Transcript Hypertension - Bradford VTS

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
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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
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
Kieran McGlade Nov 2001
Department of General Practice QUB
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
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, 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.
Kieran McGlade Nov 2001
Department of General Practice QUB
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.
Kieran McGlade Nov 2001
Department of General Practice QUB
Stages
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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
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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
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.
Kieran McGlade Nov 2001
Department of General Practice QUB
Ladder Approach
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Bendrofluazide
Bendrofluazide + Atenolol or ACE
Calcium Channel blocker
Alpha blocker
Kieran McGlade Nov 2001
Department of General Practice QUB
Tailored Approach
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Assessment of overall cardiovascular risk
Recognition of co-morbidities
Lipid profile
Renal function
Existing contra- indications
Kieran McGlade Nov 2001
Department of General Practice QUB
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
Compelling and possible indications and contrindications for
the major classes of antihypertensive drugs
INDICATIONS
CONTRAINDICATIONS
CLASSS OF DRUG
COMPELLING
POSSIBLE
POSSIBLE
COMPELLING
a-blockers
Prostatism
Dyslipidaemia
Postural Hypotension
Unrinary incontinence
Angiotensin converting enzyme (ACE) inhibitors
Heart failure
Left ventricular dysfunction
Chronic renal disease *
Type II diabetic nephropathy
Renal impairment *
Peripheral vascular disease †
Pregnancy
Renovascular disease
Angiotensin II receptor antagonists
Cough induced by ACE inhibitor ‡
Heart failure
Intolerance of other antihypertensive drugs
Peripheral vascular disease
Pregnancy
Renovascular disease
Myocardial infarction
Heart failure
b-blockers
Angina
Heart failure
Dyslipidaemia
Peripheral vascular disease
Calcium antagonists (dihydropyridine)
Isolated systolic hypertension (ISH) in elderly patients
Angina
Elderly patients
Calcium antagonists (rate limiting)
Angina
Myocardial infarction
Thiazides
Elderly patients including ISH
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Asthma or COPD
Heart block
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Combination with b-blockade
Heart block
Heart failure
Dyslipidaemia
Gout
* 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
Kieran McGlade Nov 2001
Department of General Practice QUB
British Hypertension Society Guidelines 2000
with renovascular disease.
Therapeutic targets
Measured in clinic
Blood Pressure
Optimal
Audit Standard
No diabetes
<140/85
<150/90
Diabetes
<140/80
<140/85
Mean daytime ABPM
or home measurement
No diabetes
<130/80
<140/85
Diabetes
<130/75
<140/80
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
British Hypertension Society Guidelines
Kieran McGlade Nov 2001
Department of General Practice QUB
Logical Combinations
bblocker
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Diuretic
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b-blocker
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CCB
ACE inhibitor
CCB
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a-blocker
* Verapamil + beta-blocker = absolute contra-indication
Kieran McGlade Nov 2001
ablocker
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ACE
inhibitor
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Diuretic
Department of General Practice QUB
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ACE Inhibitor Side Effects
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Cough (15% of patients. 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
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:
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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
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
Kieran McGlade Nov 2001
Department of General Practice QUB
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.
Kieran McGlade Nov 2001
Department of General Practice QUB
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 costeffective 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.
Kieran McGlade Nov 2001
Department of General Practice QUB
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
Kieran McGlade Nov 2001
Department of General Practice QUB
Practical Points
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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.
Kieran McGlade Nov 2001
Department of General Practice QUB