Infarction
Heart Failure
aneurysm, or even aortic dissection. If coronary
arteries are suddenly blocked or narrowed,
angina results. Chronic Kidney
• Heart failure occurs when the function of the Disease
Hypertension (Renal
heart deteriorates. Failure)
• Stroke or even vascular dementia are caused
Sexual
by cerebral vascular ischaemia. If kidney Dysfunction
function deteriorates, it can lead to chronic
kidney disease. Heart Disease
• Moreover, you could lose your eyesight from Stroke
retinopathic disease and even suffer sexual Kidney Disease
dysfunction.

REFERENCES:
Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: 14-26.
National Institutes of Health, and National Heart, Lung, and Blood Institute (United States). Your guide to lowering blood pressure. NIH publication, 2003, 03-5232.
Chobanian, Aram V., et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension,
2003, 42.6: 1206-1252.

2 FOR PHYSICIANS
 Complication prevention for patients with hypertension

Complications – overview (2)

Atherosclerosis
• A disease where an
artery wall thickens as a
result of accumulation
of fibrofatty plaques.
• The disease can cause
cerebral
haemorrhage,
cerebral ischaemia,
vascular dementia,
angina and myocardial
infarction.

3 FOR PATIENTS
 Complication prevention for patients with hypertension

Complications – overview (2)

Patient education
• Hypertension causes severe problems within the blood vessels. When blood pressure spikes it damages
the vessel wall, which leads to wall thickening and fat accumulation.
• This leads to angina, myocardial infarction, heart failure and kidney failure by decreasing the blood flow to
the heart, brain, kidneys and extremities.

Atherosclerosis
• A disease where an artery wall
thickens as a result of accumulation
of fibrofatty plaques.
• The disease can cause cerebral
haemorrhage, cerebral ischaemia,
vascular dementia, angina and
myocardial infarction.

REFERENCES:
Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: 14-26.
James, Paul A., et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
JAMA, 2014, 311.5: 507-520.
U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. Your guide to lowering your blood pressure with DASH. DASH eating plan,
2006.

4 FOR PHYSICIANS
 Complication prevention for patients with hypertension

Complications – overview (3)

Cardiovascular disease
• Mortality rate from cardiovascular diseases
increases as blood pressure rises.

16 times

8 times
Mortality
4 times rate
ratio
double

Blood 115/75 135/85 155/95 175/105 195/115

pressure

5 FOR PATIENTS
 Complication prevention for patients with hypertension

Complications – overview (3)

Patient education
• Mortality rate from cardiovascular disease increases as blood pressure rises.
• The graph below shows blood pressure over 155/95 mmHg which results in a risk of death from heart
disease that is four times normal, eight times normal at 175/105 and 16 times normal at 195/115.

Cardiovascular disease
• Mortality rate from cardiovascular
diseases increases as blood pressure
rises.
16 times

8 times
Mortality
4 times rate
ratio
double

Blood 135/85 155/95 175/105 195/115

115/75
pressure

REFERENCE:
Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. The
Lancet, 2002, 360.9349: 1903-1913.

6 FOR PHYSICIANS
 Complication prevention for patients with hypertension

Importance of blood pressure control:

complication prevention

By controlling blood pressure:

stroke by 30%

Cut the risk of myocardial infarction by 25%

chronic kidney diseases by 23%

7 FOR PATIENTS
 Complication prevention for patients with hypertension

Importance of blood pressure control:

complication prevention
Patient education
• Patients with hypertension often skip their medication or regular check-ups because they have no
symptoms. If hypertension is neglected, it can lead to more severe diseases or complications, such as
stroke, myocardial infarction and chronic kidney disease.
• Continuous blood pressure control is recommended to prevent these complications.

By controlling blood pressure:

stroke by 30%

Cut the risk of myocardial infarction by 25%

chronic kidney diseases by 23%

REFERENCES:
Hypertension basic theory course. Centers for Disease Control and Prevention, Republic of Korea. 2016.(http://www.kncd.org/down/sub09/01/9_1_1_1.pdf, accessed 28 September 2016).
Haroun, Melanie K., et al. Risk factors for chronic kidney disease: a prospective study of 23,534 men and women in Washington County, Maryland. Journal of the American Society of Nephrology,
2003, 14.11: 2934-2941.

