RT-ABCDEF Strategy and Seven-Core-Principles-Based Comprehensive Therapy for Hypertension

Da-Yi Hu, MD¹, Chun-Song Hu, MD² , Sheng-Shou Hu, MD³, Li-Sheng Liu, MD³  and Run-Lin Gao, MD³

1. Department of Cardiology, People’s Hospital of Peking University, Beijing 100044, China.

heart@gw-icc.org

2. Outpatient Department of Cardiovascular Medicine, Medical College of Nanchang University, Nanchang 330006, China. chunsong_hu@yahoo.com.cn

3. Cardiovascular Institute and Fu Wai Heart Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Disease Control and Research, Beijing 100037, China. huss@vip.sohu.com

ABSTRACT  The RT-ABCDEF strategy with the seven-core-principles  (SeCP)-based comprehensive therapy for hypertension is summarized in this paper. This consists of novel, programmed and standardized strategies from Step One to Step Six and has the advantage of the "full principles (FP)" strategy——SeCP. The comprehensive therapy is very suitable for patients with hypertension in clinical practice.

KEY WORDS  hypertension, treatment, seven-core-principles, RT-ABCDEF strategy

Hyper tension, a very common disease, is a challenge the whole world is facing. As  an independent risk factor of cardiovascular and cerebrovascular diseases, hypertension can result in cardiovascular and cerebrovascular events such as acute or chronic heart failure, angina pectoris, acute myocardial infarction, dangerous arrhythmia and acute cerebral accidents. However, there is the status of "three-high and three-low" in patients with hypertension in China, that is to say, prevalence, disability and mortality rates are high while awareness, treatment, and control rates are low with the control rate of only 6.1%^[1].. Because of its complicated mechanism,  the treatment for hypertension is also different as described in the traditional Chinese medical term "treating the same disease with different therapies". However, the  treatment results are not always good. There are different treatment strategies including "full principles (FP), non-principles (NP), or partial principles (PP)" ^[2] . It is a question whether a programmatic and standardized comprehensive therapy can be developed for an ideal treatment for hypertension just like chemotherapy protocols  for hematologic tumors.

In this article, the author summarized the RT-ABCDEF strategy^[3] and the  seven-core-principles (SeCP)-based^[4] comprehensive therapy for the treatment of hypertension trying to develop a standard routine therapy.

Step One: RT-ABCDEF: Follow-up

For patients or subjects who received the first treatment at out-patient or in-patient department, or did physical examination by units, doctors should adhere to regular follow-up, including the recent (1-2 years), medium (3-5 years), long-term (5-10 years or above) follow-up. Regular follow-ups, on the one hand, can improve relations between doctors and patients and strengthen effective communication of both doctors and patients, thus increase the compliance of treatment, and enhance the effect of medical or non-medical treatment; On the other hand, by follow-up, doctors can understand the treatment of short-, medium, and long-term effects and patients’ prognosis and outcome. Many large-scale evidence-based clinical researches are based on regular follow-ups and it becomes a necessity of such researches.

Step Two: RT-ABCDEF: Examination

All healthy individuals or patients should go through a thorough systematic overall  physical examination before the diagnosis is made and before treatment initiation. The examination includes body mass index(BMI), waist/hip ratio(WHR), routine experimental biochemical indices, chest X-ray, ECG and ultrasound echocardiography.

High risk populations, especially patients with hypertension or blood pressure(BP) over the normal level, must undergo a 24 h Holter ECG(24-hour ambulatory BP measures, ABPM) at least once, which can be extended up from 72 h to a week. It is not adequate to measure BP once a day for 3 days. The purpose of ABPM is to diagnose hypertension correctly and determine the peak BP time so that the patients can choose the right time to take anti-hypertension drugs which may decrease the incidence of poor efficacy and adverse reactions of anti-hypertension drugs due to a blinded time selection or routine administration. Moreover, it may help detect, diagnose and treat hypertension early thus minimizing injuries in the target organs. The treatment includes medical therapy and non-pharmacologic therapy for the patient's lifetime(SeCP1).

