Hypertension

Dr Moynul Haque GPST3

Overview
Background NICE

Guideline AKT Question

Epidemiology

15-20% of the adult population (>half of those older than 60) are hypertensive Risk associated with increasing blood pressure is continuous -with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from IHD and a 10% from stroke Diastolic pressure is more commonly elevated in people younger than 50 With ageing, systolic hypertension becomes a more significant problem, as a result of progressive stiffening and loss of compliance of larger arteries

Aetiology
Essential / Primary 95% Secondary (only 5%) Renal 80%

-GLomerulonephritis

-Pyelonephritis -Adult PCKD -Renal artery stenosis

Endocrine causes 15%

-Cushing's syndrome

-Conn's syndrome -Liddle's syndrome -Congenital adrenal hyperplasia -Phaeochromocytoma Acromegaly

-Pregnancy

Others 5%
-Coarctation of Aorta -Steroid use -COC pill -MAOI

Definition of Hypertension

Stage 1: Clinic BP 140/90 or higher and

ABPM daytime / HBPM 135/85 or higher AMBP daytime / HBPM 150/95

Stage 2: Clinic BP 160/100 or higher and

Severe : Clinic SBP 180 or higher or

Clinic DBP 110 or higher

Accelerated: Clinic BP 180/110 or higher with

Sign of papilloedema or Retinal haemorrhage

Clinic BP recording

Measure BP in both arms

If difference >20 repeat the measurements If remains >20 on 2nd time Measure BP again in the arm with the higher reading

If clinic BP140/90
Take a second measurement If 2nd measure is different from 1st , take 3rd Record the lower of the last 2 measurements as the clinic BP

Key points
If

clinic BP 140/90 (180/110) ABPM/HBPM If ABPM -At least 2 measurement / hour during waking hours (eg 08:00 & 22:00) -Use avg value (at least 14 measurement) If HBPM -2 consecutive BP taken at least 1 min apart & with the person seated -Ideally twice daily , am & pm -Recording for 7 days ( at least 4 days) -Discard the measurement taken on the 1st day and use the avg value of all remaining measurements

Management
Lifestyle interventions

1997

2011

Lifestyle interventions
Diet Exercise Cut down of Alcohol consumption Stop Smoking Low salt intake Discourage excessive consumption of coffee & other caffeine-rich products Relaxation therapy can be advised ( PCT will not provide routinely)

Initiating medication
If

Stage 1(Clinic BP140/90 + ABPM135/85) + one of the following -Target organ damage eg, LVH, -Established CVD disease -Renal disease eg,albuminuria/proteinuria, haematuria -Diabetes -A 10 yrs CV risk equivalent to 20% If Stage 2 ( Clinic BP160/100 + ABPM150/95) Severe hypertension (Clinic SBP180 or DBP110)

Start antihypertensive medication immediately

Investigation

Urine dips for haematuria Urine for ACR (Albumin: creatinine ratio) -if DM ACR>2.5 in men and >3.5 in women
If non-DM ACR> 30 significant proteinuria

Blood for U&Es, glucose, total cholesterol and HDL cholesterol Fundoscopy for hypertensive retinopathy 12 lead ECG

Drugs treatments Key points

Offer drugs taken only once a day Do not combine ACE inhibitor with ARB If > 55yrs or Afro-Caribbean offer CCB If diuretics considered offer a thiazide-like diuretics eg, Indapamide (1.5 mg MR od or 2.5 mg od) or Chlortalidone ( 12.5- 25.0 mg od) in preference to conventional thiazide eg, Bendroflumathiazide or hrdrochlorthiazide ( if already taken & well controlled then continue tx) In step 4 treatment

Consider further diuretics with low dose of Spironolactone 25mg od if K level 4.5 Consider further diuretic high dose of Thiazide like diuretics if K level 4.5

Drug of choice

HTN + DM HTN + IHD HTN + HF HTN + CKD HTN + Pregnancy

ACE/ARB B blocker ACE/ARB ACE/ARB Methyledopa/ B blocker

MONITORING

When using further diuretics (eg, Spironolactone or higher dose of Thiazide-like diuretics)
Monitor

blood Na, K and U&Es within 1 month and repeat as required

If ACE inhibitor or ARB Monitor U&Es before and after initiation and also after increasing the dose.
Rise

in Creatinine up to 30% from base line Reduce eGFR up to 20% from base line Increase K level up to 5.5

