Hypertension: Kieran Mcglade Nov 2001 Department of General Practice Qub

Kieran McGlade Nov 2001
Department of General Practice QUB

Hypertension


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


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.


The left ventricle is markedly thickened in this patient
with severe hypertension that was untreated for many
years. The myocardial fibers have undergone
hypertrophy.


H O T
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


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


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.


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 cardio-
vascular disease.
At least 60% of patients will require 2 or 3
antihypertensive agents to achieve tight
control.


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


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


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.


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


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




Coronary Risk Calculator

Launch risk calculator program


Compelling and possible indications and contrindications for
the major classes of antihypertensive drugs

INDICATIONS CONTRAINDICATIONS

CLASSS OF DRUG COMPELLING POSSIBLE POSSIBLE COMPELLING
a-blockers Prostatism Dyslipidaemia Postural Hypotension Unrinary incontinence
Angiotensin converting enzyme (ACE) inhibitors
Heart failure
Left ventricular dysfunction
Chronic renal disease *
Type II diabetic nephropathy
Renal impairment *
Peripheral vascular disease
Pregnancy
Renovascular disease
Angiotensin II receptor antagonists Cough induced by ACE inhibitor
Heart failure
Intolerance of other antihypertensive drugs
Pregnancy
Renovascular disease
b-blockers

Myocardial infarction
Angina

Heart failure

Heart failure
Dyslipidaemia

Asthma or COPD
Heart block
Calcium antagonists (dihydropyridine) Isolated systolic hypertension (ISH) in elderly patients
Angina
Elderly patients
_ _
Calcium antagonists (rate limiting) Angina Myocardial infarction Combination with b-blockade
Heart block
Heart failure
Thiazides Elderly patients including ISH _ Dyslipidaemia 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 with renovascular disease.
If ACE inhibitor indicated
f b-blockers may worsen heart failure, but in specialist hands may be used to treat heart failure

British Hypertension Society Guidelines 2000


Therapeutic targets
Therapeutic targets *

Measured in clinic Mean daytime ABPM
or home measurement

Blood Pressure No diabetes Diabetes No diabetes Diabetes
Optimal <140/85 <140/80 <130/80 <130/75
Audit Standard <150/90 <140/85 <140/85 <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


Logical Combinations
Diuretic
b-
blocker
CCB
ACE
inhibitor
a-
blocker
Diuretic - -
b-blocker - * -
CCB - * -
ACE inhibitor - -
a-blocker -
* Verapamil + beta-blocker = absolute contra-indication


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)


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)


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


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.


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 cost-
effective 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.


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


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.

Hypertension: Kieran Mcglade Nov 2001 Department of General Practice Qub

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Kieran McGlade Nov 2001

Department of General Practice QUB

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