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 Conn’s syndrome Acromegaly and hypothyroidism

– Coarctation of the aorta – Iatrogenic
• Hormonal / oral contraceptive • NSAIDs
Kieran McGlade Nov 2001
Department of General Practice QUB

The hypertension creates a greater pressure load on the heart to induce the hypertrophy. but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease.This left ventricle is very thickened (slightly over 2 cm in thickness). 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 .

790 patients in 26 countries • Followed up for an average of 3. Published in 1998 • Conducted in General Practice. 18.8 years Kieran McGlade Nov 2001 Department of General Practice QUB .HOT • Hypertension Optimal Treatment • Largest intervention trial in hypertension.

This target (compared to mean achieved of 105 mmHg was associated with a 30% reduction in main CV events.H O T Findings • Lowest incidence of major CV events occurred at a mean achieved DBP of 83 mmhg. • In diabetes – Diastolic< or = 80mmhg 51 % lower risk compared to 90 mmHg Kieran McGlade Nov 2001 Department of General Practice QUB .

Global heart threat from diabetes: A global explosion in the number of cases of diabetes is threatening to reverse the reduction in deaths from heart disease in many western countries.000 deaths per year from coronary heart disease (CHD) among people with diabetes in the UK. To coincide with World Diabetes Day on 14 November. Kieran McGlade Nov 2001 Department of General Practice QUB . Diabetes UK is calling for action to be taken to reduce the 20. including the United Kingdom.

• At least 60% of patients will require 2 or 3 antihypertensive agents to achieve tight control. Kieran McGlade Nov 2001 Department of General Practice QUB . • 70% of type II patients die from cardiovascular disease.Hypertension and Diabetes • Hypertension co-exists with type II in about 40% at age 45 rising to 60% at age 75.

Stages • • • • • • Identification of hypertensive patients Baseline investigations Initiating therapy Reviewing patients Stepping up therapy Motivation and compliance Kieran McGlade Nov 2001 Department of General Practice QUB .

Investigation of the New Hypertensive • • • • • • History and examination Exclude secondary Hypertension Urea and electrolytes FBP and ESR ECG Lipid profile • Chest x-ray no longer routinely indicated Kieran McGlade Nov 2001 Department of General Practice QUB .

• Sudden onset pulmonary oedema.Clinical clues to renal vascular disease • Hypertension under 50 Yrs of age. • Mild – moderate renal dysfunction. Kieran McGlade Nov 2001 Department of General Practice QUB . • Generalised vascular (esp peripheral) disease.

Ladder Approach • • • • Bendrofluazide Bendrofluazide + Atenolol or ACE Calcium Channel blocker Alpha blocker Kieran McGlade Nov 2001 Department of General Practice QUB .

indications Kieran McGlade Nov 2001 Department of General Practice QUB .Tailored Approach • • • • • Assessment of overall cardiovascular risk Recognition of co-morbidities Lipid profile Renal function Existing contra.

Kieran McGlade Nov 2001 Department of General Practice QUB .

Coronary Risk Calculator • Launch risk calculator program Kieran McGlade Nov 2001 Department of General Practice QUB .

but in specialist hands may be used to treat heart failure with renovascular disease. Kieran McGlade Nov 2001 British Hypertension Society Guidelines 2000 Department of General Practice QUB . 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.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 Angiotensin II receptor antagonists b-blockers Calcium antagonists (dihydropyridine) Isolated systolic hypertension (ISH) in elderly patients Angina Elderly patients Myocardial infarction _ _ _ Calcium antagonists (rate limiting) Thiazides Angina Elderly patients including ISH Combination with b-blockade Dyslipidaemia Heart block Heart failure Gout * ACE inhibitors may be beneficial in chronic renal failure but should be used with caution.

Therapeutic targets Measured in clinic Mean daytime ABPM or home measurement Blood Pressure Optimal Audit Standard No diabetes <140/85 <150/90 Diabetes <140/80 <140/85 No diabetes <130/80 <140/85 Diabetes <130/75 <140/80 The audit standard reflects the minimum recommended levels of BP control. NB: Both systolic and diastolic targets should be reached British Hypertension Society Guidelines Kieran McGlade Nov 2001 Department of General Practice QUB . it may not be achievable in some treated hypertensive patients. Despite best practice.

Logical Combinations Diuretic bblocker  * CCB ACE inhibitor   ablocker     - Diuretic b-blocker CCB ACE inhibitor   *      a-blocker * Verapamil + beta-blocker = absolute contra-indication Kieran McGlade Nov 2001 Department of General Practice QUB .

Is reversible) Taste disturbance (reversible) Angiodema First-dose hypotension Hyperkalaemia ( esp. in patients with type II diabetes and renal dysfunction) Kieran McGlade Nov 2001 Department of General Practice QUB .ACE Inhibitor Side Effects • • • • • Cough (15% of patients.

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) Kieran McGlade Nov 2001 Department of General Practice QUB .Follow-up • For patients with BP stabilised by management.

uk/bhs/ • Summary Guidelines 2000: http://www.uk/genpractice/gpaudit/htn prot.le.Web based references • British Hypertension Society: http://www.htm • Hypertension audit protocol from Leicester http://www.html Kieran McGlade Nov 2001 Department of General Practice QUB .ac.ac.hyp.ac.uk/bhs/gl2000.hyp.

• Treating isolated systolic hypertension also saves lives. and is a major risk factor for stroke and ischaemic heart disease. Kieran McGlade Nov 2001 Department of General Practice QUB . occuring in over 50% of older people.Drug Treatment of Essential Hypertension in Older People • Hypertension is very common. • Drug treatment of hypertension in older people saves lives and prevents unnecessary morbidity.

• Factors influencing patient adherence with treatment are not well understood and require further research. • Antihypertensive treatments are most costeffective when targeted at older patients. Kieran McGlade Nov 2001 Department of General Practice QUB . • There is evidence of under detection and under treatment of hypertension.Drug Treatment of Essential Hypertension in Older People • There is strong evidence to support the use of diuretics as first-line agents.

•A system of audit should be cultivated to assure adequate treatment.RECOMMENDATIONS (for the treatment of the elderly) •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. •High quality research on patient adherence with antihypertensive medications is needed. treated and followed up need to be developed. NHS Centre for reviews and dissemination 1999 Kieran McGlade Nov 2001 Department of General Practice QUB . •Systems to ensure that older people with hypertension are diagnosed. •Through the wider use of antihypertensive therapies more older people would be able to maintain a healthy and active lifestyle.

ECG. FBP. Target < 140/85. U&E.5 mg a good starting point. Primary cause identified in only 5%. ESR. Kieran McGlade Nov 2001 Department of General Practice QUB .Practical Points • • • • • • • 15 – 20% of adult western population. Isolated systolic hypertension just as dangerous. Bendrofluazide 2. Refer patients needing more than 3 drugs to control their hypertension. Lipids. Investigate – Urine.

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