Specialty referrals

If stage1 hypertension and <40 yrs old

For evaluation secondary causes of HTN

If accelerated hypertension (same day)

Sign of Papilloedema or retinal Haemorrhage

If suspected phaeochromocytoma
Labile/ postural hypotension, headache, palpitations pallor and diaphoresis

If BP remains uncontrolled with maximum tolerated doses of 4 drugs. If Postural hypotension ( SBP fall>20) + symptoms persist eg, fall, postural dizzy

Target BP

Under 80yrs

Clinic BP140/90 Daytime avg ABPM/ HBPM 135/85

-Clinic BP 150/90 -Daytime avg ABPM/ HBPM 145/85

Over 80yrs
Hypertension with diabetes

Clinic BP 140/80 If target organ damage 130/80

9/6/11

MCQ
AKT

You review a 67-year-old woman who has a history of chronic obstructive pulmonary disease and hypertension. She has develop cor pulmonale and her current medications include frusemide 80 mg bd, amlodipine 10mg od and atenolol 50 mg od. You want to initiate an ACE inhibitor. What is the most appropriate action?

A. Stop frusemide for 2 days + start ramipril 1.25 mg od + check U&Es in 2 weeks

B. Start ramipril 1.25 mg od + check U&Es in 2 weeks C. Refer to secondary care D. Reduce frusemide to 80mg od + start ramipril 1.25 mg od + check U&Es in 2 weeks E. Start ramipril 1.25 mg od + check U&Es in 5 days

Both the BNF and Clinical Knowledge Summaries recommend referring people on larger doses of diuretics to specialists for initiation of ACE inhibitors.

You review an 81-year-old man with regards to his hypertensive therapy. He is currently taking a combination of losartan and amlodipine which is failing to keep his blood pressure withing target. What is the most appropriate next step assuming he has no relevant contraindications?

A. B. C. D. E.

Add indapamide MR 1.5mg od Add atenolol 50mg od Add ramipril 1.25mg od Add doxazosin 1mg od Add bendroflumethiazide 2.5mg od

NICE now advise using alternatives to bendroflumethiazide. Patients already taking bendroflumethiazide should however not be switched over to alternative thiazide-type diuretics. A This patient is taking an angiotensin 2 receptor blocker (losartan), possibly due to having problems with ACE inhibitor therapy previously, for example a dry cough. Patients should not normally take an ACE inhibitor and A2RB at the same time.

A 65 year old female with a known history of heart failure presents to her GP for an annual check-up. She is found to have a blood pressure of 170/100 mmHg. Her current medications are furosemide and aspirin. What is the most appropriate medication to add?

A. B. C. D. E.

Bendroflumethiazid Spironolacton Bisoprolol Verapamil Enalapril

E Both enalapril and spironolactone have been shown to improve prognosis in patients with heart failure.

NICE guidelines recommend the introduction of an ACE inhibitor prior to a beta-blocker in patients with chronic heart failure

A 71-year-old woman is reviewed in her local GP surgery. She has recently changed practices and is having a routine new patient medical. Her blood pressure is 146/ 94 mmHg. This is confirmed on a second reading. In line with recent NICE guidance, what is the most appropriate management?

A. Ask her to come back in 6 months for a blood pressure check B. Arrange 3 blood pressure checks with the practice nurse over the next 2 weeks with medical review following

C. Arrange ambulatory blood pressure monitoring D. Reassure her this is acceptable for her age E. Start treatment with a calcium channel blocker

C Hypertension - NICE now recommend ambulatory blood pressure monitoring to aid diagnosis The 2011 NICE guidelines recognise that in the past there was overtreatment of 'white coat' hypertension. The use of ambulatory blood pressure monitoring (ABPM) aims to reduce this.

A 52-year-old man is seen in the hypertension clinic. He was diagnosed around three months ago and started on ramipril. This has been titrated up to 10mg od but his blood pressure remains around 156/92 mmHg. What is the most appopriate next step in management?

