Professional Documents
Culture Documents
Hypertension: Kieran Mcglade Nov 2001 Department of General Practice Qub
Hypertension: Kieran Mcglade Nov 2001 Department of General Practice Qub
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
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.
Kieran McGlade Nov 2001
Department of General Practice QUB
The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.
Kieran McGlade Nov 2001
Department of General Practice QUB
HOT
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
Kieran McGlade Nov 2001
Stages
Identification of hypertensive patients Baseline investigations Initiating therapy Reviewing patients Stepping up therapy Motivation and compliance
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 contra- indications
Compelling and possible indications and contrindications for the major classes of antihypertensive drugs
INDICATIONS
CLASSS OF DRUG a-blockers Angiotensin converting enzyme (ACE) inhibitors COMPELLING Prostatism Heart failure Left ventricular dysfunction Cough induced by ACE inhibitor Myocardial infarction Angina Heart failure Dyslipidaemia Peripheral vascular disease Asthma or COPD Heart block POSSIBLE Dyslipidaemia Chronic renal disease * Type II diabetic nephropathy Heart failure Intolerance of other antihypertensive drugs Heart failure
CONTRAINDICATIONS
POSSIBLE Postural Hypotension Renal impairment * Peripheral vascular disease Peripheral vascular disease COMPELLING Unrinary incontinence Pregnancy Renovascular disease Pregnancy Renovascular disease
b-blockers
* 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 If ACE inhibitor indicated f b-blockers may worsen heart failure, but in specialist hands may be used to treat heart failure with renovascular disease.
Therapeutic targets
Measured in clinic Mean daytime ABPM or home measurement
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
Diuretic
b-blocker CCB ACE inhibitor
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)
RECOMMENDATIONS
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
Kieran McGlade Nov 2001
Department of General Practice QUB
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.