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Hypertension

Hypertension. Dr Nidhi Bhargava 8/10/13. Why Treat. Increased risk of cardiovascular death and mortality Increased systolic, diastolic and pulse pressures (associated with arterial wall and haemodynamic changes)- all equally important Prevalence of HT increases with age

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Hypertension

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  1. Hypertension Dr Nidhi Bhargava 8/10/13

  2. Why Treat • Increased risk of cardiovascular death and mortality • Increased systolic, diastolic and pulse pressures (associated with arterial wall and haemodynamic changes)- all equally important • Prevalence of HT increases with age • Initially both systolic and diastolic increase up to 50years of age • Thereafter systolic continues to rise but diastolic plateau • Diastolic HT most prevalent up to 60years and then either isolated systolic or combined HT- Why?

  3. BP, Stroke and CHD • For each reduction of 10mmHg in SBP and 5mmHg of DBP-associated reduction of stroke by 28% and 34% resp. • HT and LVH • Sokolow-Lyon criteria for assessing LVH-ECG-depth of S wave in V1 added to height of R wave in V5 > 35mm- rule applicable to pts > 40years

  4. Diagnosing Hypertension • Clinic BP ≥ 140/90mmHg Repeat after a few minutes Offer ambulatory BP monitoring (ABPM) ABPM- 24hr BP monitor (2 measurements per hour during pt.'s waking hours and at least 14 measurements to get an average) HBPM- 2 consecutive measurements are taken at least 1-2 mins apart, with pt. seated and record lower of the two readings, twice a day for 4-7 days Discard 1st day’s readings and then taken an average

  5. Stages of Hypertension • Stage 1- clinic BP 140/90 or higher And ABPM or HBPM is ≥ 135/85 mmHg Stage 2- Clinic BP ≥ 160/100mmHg And ABPM or HBPM is ≥ 150/95mmHg Stage 3- clinic systolic BP is ≥ 180mmHg or higher or diastolic BP ≥ 110mmHg start treatment immediately

  6. Lifestyle Changes • Weight reduction- age independent correlation between HT and obesity, 3 fold increased risk in pt. with body weight > 20% • Salt intake reduction- recommended intake < 6 g/day of NaCl, salt restriction can result in >5mmHg of diastolic reduction in 30-40% • Exercise-aerobic exercise results in wt. reduction and hence BP reduction • Reduce excess alcohol intake- < 21 units for men and <14 units for women per week • Stop smoking

  7. Use of Antihypertensives-1

  8. Use of Antihypertensives-2

  9. Initiating Treatment • Pts < 80yrs with stage 1 HT with 1 or more of the following • Target organ disease • Established CVD • Renal disease • Diabetes • 10yrs CVD risk ≥ 20%

  10. Offer treatment to pts of any age with stage 2 HT • For pts <40 years with stage 1 HT investigate for secondary causes • For pts >80 yrs. same as above

  11. Assessing Cardiovascular risk • Assess target organ damage • Urine acr and urine dip for haematuria • UEs , lipids , glucose, cholesterol and eGFr • Fundi examination for hypertensive retinopathy • Routine ecg

  12. Secondary causes of HT • Renal US • Renin and aldosterone levels • 3 × 24 hour urine collections for catecholamine • CT/MRI of abdomen to look at adrenals • MRA/MRI for renal artery stenosis • Investigate if BP not controlled on 3 antihypertensive at any age

  13. Treatment options • Step 1 • If ≤ 55years • ACEI or a low cost ARB • If > 55 and pts of AfroCarribean origin CCB • if not suitable or oedema or evidence of HF then thiazides diuretics- prefer indapamide or chlorthalidone

  14. Step 2 • If ≤ 55 years • A+C or A+D • If > 55years or Afrocarribean • C+A or C+ARB • B+C rather than D if increased risk of diabetes • Before adding 3rd medication ensure step 2 treatment is at optimal or best tolerated doses

  15. Step 3 • A+C+D • If BP ≥ 140/90mmHg resistant HT • Step 4 • Add low dose spironolactone 25mgs if K ≤ 4.5 • Higher dose diuretic if K > 4.5, check UEs in a month • If UEs worsening consider α or ß blocker and refer if still not controlled

  16. BP targets • Age < 80years BP<140/90mmHg • Age > 80years BP <150/90mmHg • ABPM/HBPM • Age <80years- BP<135/85 • Age >80years-BP<145/85mmHg

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