Transcript Blood pressure …and what to do about it

Investigation and
Management of high blood
pressure:
primary and secondary care
Reecha Sofat, Ben Walsh, Raymond MacAllister
University College London and Royal Free Hospital Cardiovasular Risk and
Complex Hypertension Service
All you need to know about
blood pressure…
Keep it simple, we do
Who to treat
What to treat
with
What
treatment
target
What to do
next
o
Anyone older than 55 will benefit from a lower blood pressure – try diet
and lifestyle changes**or medicines for those who want them
o
Anyone with a prior CV event
o
Anyone with end-organ damage …irrespective of the degree of elevation
of BP level
o
Anyone with an extreme elevation of blood pressure. If they are young,
there are clues in the blood chemistry or the blood pressure does not
come down with treatment – investigate for secondary causes
o
Diet and lifestyle for all- preach hard expect little (sometimes you may be
surprised)
o
Once you have checked contraindications choose whatever is cheap and
tolerated in whatever combination you like
The lower the better without producing symptoms and address all other
risk factors
o
o
Move on to something more interesting !
**reduce salt, alcohol and weight and increase aerobic exercise and fruit/veg /oily fish
Stroke
Ischaemic Heart disease
End-point
BP difference
Observational
(Expected)
Randomised
(Observed)
Stroke
5mmHg
35-40%
42% (33-50)
CHD
5mmHg
20-25%
14% (4-22)
Collins et al., Lancet 1990
Causes of high blood pressure
Idiopathic, essential
Overweight
Alcohol
Salt intake
Sedentary lifestyle
Secondary
Coarctation
Renovascular
Renal parenchymal
Endocrine
(Conn’s, Phaeochromocytoma)
Drugs
How do we manage BP at UCLH?
Which guidelines do we use?
Diagnosis of high blood
pressure:
ESH/ ESC guidance 2013
Stroke
Ischaemic Heart disease
End-point
BP difference
Observational
(Expected)
Randomised
(Observed)
Stroke
5mmHg
35-40%
42% (33-50)
CHD
5mmHg
20-25%
14% (4-22)
Collins et al., Lancet 1990
Regarding referrals
• Do we accept referrals where 24 APBM has
not been carried out?
– Yes (2 office measures, 2 separate visits)
• Is it a criteria for referral to UCLH or Royal Free
services?
– No
• When do we use ABPM?
– White coat and white coat in those with high BP,
adherence monitoring
Treatment of high blood
pressure
Two strategies
•Lifestyle
•Pharmacological
Pharmacological , what do we know about the drugs use to
lower BP?
Problems or preferences of one drug
class over another?
Beta blockers and diabetes
Glucose lowering anti-hypertensives
Glucose raising anti-hypertensives
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Glucose mmol/L
Sofat R et al., BMJ 2012
4,000,000
3,500,000
2,500,000
Angiotensin Converting
Enzyme Inhibitors
2,000,000
Thiazides And Related Diuretics
Angiotensin II- Receptor Antagonists
Calcium -Channel Blockers
1,500,000
Beta -Adrenoceptor Blocking Drugs
Dashed vertical represents publication
of ASCOT-BPLA, September 2005
1,000,000
500,000
May 10
Feb 10
Nov 09
Aug 09
May 09
Feb 09
Nov 08
Aug 08
May 08
Feb 08
Nov 07
Aug 07
May 07
Feb 07
Nov 06
Aug 06
May 06
Feb 06
Nov 05
Aug 05
May 05
Feb 05
Nov 04
Aug 04
May 04
Feb 04
0
Nov 03
Number of Prescriptions in England
3,000,000
Date
Sofat R et al., BMJ 2012
Management of High Blood Pressure In African
American: Consensus statement of the hypertension in African
Americans Working Group of the International Society on Hypertension in
Blacks Arch Intern Med 2003; 163: 525
“All antihypertensive drug classes are associated
with blood pressure lowering efficacy in African
Americans. Thus in terms of efficacy, there is no
rationale for using race as a reason to avoid
certain classes of agents in African American
patients with high blood pressure.”
Drugs by age cut off?
Which drug?
Interpretation?
• It’s the blood pressure that is important,
regardless of the drug used to lower it
What do we do at UCLH?
What to expect when your patients are
referred to UCLH BP clinic
• History
• Exam
• If they have been difficult to manage screen
for
– Secondary causes
– Adherence (DoT)
Who to screen
• Patients with ‘resistant’ hypertension (BP
>140/90mmHg on 3 antihypertensives)
• Young patients (<40) with high blood pressure
• Patients presenting with accelerated
hypertension
– Hypertensive urgency vs emergency
SIMPLIFY!
Who to treat
What to treat
with
What
treatment
target
What to do
next
o
Anyone older than 55 will benefit from a lower blood pressure – try diet
and lifestyle changes**or medicines for those who want them
o
Anyone with a prior CV event
o
Anyone with end-organ damage …irrespective of BP level
o
Anyone with an extreme elevation of blood pressure. If they are young,
there are clues in the blood chemistry or the blood pressure does not
come down with treatment – investigate for secondary causes
o
Diet and lifestyle for all- preach hard expect little (sometimes you may be
surprised)
o
Once you have checked contraindications choose whatever is cheap and
tolerated in whatever combination you like
The lower the better without producing symptoms and address all other
risk factors
o
o
Move on to something more interesting !
**reduce salt, alcohol and weight and increase aerobic exercise and fruit/veg /oily fish