Hypertension

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

Coarctation of the aorta

Iatrogenic
Hormonal / oral contraceptive
NSAIDs

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.

The left ventricle is markedly thickened in this patient

with severe hypertension that was untreated for many
years. The myocardial fibers have undergone
hypertrophy.

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

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, including the
United Kingdom. To coincide with World
Diabetes Day on 14 November, Diabetes
UK is calling for action to be taken to
reduce the 20,000 deaths per year from
coronary heart disease (CHD) among
people with diabetes in the UK.

Hypertension and Diabetes

Hypertension co-exists with type II in about
40% at age 45 rising to 60% at age 75.
70% of type II patients die from cardiovascular disease.
At least 60% of patients will require 2 or 3
antihypertensive agents to achieve tight
control.

Stages

Identification of hypertensive patients

Baseline investigations
Initiating therapy
Reviewing patients
Stepping up therapy
Motivation and compliance

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

Clinical clues to renal vascular

disease
Hypertension under 50 Yrs of age.
Generalised vascular (esp peripheral)
disease.
Mild moderate renal dysfunction.
Sudden onset pulmonary oedema.

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

Coronary Risk Calculator

Launch risk calculator program

Compelling and possible indications and contrindications for

the major classes of antihypertensive drugs
INDICATIONS

CONTRAINDICATIONS

CLASSSOFDRUG

COMPELLING

POSSIBLE

POSSIBLE

COMPELLING

-blockers

Prostatism

Dyslipidaemia

PosturalHypotension

Unrinaryincontinence

Angiotensinconvertingenzyme(ACE)inhibitors

Heartfailure
Leftventriculardysfunction

Chronicrenaldisease*
TypeIIdiabeticnephropathy

Renalimpairment*
Peripheralvasculardisease

Pregnancy
Renovasculardisease

AngiotensinIIreceptorantagonists

CoughinducedbyACEinhibitor

Heartfailure
Intoleranceofotherantihypertensivedrugs

Peripheralvasculardisease

Pregnancy
Renovasculardisease

blockers

Myocardialinfarction

Heartfailure

Angina

Heartfailure
Dyslipidaemia
Peripheralvasculardisease

AsthmaorCOPD
Heartblock

Calciumantagonists(dihydropyridine)

Isolatedsystolichypertension(ISH)inelderlypatients

Angina
Elderlypatients

Calciumantagonists(ratelimiting)

Angina

Myocardialinfarction

Combinationwithblockade

Heartblock
Heartfailure

Thiazides

ElderlypatientsincludingISH

Dyslipidaemia

Gout

*ACEinhibitorsmaybebeneficialinchronicrenalfailurebutshouldbeusedwithcaution.Closesupervisionandspecialistadviceareneededwhenthereisestablishedand
significantrenalimpairment
CautionwithACEinhibitorsandangiotensinIIreceptorantagonistsinperipheralvasculardiseasebecauseofassociationwithrenovasculardisease.
IfACEinhibitorindicated
-blockersmayworsenheartfailure,butinspecialisthandsmaybeusedtotreatheartfailure

British Hypertension Society Guidelines 2000

Therapeutic targets
MeasuredinclinicMeandaytimeABPM
orhomemeasurement
BloodPressureNodiabetesDiabetesNodiabetesDiabetes
Optimal<140/85<140/80 <130/80<130/75
AuditStandard<150/90<140/85<140/85<140/80

TheauditstandardreflectstheminimumrecommendedlevelsofBPcontrol.Despitebestpractice,itmaynotbe
achievableinsometreatedhypertensivepatients.
NB:Bothsystolicanddiastolictargetsshouldbereached
BritishHypertensionSocietyGuidelines

Logical Combinations

Diuretic
-blocker
CCB

Diuretic
blocker

ACEinhibitor

CCB
-

*
-

ACE
inhibitor

blocker

-blocker

* Verapamil+beta-blocker=absolutecontra-indication

ACE Inhibitor Side Effects

Cough (15% of patients. Is reversible)

Taste disturbance (reversible)
Angiodema
First-dose hypotension
Hyperkalaemia ( esp. in patients with type
II diabetes and renal dysfunction)

Follow-up
ForpatientswithBPstabilisedbymanagement,
followupshouldnormallybethreemonthly(interval
shouldnotexceed6months),atwhichthefollowing
shouldbeassessedbyatrainednurse:
*MeasurementofBPandweight
*Reinforcementofnon-pharmacologicaladvice
*Generalhealthanddrugside-effects
*Testurineforproteinuria(annually)

Web based references

British Hypertension Society:
http://www.hyp.ac.uk/bhs/
Summary Guidelines 2000:
http://www.hyp.ac.uk/bhs/gl2000.htm
Hypertension audit protocol from Leicester
http://www.le.ac.uk/genpractice/gpaudit/htn
prot.html

Drug Treatment of Essential

Hypertension in Older People
Hypertension is very common, occuring in
over 50% of older people, and is a major risk
factor for stroke and ischaemic heart disease.
Drug treatment of hypertension in older
people saves lives and prevents unnecessary
morbidity.
Treating isolated systolic hypertension also
saves lives.

Drug Treatment of Essential

Hypertension in Older People
There is strong evidence to support the use of
diuretics as first-line agents.
Antihypertensive treatments are most cost-effective
when targeted at older patients.
There is evidence of under detection and under
treatment of hypertension.
Factors influencing patient adherence with
treatment are not well understood and require
further research.

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.
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

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.