Practical Management of Hypertension in Primary
Care
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Dr Rob SapsfordConsultant Cardiologist
Leeds Teaching Hospitals
Objectives
Prevalence NICE guidance (CG 127 August 2011)
Investigation Treatment Resistant Hypertension Malignant Hypertension
NICE Clinical Guideline CG 127
Kearney PM, et al. 2005
The incidence of hypertension is predicted to increase dramatically
Population with hypertension (%)
30
Overall
26
28
Men Women
20002025
24
The global incidence of hypertension in the adult population is predicted to exceed 29% by the year 2025
25% of all adults hypertensive50% adults 60yrs> hypertensive
Pulse pressure
Cardiovascular risk doubles with each 20/10 mmHg increment
0
2
4
6
8
115/75 135/85 155/95 175/105
SBP / DBP (mmHg)
CV Mortality risk (fold increase)
Lewington et al Lancet 2002:60;1903-1913
Any BP reduction makes a difference
2 mmHg decrease in mean SBP
7% reduction in risk of IHD mortality
10% reduction in risk of CVA
mortality
Lewington S et al lancet 2002:360;1903-1913
Meta-analysis of 61 prospective observational studies involving 1 million adults (12.7 million patient years)
Relative risk reduction (%)
−50
−40
−30
−20
−10
0CHDStrokeCV event
20–21
21–28
30–39
Risk of CV event with ACEI or CCB relative to placeboCV: cardiovascular CHD: coronary heart disease
Long-term antihypertensive treatment
reduces CV risk
Neal B, et al. 2000RAS07000047
Measuring BP
Standardise BP measurements Never base treatment on an isolated
reading All adults every 5 Years High / normal (130–139 / 85–89 mmHg) every 1
year
Measuring BP has improved
The modern sphygnomanometer
Rev Hales – veterinarian
Carl Ludwig’s kymograph Riva-Rocci’s sphygmomanometer
24 Hour BP Monitoring
24 Hr BP – Diagnosis ?
‘White coat effect’Discrepancy of 20/10 mmHg >between clinic and average daytime ABPM
or average HBPM at time of diagnosis
BP Problems
Unequal arm BP’sDifference in BP between arms
BP difference 20mmHg> Repeat measurements ?
persists
ActionDocument as higher risk for vascular
disease Use highest arm for subsequent monitoring
BP Problems Postural Hypotension
Falls / postural dizziness BP seated / standing 1min>Systolic BP fall on standing 20mmHg>
ActionReview medicationMeasure future BP standingConsider referral if symptoms persist
Blood Pressure Clinic BP
140 > / 90 >
Ambulatory BP MonitorABPM
Minimum 2x readings / HrAverage 14 daytime readings
Home BP MonitorHBPM
2 readings 1 min> apartMinimum 2x recordings / day
Average min 4 days – 7 days readings(disregard day 1 readings)
Hypertensive Stages
Stage 1 Clinic BP 140> / 90>Daytime ABPM 135> / 85>Average HBPM 135> / 85>
Stage 2 Clinic BP 160> / 100>Daytime ABPM 150> / 95>Average HBPM 150> / 95>
Severe Clinic BP 180> / 110>
Treatment guidelines
160> /100> mmHgABPM 150>/95>
Treat(any age)
BMJ 2004 328:634-640
<140 /90 mmHgABPM <135/<85
Annual review
140–159 / 90-99 ABPM 135-149/85-94
Assess risk
BP measurement
Treatment Guidelines
No Target Organ Damage (TOD) and
No Diabetes mellitusand
No Cardio-vascular diseaseand
No Renal Diseaseand
10 yr Cardio-vascular risk <20%*
BMJ 2004 328:634-640
Lifestyle measures Annual
review
Target Organ Damage (TOD) or
Diabetes mellitusor
Cardio-vascular diseaseor
Renal Diseaseor
10 yr Cardio-vascular risk 20%>
Treat
ABPM/HBPM 135-150 / 85-95
Investigations
Cardio-vascular risk U/E’s, FBC, TFT’s, TC:HDL, Glucose
QRISK2, Framinghm
Target Organ DamageECGUrinalysis / Alb:Creat ratio
Target Organ Damage
CVA
Nephropathy
Retinopathy
LVHLVH
Framingham Cardiovascular Risk
(morbidity and mortality)
Atherosclerotic disease anywhere – high risk
Sex
AgeSystolic BP / Diastolic BPSmoking historyTotal cholesterol : HDLECG – evidence of LVH
Calculate 10 year CV risk
Treat 20% > CV risk
Average male 45 years 1% per annum risk (10% 10 year risk)
QRISK2 Calculator
Variables included in the first version were
AgeSexSmoking statusSystolic BPRatio TC:HDLBMIFamily history of IHD (first degree relatives <60 yrs)Area measure of deprivation (Townsend score)Treatment with antihypertensive agent
Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, May M, Brindle P. BMJ 2007;335:136.