8 FOR PHYSICIANS
 Complication prevention for patients with hypertension

Complications: stroke

Stroke
Ischaemic stroke Haemorrhagic stroke

Blockage of blood vessels; Rupture of blood vessels;

lack of blood flow to affected area leakage of blood

9 FOR PATIENTS
 Complication prevention for patients with hypertension

Complications: stroke
Patient education Professional information
• Stroke is a cerebrovascular disease that is • The incidence rate of cerebral haemorrhage
caused when spontaneous vascular bleeding increases 4.3-fold when blood pressure is over
occurs (cerebral haemorrhage) or when the 160/100 mmHg.
blood vessels are blocked. • If the patient has one of the symptoms below,
• You are likely to lose consciousness and it may it is vital that a local emergency number is
lead to paralysis. called or the patient goes to the hospital.
Stroke • Treatment within three hours of onset of the
Ischaemic stroke Haemorrhagic following symptoms is often critical:
stroke
- Sudden weakness or numbness in face,
hand, legs or any part of the body;
- sudden difficulty in speaking or feeling
confused;
- sudden loss of vision;
- difficulty walking, dizziness, or poor sense
of direction; and
- sudden onset of severe headache without
Blockage of blood vessels; Rupture of blood vessels;
reason.
lack of blood flow to affected area leakage of blood

REFERENCES:
Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: 14-26.
National Institutes of Health, and National Heart, Lung, and Blood Institute (United States). Your guide to lowering blood pressure. NIH publication, 2003, 03-5232.
Chobanian, Aram V., et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension,
2003, 42.6: 1206-1252.

10 FOR PHYSICIANS
 Complication prevention for patients with hypertension

Complications: myocardial infarction

Myocardial infarction

Coronary
artery
blockage

11 FOR PATIENTS
 Complication prevention for patients with hypertension

Complications: myocardial infarction

Patient education Professional
•information
Hypertension causes myocardial infarction and • When blood pressure is not controlled, the
heart failure. incidence of myocardial infarction triples and
• Myocardial infarction, commonly known as a heart failure quadruples.
heart attack, occurs when the heart does not • If a patient exhibits any of the following, they
contract properly due to the blockage of vessels should seek medical attention immediately:
supplying the heart muscle. - Chest discomfort, pressure in the chest or
• Heart failure means not enough blood is being pain in the sternal area which continues for
supplied to the body due to the deterioration several minutes.
of heart function. - Radiating pain to the shoulder, neck or
arm.
Myocardial infarction - Dizziness, difficulty breathing, fever or
nausea with chest pain.

Coronary
artery
blockage
REFERENCES:
Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in
the community. The Journal of Clinical Hypertension, 2014, 16.1: 14-26.
National Institutes of Health, and National Heart, Lung, and Blood Institute (United
States). Your guide to lowering blood pressure. NIH publication, 2003, 03-5232.
Chobanian, Aram V., et al. Seventh report of the joint national committee on prevention,
detection, evaluation, and treatment of high blood pressure. Hypertension, 2003, 42.6: 1206-
1252.

12 FOR PHYSICIANS
 Complication prevention for patients with hypertension

Complications: chronic kidney disease

Progress of chronic kidney disease (renal failure)
• Proteinuria
Protein in urine Secretion of proteins
• Oedema, anaemia
Dilated
afferent
• Increase in blood arteriole

pressure UNHEALTHY
GLOMERULUS
Protein molecules
Constricted
• Deterioration spill in to the urine
because of damage efferent
of capillary wall arteriole
to hypertensive (high
pressur
nephropathy e)

• Dialysis, kidney NEPHRONS

Glomerular capsule
transplant GLOMERULUS
Glomerulus

Proximal convoluted tube

Distal convoluted tube

Kidney
NORMAL HYPERTENSIVE
Loop of Henle KIDNEY NEPHROPATHY
(nephron loop)

Collecting duct

13 FOR PATIENTS
 Complication prevention for patients with hypertension

Complications: chronic kidney disease

Patient education
• Renal failure is one of the Progress of chronic kidney disease (renal failure)
complications resulting from Protein in urine Secretion of proteins
hypertension.
Dilated
• When the renal capillaries afferent
arteriole
are exposed to high blood UNHEALTHY
pressure for a long time, they GLOMERULUS
Protein molecules
are damaged and become spill in to the urine
because of damage
Constricted
efferent
less of capillary wall arteriole
(high
pressur
efficient at filtering waste. e)

• In the early stage, proteinuria NEPHRONS

is detected. GLOMERULUS
Glomerular capsule
Glomerulus
• Later on, anaemia and oedema Proximal convoluted tube
could occur. Distal convoluted tube
Kidney
• If renal function gets worse, NORMAL HYPERTENSIVE
Loop of Henle
dialysis or a kidney transplant (nephron loop)
KIDNEY NEPHROPATHY

may be needed. Collecting duct

• Proteinuria
• Oedema, anaemia
• Increase in blood pressure
REFERENCE:
Chobanian, Aram V., et al. Seventh report of the joint national • Deterioration of hypertensive nephropathy
committee on prevention, detection, evaluation, and treatment
of high blood pressure. Hypertension, 2003, 42.6: 1206-1252. • Dialysis, kidney transplant

14 FOR PHYSICIANS
 Complication prevention for patients with hypertension

Hypertensive emergency

Red flag signs

• Severe headache and
loss of
consciousness
• Chest pain
• Nausea and vomiting
• Dizziness
• Visual disturbance
• Racing heartbeat

15 FOR PATIENTS
 Complication prevention for patients with hypertension

Hypertensive emergency
Patient education
• If your blood pressure is over 180/120 mmHg, it is an emergency that could cause severe complications,
such as cerebral haemorrhage, acute myocardial infarction, angina, aortic dissection, or kidney disease.
• If you have warning signs, including severe headache with loss of consciousness, chest pain, nausea and
vomiting, dizziness, visual dysfunction, tachycardia or seizure, you need urgent treatment for suspected
hypertensive emergency.

