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TBL on Hypertension Therapeutics

Assoc Prof Dr Kwa Siew Kim Family Medicine Dept IMU

April 2011 Semester 8

Pre-requisites
Before you embark on this TBL, revisit the lectures on hypertension treatment in Phase 1 You should also read up the latest 2008 Malaysian Clinical Practice Guidelines (CPG) on Management of Hypertension

Revision activity 1:
How would you classify hypertension? What are the co-morbidities that would affect the management of hypertension? What are the common medications prescribed for hypertension? What are the common side effects?

Revision activity 2:
How would you treat hypertension in the following special cases?
children, elderly, pregnant women Chronic disease: hypertension, diabetes, stroke, LVH, IHD, heart failure, renal disease, connective tissue disease, peripheral vascular disease Accelerated/emergency hypertension

Background Reading
1. Clinical Practice Guidelines: Management of Hypertension. MOH/P/PAK/156.08 (GU). 3rd Edition Feb 2008. Ministry of Health Malaysia, Academy of Medicine of Malaysia, Malaysian Society of Hypertension. http://www.malaysianheart.org/section.php?sid =23&pb=Normal (accessed on 28.2.11) 2. D Gareth Beavers, Gregory YH Lip, Eoin OBrien. ABC of Hypertension. 5th Ed. BMJ Books. Blackwell Publishing. (Available in the IMU library is the 5th Edition published in 2007)
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Prevalence of hypertension in Malaysians aged 30 years and above


?? ?
60 50 40 30 20 10 0
1986

42.6 % 29.9 % 14.4%

1996

2006

2016

What does NHMS III show?


Prevalence of hypertension has increased But there is little difference in the rate of awareness and rate of BP control in the hypertensive population Rate of blood pressure control remains poor (26%) although more diagnosed patients are prescribed with medication for hypertension
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CVD Risk Factors


Hypertension*
Diabetes mellitus* Dyslipidemia* Obesity* (BMI >30 kg/m2) * Components of the metabolic syndrome Cigarette smoking Physical inactivity Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD (men under age 55 or women under age 65)
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Benefits of Lowering BP
Average Percent Reduction Stroke incidence 3540% Myocardial infarction 2025% Heart failure 50%

State of HPT Management


In general, management of hypertension is poor despite awareness and knowledge only 1/5 of hypertensive patients are identified 1/5 are treated 1/5 are treated to target

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What is our objective?


At the end of this session, students should be able to manage the hypertension in the primary care setting based on therapeutic guidelines

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TBL-your tasks are to:


Recognise the different co-morbidities with hypertension seen in primary care List the common groups of medication prescribed for hypertension Describe the mode of action of the drug groups and its side effects Discuss and provide answers to the clinical scenarios in Clinical trigger Summarise the learning issues in Revision activity
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KEY MESSAGES: CLINICAL PRACTICE GUIDELINE ON HYPERTENSION, 2008

1.

2.
3. 4.

5.

Definition of hypertension: persistent elevation of BP of >140/90 mmHg Prevalence of hypertension in Malaysians > 30 years was 42.6% in 2006 64% of HPT in Malaysia undiagnosed. Do opportunistic BP at every encounter Not treated or poorly treated HPT leads to increased cardiovascular, cerebrovascular and renal morbidity and mortality BP of 120 to 139 over 80 to 89 mm Hg is defined as prehypertension and should be treated in certain high risk groups
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KEY MESSAGES: CLINICAL PRACTICE GUIDELINE ON HYPERTENSION, 2008


6. Lifestyle changes for all HPT/ prehypertension 7. Base drug treatment on global vascular risks 8. For new cases with no complications, first line monotherapy includes all except BB 9. Only 26% of Malaysians on treatment reach target BP (<140/90 mmHg). 10. Combination therapy is often required to achieve target and may be instituted early
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SUMMARY OF SOME RECOMMENDATIONS


From 3rd Malaysian CPG

Measurement of Blood Pressure


mercury sphygmomanometer is the gold standard Take BP in both arms, use higher reading Take lying and standing systolic drop of >20 mmHg is considered a significant postural drop Home BP measurement useful to monitor control empowers patient with BP control and may improve compliance
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HPT Emergencies
systolic BP >210 and or diastolic BP >120 admit Useful drugs are
Captopril Nifedipine Labetalol Hydralazine, etc

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Management of Severe Hypertension


Hypertensive urgencies
reduce BP slowly by 25% over 24 hours but not lower than 160/90 mmHg

Hypertensive emergencies
Reduce BP rapidly by 25% over 3 to 12 hours but not lower than 160/90 mmHg

NEVER give nifedipine sublingual


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Hypertension and Diabetes Mellitus


Rx when BP is persistently >130/80 Target to <130/80 If albuminuria, treat with ACEI even if BP normal Lower BP to <125/75 if proteinuria >1g/24 hours ACEI preferred to ARB unless cough
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Hypertension and Stroke


BP most important predictor for stroke CCB are better to protect against stroke compared to diuretic and/or BB ACEI + diuretic has been shown to reduce stroke recurrence in both normotensive and hypertensive patients morbidity and mortality from further strokes significantly lower in patients receiving ARBs compared with CCBs In haemorrhagic stroke, avoid lowering BP in the first few days of accelerated hypertension or hypertensive emergencies
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Hypertension in the Elderly


