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Overview of presentation. Introduction to hypertensionPresentation to primary careMeasurement of BP/other parametersWhen to manageHow to manageUpdate of recent evidenceQuiz. Introduction to hypertension. Hypertension is not a disease but a risk factor (modifiable)1Lowering BP decreases risk
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1. Hypertension Rosalind Powell
GPST2
2. Overview of presentation Introduction to hypertension
Presentation to primary care
Measurement of BP/other parameters
When to manage
How to manage
Update of recent evidence
Quiz
3. Introduction to hypertension Hypertension is not a disease but a risk factor (modifiable)1
Lowering BP decreases risk of stroke, coronary events, cardiac failure & renal impairment. 2
HP is undiagnosed and undertreated (<50% treated hypertensives optimally controlled)3
NICE definition: SBP >140 or DBP >90 persistently (last 3 readings)1
4. Presentation of hypertension to primary care Usually asymptomatic
May be found on routine screening/incidental.
Headache/visual disturbance.
Symptoms end organ damage: LVH, TIAs CVA,MI, angina, renal impairment, PVD, retinopathy.4
5. Causes Essential hypertension 95%
Secondary hypertension
Drugs – NSAIDS, COC, steroids liquorice, cyclosporine (recreational)
Renal disease
Endocrine: Phaeochromocytoma, Conn’s syndrome, Cushing’s, Acromegally.
Coarctation aorta 3
6. Measurement 1.Screening
British Hypertension Society suggest all adults should have BP measured every 5 years.
If BP ‘high normal’ (SBP 130-139 mmHg DBP 85-89) BP check annually.
Screen any patient with known renal, atherosclerotic disease, diabetes as part of routine follow up.
7. Measurement 2. Measuring BP (NICE)
Environment: relaxed/quiet/warm. Patient seated arm outstretched and supported
1st measurement >140/90 take second reading at end consultation.
Both arms, use higher reading.
Identifying HP: ask patient to return for 2+ appointments.
Use of home monitoring devices not recommended 5
8. Cardiovascular risk NICE suggests carrying out a cardiovascular risk assessment in all hypertensives.
Calculates risk of cardiovascular event over 10 years
Use untreated BP reading
Most primary care computer systems will calculate this
Data included: urine dip, plasma glucose, U&Es, total and HDL cholesterol, ECG 3 & 5
9. Referral to secondary care 1. Immediately:
Malignant/accelerated hypertension (BP >180/110 +papilloedema +/- retinal haemorrhage
Suspected phaeochromocytoma
2. Consider:
Secondary cause suspected
Postural hypotension 5
10. When to manage
11. Management: a NICE overview
12. Management : lifestyle intervention For all patients
Can be used alone for high normal/mild HP
25% achieve reduction of SBP 10mmHg yr 1
Include:
Smoking cessation
Weight reduction (aim BMI 20-25)
Dietary advice : low salt, low fat
Reduce alcohol consumption
Discourage caffeine 3&5
13. Management: Initiating antihypertensives Drug therapy reduces risk of CV disease and death
Offer medication to patients with:
persistent BP 160/100 or more
persistent BP >140/90 and raised CV risk (20%)
Aim to reduce BP to 140/90 (QOF 150/90)
Titrate using BNF
14. Drug choice – newly diagnosed hypertensives
15. Reason for A/CD algorithm Most patients cannot be managed on monotherapy
BHS advised AB/CD algorithm, later reviewed by NICE into A/CD algorithm
Uses age and ethnicity to decide on initial management
Special considerations for deviation.
Theory: classify patients into high and low renin groups. Younger pts have high renin concentrations and respond better to manipulation renin-angiotensin system (with ACEi /ARB), older/afro-Caribbean patients lower renin concentrations, respond better to ca channel blockers/diuretics. 3
16. Beta-blockers NICE state ‘no longer preferred as initial therapy’ as not as effective.
Based on ASCOT study reported in Lancet 2005. Study showed amlodipine (+ACEi) v atenolol (+ BFZ) had similar BP lowering effect but significantly reduced cardiovascular end points. (reduced risk stroke). 6
Used still in younger patients (women child bearing potential, or if contraindication to ACE/ARB
If BP already well controlled on beta blocker, no need to change.
continue beta blockers if angina/post MI 4
17. Drug indications/cautions
18. Hypertension in the elderly Same treatment of >80s as >55s.
Take into account co-morbidities and polypharmacy.