Red flag signs

• Severe headache and
loss of
consciousness
• Chest pain
• Nausea and vomiting
• Dizziness
• Visual disturbance
• Racing heartbeat

REFERENCE:
Grassi D. et al., Hypertensive urgencies in emergency department: evaluating blood pressure response to rest and to antihypertensive drugs with different profiles. J Clin Hypertens, 2008,
10(9): 662-7.

16 FOR PHYSICIANS
 Complication prevention for patients with hypertension

In case of emergency

• Do not delay calling the

local emergency number
and going to the hospital.
• Loosen tight clothes
around body and chest. T:
T TEX ncy
• If you vomit, turn your ER rge
INS al emme ber
face to the side to loc nu
protect the airway.

17 FOR PATIENTS
 Complication prevention for patients with hypertension

In case of emergency
Patient education
• If there is an emergency, do not delay calling the local emergency number.
• You should stop all activities and rest with your head in an upper position.
• Tight clothes should be loosened.
• If you vomit, turn to the side and remove food with your hand so that the food or tongue does not
block the airway.

• Do not delay calling the

local emergency number
and going to the hospital.
• Loosen tight clothes
around body and chest. EX
T:
R e T T ncy
• If you vomit, turn your SE merg
IN cal e mber
face to the side to protect lo nu
the airway.

REFERENCE:
Grassi D. et al., Hypertensive urgencies in emergency department: evaluating blood pressure response to rest and to antihypertensive drugs with different profiles. J Clin Hypertens, 2008,
10(9): 662-7.

18 FOR PHYSICIANS
 Complication prevention for patients with hypertension

Regular check-ups for hypertension

Measuring blood Electrocardiogram

pressure test (if available)

Blood glucose test Urinalysis

(if available) (if available, urine
dipstick)

19 FOR PATIENTS
 Complication prevention for patients with hypertension

Regular check-ups for hypertension

Patient education Professional information
• It is important to maintain a healthy lifestyle, Routine tests for hypertension:
visit the hospital regularly and take medication
continuously to prevent complications. • Haemoglobin/haematocrit, sodium, potassium,
• Regular check-ups are also needed to prevent glomerular filtration rate, uric acid
complications. • Fasting blood glucose, fasting lipid profile
• Annual blood and urine tests should be done,
as well as regular tests to detect any damage to • Liver function test
eyes, heart or kidneys.
• Urine analysis (proteinuria, haematuria,
albumin/creatinine ratio)
• 12 lead electrocardiogram

Measuring blood Electrocardiogram Blood glucose test Urinalysis (if available,

pressure test (if available) (if available) urine dipstick)

REFERENCE:
Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: 14-26.

20 FOR PHYSICIANS
 Complication prevention for patients with hypertension

Possible causes of uncontrolled blood pressure

Non- Taking other Excessive Binge Sudden

adherence medicines salt drinking or weight gain
to prescribed that can intake otherwise and sleep
medicine interfere harmful use apnoea
with your of alcohol
hypertensio
n
treatment
(nonsteroidal
anti-inflammatory
drugs, steroids,
oral
contraceptives,
etc.)

21 FOR PATIENTS
 Complication prevention for patients with hypertension

Possible causes of uncontrolled blood pressure

Patient education
• When blood pressure is not maintained below 140/90 mmHg, you should consult your doctor.
• Common reasons include, wrong blood pressure measurement, lifestyle problems (obesity, excessive
alcohol intake and sleep apnoea), excessive body fluid due to high salt intake, poor adherence to
prescribed medicine, inappropriate prescription and drug interaction (nonsteroidal anti-inflammatory
drugs, steroids and oral contraceptives).

Non- Taking other Excessive Binge Sudden

adherence medicines salt drinking or weight gain
to prescribed that can intake otherwise and sleep
medicine interfere harmful use apnoea
with your of alcohol
hypertensio
n
treatment
(nonsteroidal
anti-inflammatory
drugs, steroids,
oral
contraceptives,
etc.)
REFERENCES:
Weber, Michael A., et al. Clinical practice guidelines for the management of hypertension in the community. The Journal of Clinical Hypertension, 2014, 16.1: 14-26.
Chobanian, Aram V., et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension, 2003, 42.6: 1206-1252.

22 FOR PHYSICIANS
 Complication prevention for patients with hypertension

Take-home message
Complication prevention

When blood pressure is

controlled:
• Risk of complications (stroke,
myocardial infarction, chronic
kidney disease) decreases.
• Mortality rate from
complications decreases.

To manage blood
pressure
properly
• Detection of complications
is achieved by regular check-
ups, including blood pressure
measurement, blood and urine
testing and electrocardiogram
exam.
23 FOR PATIENTS