Transcript Home BP Measurements

Hypertension
What to do when you don’t know what to do!
Fiona Stewart
Auckland Heart Group
Auckland City Hospital
2nd Sept 2011
Essential Hypertension
Hypertension with
Diabetes
Renal disease
Proteinuria > 1g/d
Age > 80
BP < 140/85
BP < 130/80
BP < 130/80
BP < 125/75
BP < 150/
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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
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History
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Lifestyle assessment
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Basic tests
◦ Other illnesses (cardiovascular disease, diabetes,
renal disease, gout)
◦ Family history
◦ Smoking, alcohol (max 1-2/d) salt intake,
liquorice ingestion, weight, exercise, stress
◦ FBC, U + E, urate, creat, eGFR, gluc, lipids, MSU
◦ ECG
Indication
◦ Abnormal screening tests
◦ Young
◦ BP severe or hard to control
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Renin, aldosterone, cortisol
24h U metanephrines
Renal scan and doppler study
Echocardiogram – LVH, ascending aorta
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Linear increase in risk from BP 115/75
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↑20mmHg SBP or ↑10mmHg DBP doubles mortality
from cardiovascular disease
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BP 120-139/80-89 “prehypertension”
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Weight
Salt intake (including soya sauce)
Liquorice ingestion
Alcohol
Stress
Exercise
Contributing drugs (NSAIDs)
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Systolic BP better predictor of adverse
cardiovascular events especially in elderly
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Persistent BP > 140/85 → treat
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Over 80 years – aim for SBP<150
◦ Always check standing BP
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Chlorthalidone 12.5 – 25mg
Amlodipine
Lisinopril
Doxazosin
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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
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ACEI + Amlodipine
ACEI + Hydrochlorothiazide
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21% Reduction in CV death, MI, CVA over 3
years
NNT to prevent one major event = 77
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37% were taking > 3 agents
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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
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Patients aged > 80
SBP >160mmHg, DBP < 110mmHg
Indapamide 1.5mg + Perindopril 2-4mg
vs placebo
Target BP 150/80
180
15 mmHg
170
160
Blood Pressure (mmHg)
150
140
Placebo
130
120
Indapamide SR +/perindopril
Median follow-up 1.8
years
6 mmHg
I
110
100
90
80
70
0
1
2
3
Follow-up (years)
4
5
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
P=0.046
Indapamide
SR
±perindopril
Placebo
IndapamideSR ±perindopril
Heart Failure
(64% reduction)
Placebo
P<0.0001
IndapamideSR
±perindopril
Placebo
IndapamideSR ±perindopril
ITT – Summary
HR
95% CI
All Stroke
0.70
(0.49, 1.01)
Stroke Death
0.61
(0.38, 0.99)
All cause
mortality
0.79
(0.65, 0.95)
NCV/Unknown
death
0.81
(0.62, 1.06)
CV Death
0.77
(0.60, 1.01)
Cardiac Death
0.71
(0.42, 1.19)
Heart Failure
0.36
(0.22, 0.58)
CV events
0.66
(0.53, 0.82)
0.1
0.2
0.5
0
2
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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
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Confirm hypertension with 24hr monitor
Check for secondary causes
◦ Renal scan ? Renal artery stenosis
◦ Cortisol, renin, aldosterone, metanephrines
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Lifestyle adjustments – stress, salt
Compliance
Optimal medication dose and frequency
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Thiazides
◦ Chlorthalidone more effective than HCZ
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ACEI
◦ Cilazapril and lisinopril – daily dose
◦ Enalapril and quinapril – bd dose
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Angiotensin II Blockers
◦ Titrate dose to 32mg candesartan, 100mg losartan
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CCBs
◦ Amlodipine and felodipine 10mg
Measurement
◦ Sitting
◦ DBP 4th Korotkoff 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 betablockers
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
Insulin
Resistance
Sleep
Disturbances
Renal Afferent
Nerves
Hypertrophy
Arrhythmia
Oxygen Consumption
Renal Efferent
Nerves
↑ Renin Release  RAAS activation
↑ Sodium Retention
↓ Renal Blood Flow
Radiofrequency energy can ablate the renal
sympathetic nerves
Symplicity HTN-1
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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
10
0
BP
change
(mmHg)
Systolic
Diastolic
-20-10
-24-11
-25-11
-23-11
-26-14
-32-14
1M
(n=138)
3M
(n=135)
6M
(n=86)
12 M
(n=64)
18 M
(n=36)
24 M
(n=18)
-10
-20
-30
-40
-50
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Primary Endpoint: 6-Month Office BP
∆ from
Baseline
to
6 Months
(mmHg)
Systolic
Diastolic
Diastolic
Systolic
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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 Tolerance
at 3 Months after Renal Denervation
Mahfoud et al. European Society of
Cardiology. 2010.