For patients with mild hypertension, early treatment may effectively control the disease at the initial stage and may save the patients from  life-long medical treatments because of the progression of hypertension. This embodies the concept that prevention is the best and simplest treatment. All of the original data from the physical examination should be kept as "primary data" so that  they can be compared with the future data for the determination of the disease development. ABPM, during treatment, may also be used as a tool to evaluate drug effects and to guide the treatment of hypertension^[5].

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Step Three: RT-ABCDEF: Diseases and Risk Factors Control

Among patients with hypertension, more than 90% are primary or essential hypertension and only 5%-0% are secondary hypertension caused mostly by kidney diseases such as chronic glomerulonephritis, renal artery stenosis, obesity, stress, smoking and alcoholic beverage drinking as well as sleep disorders including obstructive sleep apnea syndrome (OSAS) ^[6]. Presently, negative life styles such as staying up late^[7], obesity, lack of exercise and psychological stress are common causes for hypertension. Therefore, controlling or relieving the primary diseases and risk factors such as renal artery stenosis, obesity and OSAS may make most of patients' BP return to the normal level. Health education and compliance education(SeCP7) is essential to help patients modify and accept  their new life styles (See Step 3).

Step Four: RT-ABCDEF: Changing Bad Life Style

Based on Step2, life style modification is required. First, it may correct abnormal BP due to a negative life style. Second, it is the ?rst line therapy for mild hypertension and it aids drug therapy for severe hypertension. Thirdly, no matter what level the BP  is, patients need to modify their life styles and continue the treatment throughout  their lifetimes. On the one hand, life style is a new target for the treatment of cardiovascular and cerebrovascular diseases and lifestyle modification is a very  important part in the non-pharmacologic therapy. On the other hand, it can greatly relieve the economic burden and psychological stress from drug therapy. Life    style modification should follow the "E(e)SEED" rule(8) which includes: (1) a suitable environment far away from pollution; (2) rational sleep habits and naps at noon; (3) stable emotion and a calm attitude; (4) appropriate exercise (aerobic exercise); (5) a scienti?c diet with balanced nutrition and abstinence from smokes and alcohol.

Step Five: RT –ABCDEF: Bio-Hazard Control

In many patients with hypertension, there are often complications like secondary hyperlipidemia, hyperglycemia or diabetes mellitus, high BMI or obesity,  hyperuricemia, abnormal liver or renal function, heart failure, a low potassium level  in patients with primary aldosteronism and abnormal urinary vanylmandelic acid  levels in patients with pheochromocytoma. On the one hand, abnormal biochemical and physiological indexes need to be adjusted or regulated(such as supplementing K+ improving the functions of liver and kidney), which can benefit the BP-lowering  therapies and help patients continue their treatment. Otherwise, drug therapy will have to be discontinued due to abnormal physiological and biochemical indices. On the other hand, in some patients with mild or moderate hypertension, blood pressure may return to the normal levels by regulating the abnormal physiological and biochemical  indices and drug therapy may not be necessary for these patients.

Step Six: RT-ABCDEF: Anti-Hypertensive Treatment

Based on the aforementioned four steps, anti-hypertension drugs are necessary for patients with mild, moderate or severe hypertension if the disease shows no  response or no significant response to lifestyle modification. Anti-hypertensive  treatment should be decided based on examination results. Individual and racial  (SeCP4) conditions should be considered and long-act ing or slow-release preparations(SeCP2) as well as combined therapies with small doses of antihypertensive drugs(SeCP3) may be selected. At the same time, integration of Western medicine with traditional Chinese medicine (SeCP5) of activating blood circulation and removing stasis or adoption of traditional Chinese medicine alone may be applied for those with mild hypertension. It should be emphasized that health education and compliance education (SeCP7) should be conducted again for moderate to severe hypertension patients. Patients should be advised lifelong therapeutic treatment(SeCP1) as well as lifestyle modification(SeCP6). Only with  comprehensive therapy can the hypertension optimal treatment be realized for patients with hypertension, thus minimizing the target organ damage, preventing or decreasing  cardio-/cerebrovascular events, and enhancing the quality of life and prolonging life expectancy.

All in all, the RT-ABCDEF strategy and SeCP-based comprehensive  therapy is the best, most effective and  rational  therapy for hypertension. It is suitable for application in clinical practice as a routine and proper therapeutic method.

Acknowledgement

Thanks for the help and critical review from Dr. Celso Gomez-Sanchez. 

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