Hypertension

Kieran McGlade Nov 2001

Department of General Practice QUB

Aetiology of Hypertension
Primary 90-95% of cases also termed essential of idiopathic Secondary about 5% of cases Renal or renovascular disease Endocrine disease
Phaeochomocytoma Cusings syndrome Conns syndrome Acromegaly and hypothyroidism

Coarctation of the aorta Iatrogenic

Hormonal / oral contraceptive NSAIDs
Kieran McGlade Nov 2001 Department of General Practice QUB

This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy.
Kieran McGlade Nov 2001 Department of General Practice QUB

The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.
Kieran McGlade Nov 2001 Department of General Practice QUB

HOT
Hypertension Optimal Treatment Largest intervention trial in hypertension. Published in 1998 Conducted in General Practice. 18,790 patients in 26 countries Followed up for an average of 3.8 years

Kieran McGlade Nov 2001

Department of General Practice QUB

H O T Findings
Lowest incidence of major CV events occurred at a mean achieved DBP of 83 mmhg. This target (compared to mean achieved of 105 mmHg was associated with a 30% reduction in main CV events. In diabetes Diastolic< or = 80mmhg 51 % lower risk compared to 90 mmHg
Kieran McGlade Nov 2001

Department of General Practice QUB

Global heart threat from diabetes:

A global explosion in the number of cases of diabetes is threatening to reverse the reduction in deaths from heart disease in many western countries, including the United Kingdom. To coincide with World Diabetes Day on 14 November, Diabetes UK is calling for action to be taken to reduce the 20,000 deaths per year from coronary heart disease (CHD) among people with diabetes in the UK.

Kieran McGlade Nov 2001

Department of General Practice QUB

Hypertension and Diabetes

Hypertension co-exists with type II in about 40% at age 45 rising to 60% at age 75. 70% of type II patients die from cardiovascular disease. At least 60% of patients will require 2 or 3 antihypertensive agents to achieve tight control.
Kieran McGlade Nov 2001 Department of General Practice QUB

Stages
Identification of hypertensive patients Baseline investigations Initiating therapy Reviewing patients Stepping up therapy Motivation and compliance

Kieran McGlade Nov 2001

Department of General Practice QUB

Investigation of the New Hypertensive

History and examination Exclude secondary Hypertension Urea and electrolytes FBP and ESR ECG Lipid profile

Chest x-ray no longer routinely indicated

Kieran McGlade Nov 2001 Department of General Practice QUB

Clinical clues to renal vascular disease

Hypertension under 50 Yrs of age. Generalised vascular (esp peripheral) disease. Mild moderate renal dysfunction. Sudden onset pulmonary oedema.

Kieran McGlade Nov 2001

Department of General Practice QUB

Ladder Approach
Bendrofluazide Bendrofluazide + Atenolol or ACE Calcium Channel blocker Alpha blocker

Kieran McGlade Nov 2001

Department of General Practice QUB

Tailored Approach
Assessment of overall cardiovascular risk Recognition of co-morbidities Lipid profile Renal function Existing contra- indications

Kieran McGlade Nov 2001

Department of General Practice QUB

Kieran McGlade Nov 2001

Department of General Practice QUB

Coronary Risk Calculator

Launch risk calculator program

Kieran McGlade Nov 2001

Department of General Practice QUB

Compelling and possible indications and contrindications for the major classes of antihypertensive drugs
INDICATIONS
CLASSS OF DRUG E-blockers Angiotensin converting enzyme (ACE) inhibitors COMPELLING Prostatism Heart failure Left ventricular dysfunction Cough induced by ACE inhibitor Myocardial infarction Fblockers Angina Heart failure Dyslipidaemia Peripheral vascular disease Asthma or COPD Heart block POSSIBLE Dyslipidaemia Chronic renal disease * Type II diabetic nephropathy Heart failure Intolerance of other antihypertensive drugs Heart failure

CONTRAINDICATIONS
POSSIBLE Postural Hypotension Renal impairment * Peripheral vascular disease Peripheral vascular disease COMPELLING Unrinary incontinence Pregnancy Renovascular disease Pregnancy Renovascular disease

Angiotensin II receptor antagonists

Calcium antagonists (dihydropyridine)

Isolated systolic hypertension (ISH) in elderly patients

Angina Elderly patients Myocardial infarction _

Calcium antagonists (rate limiting) Thiazides

Angina Elderly patients including ISH

Combination with Fblockade Dyslipidaemia

Heart block Heart failure Gout

* ACE inhibitors may be beneficial in chronic renal failure but should be used with caution. Close supervision and specialist advice are needed when there is established and significant renal impairment Caution with ACE inhibitors and angiotensin II receptor antagonists in peripheral vascular disease because of association If ACE inhibitor indicated J F-blockers may worsen heart failure, but in specialist hands may be used to treat heart failure with renovascular disease.

