Hypertension What to do when you don’t know what to do! Fiona Stewart Auckland Heart Group

1. Hypertension What to do when you don’t know what to do! Fiona Stewart Auckland Heart Group Auckland City Hospital 2nd Sept 2011

2. HypertensionNZ Heart Foundation Recommendations Essential Hypertension BP < 140/85 Hypertension with Diabetes BP < 130/80 Renal disease BP < 130/80 Proteinuria > 1g/dBP < 125/75 Age > 80 BP < 150/

3. Blood Pressure Measurement • 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

4. Home BP Measurements

5. Ambulatory Blood Pressure Monitoring

6. Blood Pressure Review • History • Other illnesses (cardiovascular disease, diabetes, renal disease, gout) • Family history • Lifestyle assessment • Smoking, alcohol (max 1-2/d) salt intake, liquorice ingestion, weight, exercise, stress • Basic tests • FBC, U + E, urate, creat, eGFR, gluc, lipids, MSU • ECG

7. Blood Pressure ReviewAdditional Tests Indication • Abnormal screening tests • Young • BP severe or hard to control • Renin, aldosterone, cortisol • 24h U metanephrines • Renal scan and doppler study • Echocardiogram – LVH, ascending aorta

8. Prehypertension • Linear increase in risk from BP 115/75 • ↑20mmHg SBP or ↑10mmHg DBP doubles mortality from cardiovascular disease • BP 120-139/80-89 “prehypertension”

9. Prehypertension Management • Weight • Salt intake (including soya sauce) • Liquorice ingestion • Alcohol • Stress • Exercise • Contributing drugs (NSAIDs)

10. Hypertension - Treatment • Systolic BP better predictor of adverse cardiovascular events especially in elderly • Persistent BP > 140/85 → treat • Over 80 years – aim for SBP<150 • Always check standing BP

11. Which Antihypertensive is Best?ALLHAT Trial • Chlorthalidone 12.5 – 25mg • Amlodipine • Lisinopril • Doxazosin

12. Doxazosin or Chlorthalidone?ALLHAT Trial

13. ALLHAT TrialDoxazosin and Chlorthalidone

14. ALLHAT TrialBP Control

15. ALLHAT Trial • 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

16. ALLHAT TrialFatal Cardiac Event and Nonfatal MI

17. ACCOMPLISH Trial • ACEI + Amlodipine • ACEI + Hydrochlorothiazide

18. ACCOMPLISH Trial

19. ACCOMPLISH Trial Cardiovascular Events

20. ACCOMPLISH Trial • 21% Reduction in CV death, MI, CVA over 3 years • NNT to prevent one major event = 77 • 37% were taking > 3 agents

21. HypertensionTreatment Choice 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

22. Treatment of Hypertension in the Very Elderly > 80HYVET trial • Patients aged > 80 • SBP >160mmHg, DBP < 110mmHg • Indapamide 1.5mg + Perindopril 2-4mg vs placebo • Target BP 150/80

23. Blood pressure separation 15 mmHg Median follow-up 1.8 years 6 mmHg

24. All stroke (30% reduction) Placebo P=0.055 Indapamide SR ±perindopril Placebo IndapamideSR ±perindopril

25. Total Mortality (21% reduction) Placebo P=0.019 Indapamide SR ±perindopril Placebo IndapamideSR ±perindopril

26. Fatal Stroke (39% reduction) Placebo Indapamide SR ±perindopril P=0.046 Placebo IndapamideSR ±perindopril

27. Heart Failure (64% reduction) Placebo P<0.0001 IndapamideSR ±perindopril Placebo IndapamideSR ±perindopril

28. 0.1 0.2 0.5 0 2 ITT – Summary

29. Starting Antihypertensive Treatment • 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

30. BP Remains Elevated • Confirm hypertension with 24hr monitor • Check for secondary causes • Renal scan ? Renal artery stenosis • Cortisol, renin, aldosterone, metanephrines • Lifestyle adjustments – stress, salt • Compliance • Optimal medication dose and frequency

31. Optimising Medication • Thiazides • Chlorthalidone more effective than HCZ • ACEI • Cilazapril and lisinopril – daily dose • Enalapril and quinapril – bd dose • Angiotensin II Blockers • Titrate dose to 32mg candesartan, 100mg losartan • CCBs • Amlodipine and felodipine 10mg

32. Chronic Hypertension and Pregnancy Measurement • Sitting • DBP 4thKorotkoff 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 beta-blockers Methydopa has a long record of safety in pregnancy CCBs are well tolerated in pregnancy

33. The kidney as origin of sympathetic drive carried centrally via renal afferent sympathetic nerves generating central sympathetic drive Vasoconstriction Atherosclerosis Hypertrophy Arrhythmia Oxygen Consumption Sleep Disturbances Renal Afferent Nerves Insulin Resistance Renal Efferent Nerves ↑ Renin Release  RAAS activation ↑ Sodium Retention ↓ Renal Blood Flow

34. Radiofrequency energy can ablate the renal sympathetic nerves

35. Symplicity HTN-1 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

36. Significant, Sustained BP Reduction BP change (mmHg) 36

37. Primary Endpoint: 6-Month Office BP ∆ from Baseline to 6 Months (mmHg) Systolic Diastolic Diastolic Systolic 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

38. Changes in Glucose Toleranceat 3 Months after Renal Denervation Mahfoud et al. European Society of Cardiology. 2010.