A more recent version (QRISK2) has additional variables
Self assigned ethnicityType 2 diabetes Rheumatoid arthritis Renal diseaseAtrial fibrillation
When to refer ?
Stage 1 hypertension in young (<40 yrs) :even if low estimated 10 yr risk (under-estimation of lifetime risk)
Target organ damage (LVH / albuminria / proteinuria) : but no evidence of hypertension
Accelerated Hypertension (BP usually 180/110 > with papilloedema / retinal changes) – urgent admission
Supected phaeochromocytoma (labile BP, headache, palpitations, sweating) – urgent admission
Secondary cause supected on signs or symptoms (RAS – bruit, young female, PVD, Renal dysfunction)
Treatment Lifestyle advice
Diet / exerciseAlcohol reductionCaffeine reductionReduce dietary Sodium Smoking cessation
NICE / BHS guidelines
Step 1
Step 2
Step 3
Step 4
Age (<55) Older(>55) or black any age
A C
A + C
A C D+ +Resistant Hypertension
A+C+D+further diuretic / alpha or BB
Key :
A = ACE-I / ARB
B = Beta-blocker
C = Calcium antagonist
D = Diuretic (chlortalidone / indapamide)
NICE CG 127
Spironolactone 25mg if K<4.5 Higher dose thiazide if K higher
Treatment - ? Beta-blockers
If co-morbidity benefiting from use (angina / systolic heart failure)
Younger patient (<55yrs) intolerance or contra-indication to ACE/ARB
Women of child bearing potential Evidence increased sympathetic drive Avoid BB with thiazide like diuretic
Optimal BP Targets
Patients <80yrs
Patients 80yrs >
<140 / <90 mmHg
<150 / <90 mmHg
Clinic BP
<145 / <85 mmHg
<135 / <85 mmHg
NICE CG 127 2011
ABPM / HBPM
Resistant Hypertension
Failure to achieve goal BP despite optimal doses of 3 or more agents from different classes (ideally one a diuretic)
Prevalence around 10%
True resistance: secondary causes, OSA, Volume overload, Drug induced, obesity, alcohol excess
Apparent resistance – non compliance, cuff related artefacts, white coat resistance (25-37% reclassified)
Heart 2012;98:254-261
Malignant Hypertension
Sudden / rapid hypertension with diastolic 130mmHg>
1% hypertensives (particularly african-americans) Associated CTD, CKD, pregnancy toxaemia, RAS Symptoms – retinal / cerebral / renal / cardiac Signs – retinal / +/- oedema Treatment – IV / oral (aim diastolic <110 within 24
hrs)
Aspirin in Hypertensives Recommended : Primary prevention
75mg / day if Patientaged >50 yrsBP controlled <150 / 90target organ damageDiabetic10 CV risk >20%
And one of
BMJ 2004 328:634-640
Statin Trials: ASCOT - LLAP
erce
nta
ge
wit
h C
HD
eve
nt
Primary prevention
Pravastatin
Lovastatin
Modified from Kastelein JJP. Atherosclerosis. 1999; 143(suppl 1): S17-S21
Atorvastatin
10
5.4 (210)2.3 (90) 2.8 (110) 3.4 (130) 3.9 (150) 4.4 (170) 4.9 (190)
WOSCOPS-S WOSCOPS-P
0
5AFCAPS-S AFCAPS-P
9
8
7
6
4
3
2
1
ASCOT-P
ASCOT-S
LDL-C, mmol/L (mg/dL)
S = statin treated; P = placebo treated ASCOT 10 yr CV risk 9%
Conclusion
Treatment of BP dependent on level and assessment of baseline CV risk
Individualise treatment accepting several agents will be required
Compliance important Treat all CV risk factors – statins usually
indicated
NICE Guidelines: Primary Prevention
Statins are recommended as part of management strategy for primary prevention of CVD for adults who have a 20% 10-year risk of developing CVD
Statins for the prevention of cardiovascular events. NICE Technology Appraisal 94. January 2006
24 Hour Ambulatory BP
Ambulatory BP measurement
Unusual variation Possible white coat hypertension Equivocal treatment decisions Evaluation nocturnal hypertension Evaluation of drug resistant hypertension Evaluation 24 hour treatment control Diagnosis and treatment of pregnancy
hypertension Evaluation of symptomatic hypotension
BP thresholds 10 / 5 mmHg lower than clinic BP’s
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