Target BP level same as for the young < 140/90 Those with high systolic hypertension can reduce SBP to below 160 mmHg initially Weight loss and salt reduction effective because of their greater sensitivity to sodium intake All 5 major classes of drugs (diuretics, BB, CCBs, ACEIs and ARBs) reduce CVD events in elderly But elderly more sensitive to diuretics and CCB ACEI is drug of choice for those with concomitant left ventricular systolic dysfunction, post myocardial infarction or diabetes mellitus. Standing BP should be measured to detect postural hypotension
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Drug Classes in HPT


Diuretics ACEI / ARB Calcium channel blockers blockers blockers Combined blockers Centrally-acting drugs-methyldopa, moxonidine Direct renin inhibitor (Aliskiren)-new kid on the block
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Effective combination
-blockers + diuretics -blockers + CCBs CCBs + ACEIs ACEIs + diuretics ACEI/ARBs + diuretics Benefits proven in the elderly (diuretics & CCB), cost-effective. Relatively cheap, appropriate for concurrent CHD. Appropriate for concurrent dyslipidaemias and diabetes mellitus. Appropriate for concurrent heart failure, diabetes mellitus and stroke.

Appropriate for concurrent heart failure, left-ventricular hypertrophy and diabetes mellitus.
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Choice of HPT drugs


Dyslipidaemia- ACEI & ARB, CCB LVH- ARB/ACEI Diabetes- ACEI & ARB, CCB, diuretics Elderly- diuretics & CCB Stroke- CCB (10 prevention) & ACEI (post stroke) CHD & Angina- -blockers & long acting CCB LV dysfunction & post MI- -blockers & ACEI Heart failure- ACEI & diuretics (-blockers metoprolol, bisoprolol, carvedilol (alpha and beta)) Proteinuria- ACEI & ARB Benign prostate enlargement- blockers HPT in pregnancy- methyldopa, labetalol
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Some contraindications
Diuretics: gout ?dyslipidaemia, ?diabetes ACEI/ARB: bilateral renal artery stenosis -blockers: asthma, PVD, ?DM ?dyslipidaemia Avoid using short acting CCB (nifedipine) in CHD and unstable angina Be careful about BP lowering immediately after stroke
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Hypertension Cases for Discussion


There are 2 OBAQ There are 6 cases for discussion Divide into your 2 groups Each group is to work through ALL cases You can use the references provided to guide you through the cases

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Work through these: OBAQ 1


A 28-year-old man is found to have a BP reading of between 130/82-139/88 mmHg This is confirmed on two further occasions What is the most appropriate diagnosis?
A. Stage 3 Hypertension Stage 2 Hypertension Stage 1 Hypertension Prehypertension

B.

C.

D.

E.

Normal

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OBAQ 2
A 70-year-old man is diagnosed with hypertension His BP reading is 186/74mm Hg He also has BPH What is the most appropriate BP therapy?
A. Alpha blockers
Angiotensin Receptor Blockers Angiotensin Receptor Inhibitors Beta blockers

B.

C.

D. E.

Thiazide diuretics
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Case study 1 Hypertension and the Elderly


Mr. Ismail is a 72-year-old Malay man who has 3 repeated blood pressure reading of 180/80 mm Hg despite lifestyle changes. He is asymptomatic and does not have any end organ damage from hypertension. Questions: What condition does he have? Would he benefit from pharmacological treatment? Give reasons for your answer. Which drug(s) is suitable?
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Case study 2 Hypertension and pregnancy


28-year-old primigravida who has a prepregnancy blood pressure reading of 100/60 mm Hg. Blood pressure reading at 24 weeks gestation is sustained at 130/82. Question: Does she have PIH? For hypertension in pregnancy, which antihypertensive drug(s) would you advise? Give reasons for your choice
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Case 3: 57 years old Malay contractor


Severe hypertension started on Rx with atenolol 100 mg bd and nifedipine 20 mg tds BP was uncontrolled at 190/110 mm Hg. Started on hydrochlorothiazide 25 mg om 3 days ago Sudden onset of right knee pain on waking up On examination, BP is 170/100 mm Hg. Pulse is 54 beats per min. BMI 35 WC 110 cm Right knee joint: red, swollen, hot, very tender Questions: What is the cause of his knee arthritis? How would you manage his hypertension? He develops angina. Would you offer him aspirin for secondary prevention?
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Case study 4 Hypertension and Comorbid conditions


Muthusamy is a 48-year-old smoker with gout, hypertension, dyslipidaemia and previous MI His wife is asthmatic and his son has eczema He is on treatment with metoprolol 50 mg daily. His blood pressure reading is between 140/90160/100 mm Hg Questions: Comment on his hypertension treatment. What hypertensive drug(s) are suitable for him?
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Case study 5 ACEI


Mr. Lim, a 52-year-old diabetic was prescribed ACEI for newly-diagnosed hypertension. His initial serum creatinine prior to treatment is 100 mol/l One week later, his serum creatinine is 150 mol/l

Questions: Explain why. What should you do?


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Case study 6 Hypertensive Urgencies


Mr. Lim, a 52-year-old asymptomatic man was incidentally found to have BP of 190/112 mm Hg repeated three times He was treated with sublingual nifedipine and his BP dropped to 100/60 mmHg He then developed left-sided hemiplegia Questions: What went wrong? Comment on his hypertension management.
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