A. B. C. D. E.

Add bendroflumethiazide Add bisoprolol Switch ramipril to perindopril Add amlodipine Add losartan

D Calcium channel blockers are now preferred to thiazides in the treatment of hypertension The 2011 NICE guidelines reflected the changing evidence base supporting the use of calcium channel blockers in preference to thiazide-type diuretics in the management of hypertension.

You review a 60-year-old man in the hypertension clinic. His past medical history includes depression and peripheral arterial disease. He is currently prescribed aspirin, simvastatin, citalopram and co-codamol 8/500. Two weeks ago he was started on ramipril 1.25 mg od. His blood pressure has decreased from 160/100 mmHg to 114/ 72 mmHg and the creatinine has increased from 102 mol/l to 230 mol/l. Which one of the following is most likely to explain the rise in creatinine?

A.Medication-induced urinary retention with secondary obstructive nephropathy B. Concurrent paracetamol overdose C. ACE-related nephropathy D. Normal, acceptable rise in creatinine for patients taking an ACE inhibitor E. Underlying renovascular disease

You admit a woman who is 34 weeks pregnant to the obstetric ward. She has been monitored for the past few weeks due to pregnancyinduced hypertension but has now developed proteinuria. Her blood pressure is 162/94 mmHg. Which one of the following antihypertensives is she most likely to be commenced on?

A. B. C. D. E.

Moxonidine Atenolol Methyldopa Losartan Verapamil

C Consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold Oral methyldopa is often used first-line with oral labetalol, nifedipine and hydralazine also being used For severe hypertension IV labetalol and IV hydralazine are used Addition to the above Delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario.

A 74-year-old man presents to his GP for a medication review. Blood pressure is recorded as 184/72. This is confirmed on two further occasions. What is the most appropriate first line therapy?

A. B. C. D. E.

Ramipril Losartan Bendroflumethiazide Amlodipine Atenolol

D The 2011 NICE guidelines recommended treating isolated systolic hypertension the same way as standard hypertension. In this age group calcium channel blockers would be first-line.

The use of beta-blockers in treating hypertension has declined sharply in the past five years. Which one of the following best describes the reasons why this has occurred?

A. Less likely to prevent stroke + potential impairment of glucose tolerance B. Less likely to prevent myocardial infarctions + potential impairment of glucose tolerance C. High rate of interactions with other commonly prescribed medications (e.g. Calcium channel blockers) D. Increased incidence of reported adverse effects E. Increased incidence of chronic obstructive pulmonary disease

A This was demonstrated in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA).

You review an 82-year-old woman in clinic. Last month she had a one-off blood pressure reading of 150/92 mmHg and was offered ambulatory blood pressure monitoring. This shows an average reading of 146/94 mmHg. She has no significant past medical history of note other than hypothyroidism. What is the most appropriate management?

A. Arrange further ambulatory blood pressure monitoring B. Start a thiazide-type diuretic C. Give lifestyle advice and repeat blood pressure in 6 months D. Start an ACE inhibitor E. Start a calcium channel blocker

C NICE now only recommend diagnosing people over the age of 80 years as hypertensive if they have stage 2 hypertension (ABPM daytime average or HBPM average BP >= 150/95 mmHg).

Your next appointment is with a 47-year-old woman. She has come for the results of her ambulatory blood pressure monitoring (ABPM). This was arranged as a clinic reading one month ago was noted to be 146/92 mmHg. The results of the ABPM show an average reading of 126/78 mmHg. What is the most appropriate course of action?

A. Make the final decision based on a clinic blood pressure reading today B. Offer repeat ABPM in 6 months time C. Offer repeat ABPM in 12 months time D. Reassure her that she does not need another blood pressure check for 10 years E. Offer to measure the patient's blood pressure at least every 5 years

E In this situation where the ABPM has shown a sub-threshold average blood pressure NICE recommend offering to measure the patient's blood pressure at least every 5 years.

An 83-year-old woman is reviewed in the hypertension clinic. What should her target blood pressure be once on treatment?

A. 140/80 mmHg B. 140/90 mmHg C. 130/80 mmHg D. 140/85 mmHg E. 150/90 mmHg

E Blood pressure target (based on clinic readings) for patients > 80 years - 150/90 mmHg

Many Thanks