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Hypertension What to do when you don’t know what to do! Fiona Stewart Auckland Heart Group Auckland City Hospital 2 nd Sept 2011. Hypertension NZ Heart Foundation Recommendations. Essential Hypertension BP < 140/85 Hypertension with Diabetes BP < 130/80
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Hypertension What to do when you don’t know what to do! Fiona Stewart Auckland Heart Group Auckland City Hospital 2nd Sept 2011
HypertensionNZ Heart Foundation Recommendations Essential Hypertension BP < 140/85 Hypertension with Diabetes BP < 130/80 Renal disease BP < 130/80 Proteinuria > 1g/dBP < 125/75 Age > 80 BP < 150/
Blood Pressure Measurement • Correct cuff size • Sitting x2 at 2 minute intervals • Standing BUT in patients with borderline BPs • Single recordings are unreliable • Multiple clinic recordings correlate poorly with ABU • Home BP monitoring is not much better Consider Repeat visit Nurse check (“white coat hypertension”) Home BP monitoring Ambulatory 24hr BP monitoring
Blood Pressure Review • History • Other illnesses (cardiovascular disease, diabetes, renal disease, gout) • Family history • Lifestyle assessment • Smoking, alcohol (max 1-2/d) salt intake, liquorice ingestion, weight, exercise, stress • Basic tests • FBC, U + E, urate, creat, eGFR, gluc, lipids, MSU • ECG
Blood Pressure ReviewAdditional Tests Indication • Abnormal screening tests • Young • BP severe or hard to control • Renin, aldosterone, cortisol • 24h U metanephrines • Renal scan and doppler study • Echocardiogram – LVH, ascending aorta
Prehypertension • Linear increase in risk from BP 115/75 • ↑20mmHg SBP or ↑10mmHg DBP doubles mortality from cardiovascular disease • BP 120-139/80-89 “prehypertension”
Prehypertension Management • Weight • Salt intake (including soya sauce) • Liquorice ingestion • Alcohol • Stress • Exercise • Contributing drugs (NSAIDs)
Hypertension - Treatment • Systolic BP better predictor of adverse cardiovascular events especially in elderly • Persistent BP > 140/85 → treat • Over 80 years – aim for SBP<150 • Always check standing BP
Which Antihypertensive is Best?ALLHAT Trial • Chlorthalidone 12.5 – 25mg • Amlodipine • Lisinopril • Doxazosin
ALLHAT Trial • Target BP < 140/90 • 67% achieved target • 2/3 were taking 2+ agents • 1/4 were taking 3+ agents • Expect to need multiple medications to control BP
ACCOMPLISH Trial • ACEI + Amlodipine • ACEI + Hydrochlorothiazide
ACCOMPLISH Trial • 21% Reduction in CV death, MI, CVA over 3 years • NNT to prevent one major event = 77 • 37% were taking > 3 agents
HypertensionTreatment Choice Assess comorbidity. Multiple drugs are usually necessary First Line • Thiazides • ACEI/ARB • CCB Second Line • Beta blockers Third Line • Spironolactone • Alpha blockers • Clonidine Fourth Line • Ardian radiofrequency ablation of renal artery Statin
Treatment of Hypertension in the Very Elderly > 80HYVET trial • Patients aged > 80 • SBP >160mmHg, DBP < 110mmHg • Indapamide 1.5mg + Perindopril 2-4mg vs placebo • Target BP 150/80
Blood pressure separation 15 mmHg Median follow-up 1.8 years 6 mmHg
All stroke (30% reduction) Placebo P=0.055 Indapamide SR ±perindopril Placebo IndapamideSR ±perindopril
Total Mortality (21% reduction) Placebo P=0.019 Indapamide SR ±perindopril Placebo IndapamideSR ±perindopril
Fatal Stroke (39% reduction) Placebo Indapamide SR ±perindopril P=0.046 Placebo IndapamideSR ±perindopril
Heart Failure (64% reduction) Placebo P<0.0001 IndapamideSR ±perindopril Placebo IndapamideSR ±perindopril
0.1 0.2 0.5 0 2 ITT – Summary
Starting Antihypertensive Treatment • Change only one medication at a time • Arrange follow up BP measurements (L+S) • Check electrolytes with diuretics • Escalate early to a second agent • Feedback results to the patient
BP Remains Elevated • Confirm hypertension with 24hr monitor • Check for secondary causes • Renal scan ? Renal artery stenosis • Cortisol, renin, aldosterone, metanephrines • Lifestyle adjustments – stress, salt • Compliance • Optimal medication dose and frequency
Optimising Medication • Thiazides • Chlorthalidone more effective than HCZ • ACEI • Cilazapril and lisinopril – daily dose • Enalapril and quinapril – bd dose • Angiotensin II Blockers • Titrate dose to 32mg candesartan, 100mg losartan • CCBs • Amlodipine and felodipine 10mg
Chronic Hypertension and Pregnancy Measurement • Sitting • DBP 4thKorotkoff sound DBP <90mmHg from conception to 20/40 is strongly correlated with lower rates of pre-eclampsia ACEI and ARB are contraindicated from 6 weeks gestation. ACEI are safe with breast feeding. Metoprolol, oxprenolol and labetalol are associated with a better fetal outcome than other beta-blockers Methydopa has a long record of safety in pregnancy CCBs are well tolerated in pregnancy
The kidney as origin of sympathetic drive carried centrally via renal afferent sympathetic nerves generating central sympathetic drive Vasoconstriction Atherosclerosis Hypertrophy Arrhythmia Oxygen Consumption Sleep Disturbances Renal Afferent Nerves Insulin Resistance Renal Efferent Nerves ↑ Renin Release RAAS activation ↑ Sodium Retention ↓ Renal Blood Flow
Radiofrequency energy can ablate the renal sympathetic nerves
Symplicity HTN-1 Lancet. 2009;373:1275 • First-in-man, non-randomized • 45 patients with resistant HTN (SBP ≥160 mmHg on ≥3 anti-HTN drugs, including a diuretic) • Expanded cohort of patients (n=153) • 24-month follow-up 35
Significant, Sustained BP Reduction BP change (mmHg) 36
Primary Endpoint: 6-Month Office BP ∆ from Baseline to 6 Months (mmHg) Systolic Diastolic Diastolic Systolic 33/11 mmHg difference between RDN and Control (p<0.0001) • 84% of RDN patients had ≥ 10 mmHg reduction in SBP • 10% of RDN patients had no reduction in SBP Symplicity HTN-2 Investigators. Lancet. 2010;376:1903. 37
Changes in Glucose Toleranceat 3 Months after Renal Denervation Mahfoud et al. European Society of Cardiology. 2010.