Transcript Illustrative Cases and Summary

Illustrative Cases and
Summary
A 50 year old European woman who is new to
your practice comes to see you late on Friday
afternoon with a sore throat which is probably
viral. She has a past history of hypertension,
but is not on antihypertensives currently. You
take her blood pressure and it is 230/130. After
15 minutes quiet rest your nurse remeasures
the blood pressure at 210/110.
How should she be managed from here?
Hypertensive Urgency or Emergency?
Hypertensive Emergency
Very high BP with evidence of rapidly progressive target organ damage
• retinopathy
• heart failure
• rapidly progressive renal impairment
• neurological
-TIA/ stroke/ reduced level of consciousness
Medical emergency – requiring hospital admission
Hypertensive Urgency
Very high BP without evidence of rapidly progressive target organ damage
Does not require urgent hospital admission, but does require careful
management, close supervision, and review within 1-3 days
This patient needs:-
careful physical examination including fundoscopy
12-lead ECG
urine Dipstick
And send off
FBC
urea creatinine, electrolytes
urine microscopy and spot urine albumin/creatinine ratio
Assuming no evidence of “hypertensive emergency”, start on
medication and see again on Monday
Start on 2 drugs, either ACE-inhibitor/ thiazide or ACEinhibitor/CCB
eg lisinopril 10mg/ chlorthalidone 12.5mg stat and daily until
reviewed
or lisinopril 10mg/ amlodipine 5mg stat and daily until
reviewed
You see her again on Monday afternoon:Lab tests have come back normal
She feels OK
Resting BP 170/100 (on lisinopril 10mg and
amlodipine 5mg)
Where to from here?
Leave on same meds and review in 2 weeks
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BP 160/95
↓
Increase lisinopril to 20mg and review in 2 weeks
↓
BP 155/92
↓
Increase amlodipine to 10mg and review in 2 weeks
↓
BP 148/90
↓
Add chlorthlalidone 12.5mg and review in 2 weeks
↓
BP 143/88
↓
Increase chlorthalidone to 25mg and review in 2 weeks
↓
BP 137/85 (at target)
You take over the care of a 37 year old Indian man. He has a bad family history of
diabetes and premature cardiovascular disease. His father (who was not known to
be diabetic) died at 43 of an apparent heart attack. You are only seeing him
because his wife forces him to come in for a checkup because she is worried about
his family history. He is a non-smoker and currently on no medication
Examination
BMI 27, abdominal girth 95cm, BP 134/90
Investigations
Fasting glucose 5.6mmol/l, cholesterol 4.4mmol/l HDL 0.8mmol/l LDL 3.0mmo/l
triglyceride 2.2mmol/l creatinine 75umol/l spot urine albumin-creatinine ratio
5mg/mmol (N < 2.5)
What are his prospects for the future, and how should he be managed?
Superficially:
Not overweight
Not hypertensive
Non-diabetic
Total cholesterol 4.4
5 year cardiovascular risk on NZ CV risk calculator < 5%
So – is there a problem?
What is your advice?
Yes – he has a big problem – he is genetically programmed to die of
cardiovascular disease in his 40’s or 50’s
Why?
Taking a less superficial look at him…
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Being South Asian (on its own) is an important risk factor for type 2 diabetes
and cardiovascular disease
History of MI or stroke in family members < 55 (men) and <65 (women) is a
separate cardiovascular risk factor
Abdominal girth 95cm (normal for S.Asians < 90)*
Impaired fasting glucose*
Prehypertension*
Low HDL, elevated triglyceride (atherogenic lipid profile)**
Microalbuminuria*
- all of the above are separate, quantifiable, and cumulative cardiovascular
risk factors
in addition he has 6 features* of the metabolic syndrome which confers:
- 2-3 x increased risk of cardiovascular events than a simple cumulation
of his individial risk factors
- substantial (5-10x) higher risk of developing type 2 diabetes
Aims of treatment
BMI < 25
Abdominal girth < 90cm
BP < 130/80
Fasting glucose < 5.4
LDL cholesterol < 2
Resolution of microalbuminuria
How to achieve these goals
DASH-Sodium diet
High levels of physical activity
ACE-inhibitor +/- CCB
As much statin as he can tolerate
Aspirin
Consider metformin
An 83 year old female patients of yours has a long history of systolic hypertension. She had a
minor stroke a year ago with good recovery. Recently her BP has been less well-controlled.
You see her for a check:- resting seated BP is 180/85, standing 170/82, heart rate 60 bpm.
Renal function is normal for age.
Her current antihypertensive medications are:
metoprolol CR 95mg daily, diltiazem CD 120mg /day, candesartan 32mg daily
She is intolerant of thiazides (hyponatraemia – proven on rechallenge)
At this age – is more aggressive treatment warranted?
If so, how can you improve her blood pressure?
Mean Blood Pressure, Measured while Patients Were Seated, in the Intention-to-Treat
Population, According to Study Group
Beckett NS et al. N Engl J Med 2008;358:1887-1898
www.hypertensiononline.org
Treatment Group had:
- 30% reduction in in rate of fatal or non-fatal
stroke
- 39% reduction in rate of death from stroke
- 21% reduction in rate of death from any cause
- 23% reduction in rate of death from
cardiovascular causes
- 64% reduction in rate of heart failure
Therapeutic options –
Can’t increase metoprolol or diltiazem doses (HR 60)
Options
(1) Diuretic likely beneficial but can’t tolerate thiazide
• spironolactone 12.5 – 25mg daily
• or frusemide 10-20mg BD or TDS
…with close monitoring of electrolytes
(2) Add amlodipine at 2.5mg daily increasing as tolerated
(3) Doxazosin 1mg nocte increasing dose weekly as required
Take Home Messages
(1) Hypertension is common in all age groups and is the leading cause of
preventable death and disability
(2) Most of the excess risk associated with hypertension can be obviated
by treating blood pressure to target levels
(3) Treatment is complex and time-consuming and patient expectations
need to be adjusted accordingly
(4) Multi-drug regimens are the norm, and an algorithmic approach to
medication adjustment is more likely to be successful than a
haphazard one
(5) Global cardiovascular risk is an important concept, but don’t get
bogged down in the NZ Cardiovascular Risk Guideline which has
serious limitations
(6) Lifestyle modification is important but (almost) never obviates the need
for drugs
(7) Any regimen which contains > 2 classes of antihypertensive
medication should (almost) always include a diuretic
(8) Chlorthalidone is (by far) the most effective thiazide