Poorly represented in clinical trials
Studies show benefit including reduction cognitive impairment, strokes and CV events.
No change to overall mortality. 3
19. Hypertension in Diabetes BNF : aim for 130/80 or less.
NICE: aim 140/80 or 130/80 if end organ damage
QOF: 145/85
Hypertension common in type 2 DM, treating HP prevents macro and microvascular complications.
ACE inhibitor or ARB can delay progression of microalbuminuria to nephropathy. 2
20. Hypertension in renal disease CKD aim BP 140/90 (NICE)
Aim for BP 130/80 if proteinuria >1gram/24hours (NICE)
ACE inhibitor or ARB should be considered for patients with proteinuria but must be used with caution in renal impairment.
Ca channel blockers can be used as can loop diuretics – thiazides may be ineffective. 2
21. Additional medication to reduce CV risk If CV risk >20% consider:
Statin
Low dose aspirin once BP controlled
Lower cholesterol to <4.0mmol/L LDL <2.0 3
22. Monitoring/Review Dependent on degree of control, types of therapy and patient compliance
If well controlled, monotherapy and no other co-morbidities may have annual review.
After starting treatment: review 1 month, if controlled review in 3 months, then 6 months, then annually
Reviews to include : BP, urinalysis for proteinuria, bloods for renal function, glucose and lipids and recalculation CV risk.
Lifestyle advice
Discuss side effects/problems
Emphasise importance of life-long treatment 4&5
23. An update of recent evidence ‘Challenging our thinking in hypertension’ BMJ 2009; 338b1665
Meta-analysis looking at impact of different drugs on blood pressure.
Half a million people included in RCT analysis
Summary of findings:
Antihypertensives reduce CV risk regardless of baseline BP
Reduction in CVD in those on antihypertensives can be explained solely through reduction in BP
All classes of antihypertensives have similar effects on CV endpoints. Ca channel blockers reduce incidence CVA than other classes. (Beta blockers do not seem any less effective than other agents when ca channel blockers are removed from the analysis)
In those with CHD beta blockers remain important drug – giving added protection reducing risk further CHD
24. Summary HP under diagnosed and undertreated in UK
Consider causes secondary hypertension in young patients/uncontrolled on 3 antihypertensives
Calculate cardiovascular risk
Lifestyle modification for all patients
Antihypertensives if BP >160/100 or 140/90 with CVD risk >20% or diabetes or target organ damage
ACD algorithm, but consider beta blockers
Regular review
Watch out for NICE/BHS updates
25. AKT! A Angiotensin-converting enzyme inhibitor
B Calcium channel blocker
C Thiazide diuretic
D Beta blocker
E Angiotensin II receptor antagonist
Consider the following hypertensive patients, all of whom need treatment and, bearing recent evidence and guidelines in mind, suggest the single best class of anti-hypertensive for each patient from the list above.
A 40 year old Caucasian lady.
A 60 year old Caucasian man with a past history of gout.
A 40 year old man of Afro-Caribbean origin, also with a history of gout.
A 55year old man who also suffers with angina.
A patient who was initially on Enalapril but has a troublesome tickly cough. 7
26. References www.gp-update.co.uk
BNF 59
InnovAiT vol 2 issue 12 Dec 2009
Oxford handbook of General Practice 3rd edition
NICE clinical guideline 34 ‘Hypertension: management of hypertension in primary care’ (partial update clinical guideline 18) June 2006
‘Guidelines in practice’ ‘Variability in blood pressure is a predictor of stroke’ vol 13 issue 4 April 2010
Applied knowledge test for the new MRCGP Questions and answers for the AKT Nuzhet A-Ali, 2008
27. Thank you!
Any Questions?