Hypertension

1. Hypertension Rosalind Powell GPST2

2. Overview of presentation Introduction to hypertension Presentation to primary care Measurement of BP/other parameters When to manage How to manage Update of recent evidence Quiz

3. Introduction to hypertension Hypertension is not a disease but a risk factor (modifiable)1 Lowering BP decreases risk of stroke, coronary events, cardiac failure & renal impairment. 2 HP is undiagnosed and undertreated (<50% treated hypertensives optimally controlled)3 NICE definition: SBP >140 or DBP >90 persistently (last 3 readings)1

4. Presentation of hypertension to primary care Usually asymptomatic May be found on routine screening/incidental. Headache/visual disturbance. Symptoms end organ damage: LVH, TIAs CVA,MI, angina, renal impairment, PVD, retinopathy.4

5. Causes Essential hypertension 95% Secondary hypertension Drugs – NSAIDS, COC, steroids liquorice, cyclosporine (recreational) Renal disease Endocrine: Phaeochromocytoma, Conn’s syndrome, Cushing’s, Acromegally. Coarctation aorta 3

6. Measurement 1.Screening British Hypertension Society suggest all adults should have BP measured every 5 years. If BP ‘high normal’ (SBP 130-139 mmHg DBP 85-89) BP check annually. Screen any patient with known renal, atherosclerotic disease, diabetes as part of routine follow up.

7. Measurement 2. Measuring BP (NICE) Environment: relaxed/quiet/warm. Patient seated arm outstretched and supported 1st measurement >140/90 take second reading at end consultation. Both arms, use higher reading. Identifying HP: ask patient to return for 2+ appointments. Use of home monitoring devices not recommended 5

8. Cardiovascular risk NICE suggests carrying out a cardiovascular risk assessment in all hypertensives. Calculates risk of cardiovascular event over 10 years Use untreated BP reading Most primary care computer systems will calculate this Data included: urine dip, plasma glucose, U&Es, total and HDL cholesterol, ECG 3 & 5

9. Referral to secondary care 1. Immediately: Malignant/accelerated hypertension (BP >180/110 +papilloedema +/- retinal haemorrhage Suspected phaeochromocytoma 2. Consider: Secondary cause suspected Postural hypotension 5

10. When to manage

11. Management: a NICE overview

12. Management : lifestyle intervention For all patients Can be used alone for high normal/mild HP 25% achieve reduction of SBP 10mmHg yr 1 Include: Smoking cessation Weight reduction (aim BMI 20-25) Dietary advice : low salt, low fat Reduce alcohol consumption Discourage caffeine 3&5

13. Management: Initiating antihypertensives Drug therapy reduces risk of CV disease and death Offer medication to patients with: persistent BP 160/100 or more persistent BP >140/90 and raised CV risk (20%) Aim to reduce BP to 140/90 (QOF 150/90) Titrate using BNF

14. Drug choice – newly diagnosed hypertensives

15. Reason for A/CD algorithm Most patients cannot be managed on monotherapy BHS advised AB/CD algorithm, later reviewed by NICE into A/CD algorithm Uses age and ethnicity to decide on initial management Special considerations for deviation. Theory: classify patients into high and low renin groups. Younger pts have high renin concentrations and respond better to manipulation renin-angiotensin system (with ACEi /ARB), older/afro-Caribbean patients lower renin concentrations, respond better to ca channel blockers/diuretics. 3

16. Beta-blockers NICE state ‘no longer preferred as initial therapy’ as not as effective. Based on ASCOT study reported in Lancet 2005. Study showed amlodipine (+ACEi) v atenolol (+ BFZ) had similar BP lowering effect but significantly reduced cardiovascular end points. (reduced risk stroke). 6 Used still in younger patients (women child bearing potential, or if contraindication to ACE/ARB If BP already well controlled on beta blocker, no need to change. continue beta blockers if angina/post MI 4

17. Drug indications/cautions

18. Hypertension in the elderly Same treatment of >80s as >55s. Take into account co-morbidities and polypharmacy. Poorly represented in clinical trials Studies show benefit including reduction cognitive impairment, strokes and CV events. No change to overall mortality. 3

19. Hypertension in Diabetes BNF : aim for 130/80 or less. NICE: aim 140/80 or 130/80 if end organ damage QOF: 145/85 Hypertension common in type 2 DM, treating HP prevents macro and microvascular complications. ACE inhibitor or ARB can delay progression of microalbuminuria to nephropathy. 2

20. Hypertension in renal disease CKD aim BP 140/90 (NICE) Aim for BP 130/80 if proteinuria >1gram/24hours (NICE) ACE inhibitor or ARB should be considered for patients with proteinuria but must be used with caution in renal impairment. Ca channel blockers can be used as can loop diuretics – thiazides may be ineffective. 2

21. Additional medication to reduce CV risk If CV risk >20% consider: Statin Low dose aspirin once BP controlled Lower cholesterol to <4.0mmol/L LDL <2.0 3

22. Monitoring/Review Dependent on degree of control, types of therapy and patient compliance If well controlled, monotherapy and no other co-morbidities may have annual review. After starting treatment: review 1 month, if controlled review in 3 months, then 6 months, then annually Reviews to include : BP, urinalysis for proteinuria, bloods for renal function, glucose and lipids and recalculation CV risk. Lifestyle advice Discuss side effects/problems Emphasise importance of life-long treatment 4&5

23. An update of recent evidence ‘Challenging our thinking in hypertension’ BMJ 2009; 338b1665 Meta-analysis looking at impact of different drugs on blood pressure. Half a million people included in RCT analysis Summary of findings: Antihypertensives reduce CV risk regardless of baseline BP Reduction in CVD in those on antihypertensives can be explained solely through reduction in BP All classes of antihypertensives have similar effects on CV endpoints. Ca channel blockers reduce incidence CVA than other classes. (Beta blockers do not seem any less effective than other agents when ca channel blockers are removed from the analysis) In those with CHD beta blockers remain important drug – giving added protection reducing risk further CHD

24. Summary HP under diagnosed and undertreated in UK Consider causes secondary hypertension in young patients/uncontrolled on 3 antihypertensives Calculate cardiovascular risk Lifestyle modification for all patients Antihypertensives if BP >160/100 or 140/90 with CVD risk >20% or diabetes or target organ damage ACD algorithm, but consider beta blockers Regular review Watch out for NICE/BHS updates

25. AKT! A Angiotensin-converting enzyme inhibitor B Calcium channel blocker C Thiazide diuretic D Beta blocker E Angiotensin II receptor antagonist Consider the following hypertensive patients, all of whom need treatment and, bearing recent evidence and guidelines in mind, suggest the single best class of anti-hypertensive for each patient from the list above. A 40 year old Caucasian lady. A 60 year old Caucasian man with a past history of gout. A 40 year old man of Afro-Caribbean origin, also with a history of gout. A 55year old man who also suffers with angina. A patient who was initially on Enalapril but has a troublesome tickly cough. 7

26. References www.gp-update.co.uk BNF 59 InnovAiT vol 2 issue 12 Dec 2009 Oxford handbook of General Practice 3rd edition NICE clinical guideline 34 ‘Hypertension: management of hypertension in primary care’ (partial update clinical guideline 18) June 2006 ‘Guidelines in practice’ ‘Variability in blood pressure is a predictor of stroke’ vol 13 issue 4 April 2010 Applied knowledge test for the new MRCGP Questions and answers for the AKT Nuzhet A-Ali, 2008

27. Thank you! Any Questions?