British Hypertension Society Guidelines 2000

Kieran McGlade Nov 2001

Department of General Practice QUB

Therapeutic targets
Measured in clinic Mean daytime ABPM or home measurement

Blood Pressure Optimal Audit Standard

No diabetes <140/85 <150/90

Diabetes <140/80 <140/85

No diabetes <130/80 <140/85

Diabetes <130/75 <140/80

The audit standard reflects the minimum recommended levels of BP control. Despite best practice, it may not be achievable in some treated hypertensive patients. NB: Both systolic and diastolic targets should be reached

British Hypertension Society Guidelines

Kieran McGlade Nov 2001 Department of General Practice QUB

Logical Combinations Diuretic Diuretic F-blocker CCB ACE inhibitor   Fblocker  * CCB *  ACE inhibitor   Eblocker     -

E-blocker     * Verapamil + beta-blocker = absolute contra-indication

Kieran McGlade Nov 2001 Department of General Practice QUB

ACE Inhibitor Side Effects

Cough (15% of patients. Is reversible) Taste disturbance (reversible) Angiodema First-dose hypotension Hyperkalaemia ( esp. in patients with type II diabetes and renal dysfunction)

Kieran McGlade Nov 2001

Department of General Practice QUB

Follow-up
For patients with BP stabilised by management, follow up should normally be three monthly (interval should not exceed 6 months), at which the following should be assessed by a trained nurse: * * * * Measurement of BP and weight Reinforcement of non-pharmacological advice General health and drug side-effects Test urine for proteinuria (annually)

Kieran McGlade Nov 2001

Department of General Practice QUB

Web based references

British Hypertension Society: http://www.hyp.ac.uk/bhs/ Summary Guidelines 2000: http://www.hyp.ac.uk/bhs/gl2000.htm Hypertension audit protocol from Leicester http://www.le.ac.uk/genpractice/gpaudit/htn prot.html
Kieran McGlade Nov 2001 Department of General Practice QUB

Drug Treatment of Essential Hypertension in Older People

Hypertension is very common, occuring in over 50% of older people, and is a major risk factor for stroke and ischaemic heart disease. Drug treatment of hypertension in older people saves lives and prevents unnecessary morbidity. Treating isolated systolic hypertension also saves lives.
Kieran McGlade Nov 2001 Department of General Practice QUB

Drug Treatment of Essential Hypertension in Older People

There is strong evidence to support the use of diuretics as first-line agents. Antihypertensive treatments are most costeffective when targeted at older patients. There is evidence of under detection and under treatment of hypertension. Factors influencing patient adherence with treatment are not well understood and require further research.
Kieran McGlade Nov 2001 Department of General Practice QUB

RECOMMENDATIONS

(for the treatment of the elderly)

Through the wider use of antihypertensive therapies more older people would be able to maintain a healthy and active lifestyle. Through the wider use of antihypertensive therapies more older people would be able to maintain a healthy and active lifestyle. For first-line agents there is strong evidence to support the use of diuretics and some evidence for the use of beta-blockers. Systems to ensure that older people with hypertension are diagnosed, treated and followed up need to be developed. A system of audit should be cultivated to assure adequate treatment. High quality research on patient adherence with antihypertensive medications is needed. NHS Centre for reviews and dissemination 1999
Kieran McGlade Nov 2001 Department of General Practice QUB

Practical Points
15 20% of adult western population. Isolated systolic hypertension just as dangerous. Primary cause identified in only 5%. Investigate Urine, FBP, ESR, ECG, U&E, Lipids. Target < 140/85. Bendrofluazide 2.5 mg a good starting point. Refer patients needing more than 3 drugs to control their hypertension.

Kieran McGlade Nov 2001

Department of General Practice QUB