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HYPERTENSION

HYPERTENSION. NMP. How Common?. 25% UK adults > 50% adults over 60. Hypertension: the silent killer. Asymptomatic Not associated with Headaches nosebleeds. CVA MI CCF CKD PVD Cognitive decline Premature death. Depends on ethnicity Cf diabetes. Complications. Treatment.

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HYPERTENSION

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  1. HYPERTENSION NMP

  2. How Common? • 25% UK adults • > 50% adults over 60

  3. Hypertension: the silent killer • Asymptomatic • Not associated with • Headaches • nosebleeds

  4. CVA MI CCF CKD PVD Cognitive decline Premature death Depends on ethnicity Cf diabetes Complications

  5. Treatment • Life style • Drugs • Rarely surgery • Bariatric surgery • Endocrine surgery • Renal artery angioplasty • Renal denervation

  6. NICE guidelines Aug 2011 • Primary care • Excludes • Diabetes • 18 yrs • pregnancy

  7. 3 Stages of hypertension • 1 clinic BP >140/90 • ABPM is >135/85 • 2 clinic BP >160/100 • ABPM >150/95 • 3 SEVERE BP>180/110

  8. ABPM • Do not start treatment without ABPM unless severe hypertension ie 180/110 • Monitor about half the size of the BNF • Home monitoring an alternative but much less data • Huge resource implications • ?? Save money

  9. Who To Treat? • Stage 1 • Under 80 • Target organ damage • Established cardiovascular disease • Renal disease • Diabetes • 10 year cardiovascular risk>20% • Think about under 40 • Stage 2 treat

  10. Relearn your alphabet • No longer ABCD • Now ACDD

  11. Step 1 • Under 55 • A ACE or ARB • Ramipril, perindopril • Losarten irbesarten candasarten • C Over 55, or African or carribean • C calcium channel blocker • Amlodipine

  12. Step 2 • Add A to C

  13. Step 3 • Add A to C to D • Now using thiazide like diuretics NOT bendroflumethazide or hydrochlorothiazide • Indapamide or chlortalidone

  14. Step 4 • Add in further diuretic • D Spironolactone • If Potassium <4.5 • NB low GFR • Increase dose of non thiazide

  15. Step 5 • Free for all • ? Refer • ? Alpha blocker • ? Beta blocker

  16. Own Goals • Spironolactone does not have a product license for hypertension • Recommended dose of chlortalidone is 12.5 or 25 and only 50 mg is available.

  17. Pharmacology ACE/ARB • ACE 10-20% will have a dry cough • ARB is an ACE without the dry cough and without angio oedema • First dose hypotension • Bilateral renal artery stenosis • Worsening U and E • High potassium

  18. Renin angiotensin system Low BP Renin excretion from kidney (enzyme) Renininhibitor Spironalactone Angiotensinogen Inc. aldosterone from adrenals Retention of salt and water from kidney Angiotensin 1 ACE-I Angiotensin II Vasoconstriction ARBs Renal retention of salt and water

  19. Calcium channel blockers • Usually amlodipine but I also use diltiazem and verapamil • Main side effect is ankle oedema with amlodipine • Swop to verapamil or diltiazem • Lower the dose. Try 2.5mg • Gum hyperplasia • Drug interaction with simvastatin

  20. Spironolactone • (Potassium sparing diuretic) • Aldosterone antagonist • Oestrogen like side effects • Gynacomastia and high potassium

  21. Chronic diseases • No decision about me without me

  22. Case study • 32 year old city worker • Presented to GP with headaches • Found to be hypertensive

  23. Referred to a neurologist No cause found for headaches Multiple intolerances to BP drugs Referred to hypertensive clinic

  24. Full history and examination BP 165/104 Confirmed on ABPM Amlodipine 5 mg started

  25. Comes back 4 weeks later complaining of a headache Stopped Amlodipine BP still high

  26. Explained that he always has headaches and no serious cause found If BP remains high he is at risk of CVA/MI Asked him want he wanted to do

  27. I will take the amlodipine

  28. Non Pharmacological management • This has not changed • Alcohol • Smoking • Diet • Decrease caffeine • decrease salt • (5 a day) • (Low fat dairy products) • Wt loss if appropriate • Exercise

  29. Summary • Down load new guidelines • NB Amlodipine and Simvastatin • No decision about me without me.

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