Hypertension in primary care Dr Kunal Kothari Bute House Medical Centre 11th October 2016

Impact on NHS High blood pressure accounts for approximately 12% of all GP consultations Estimated £1bn drug costs for high blood pressure per year Diseases caused by high blood pressure cost the NHS over £2bn every year (~£10m per CCG) Stroke £850m Coronary heart disease £750m Vascular dementia £320m Chronic kidney disease £200m Additional cost of social care

GLOBAL BURDEN OF DISEASE

Prevalence

How to measure BP If the first blood pressure measurement is 140/90 mmhg or greater, measure BP again after 1 minute. If the second measurement is substantially different from the first, take a third measurement after 1 minute. Use the lower of the last two measurements as the recorded clinic blood pressure.

Hypertensive emergency Arrange same-day admission if: BP is 220/120 mmhg or higher. BP is 180/110 mmhg or higher with signs of accelerated (malignant) hypertension (papilloedema and/or retinal haemorrhage). Start antihypertensives immediately if no signs of accelerated hypertension and: Systolic BP is 180 mmhg or higher, or  Diastolic BP is 110 mmhg or higher.

Diagnosing HTN If blood pressures are persistently above 140/90 mmhg in clinic: Arrange ambulatory bp monitoring (ABPM) to confirm the diagnosis. If ABPM is not available or the person cannot tolerate abpm use home blood pressure monitoring (HBPM).

hBPM Two blood pressure readings twice daily, ideally in the morning and evening, for at least four days, and ideally for seven days. The first day’s readings should be discarded, and the remainder averaged to determine the mean home blood pressure

Nice Definition Stage 1 hypertension: clinic blood pressure is 140/90 mmhg or higher, and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmhg or higher Stage 2 hypertension: clinic blood pressure is 160/100 mmhg or higher, and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmhg or higher Severe hypertension: clinic systolic blood pressure is 180 mmhg or higher, or clinic diastolic blood pressure is 110 mmhg or higher

Management Read code Blood tests Urine dip/ACR ECG Life style advice Qrisk calculations

Lifestyle advice Reinforce lifestyle advice such as: Stopping smoking. Moderation in alcohol, salt, and caffeine consumption. Give advice on weight loss (if appropriate).

HOPE3 Study (2016) Randomised 12 705 people at 10% 10 year risk, with mean baseline blood pressures of 138/82 mmhg, to blood pressure lowering with candesartan plus hydrochlorothiazide, or placebo. After 5.6 years, with an average 6.0/3.0 mmhg reduction in blood pressure in the treatment group, they found no significant reduction in major cardiovascular events in the treatment group compared to controls.

When to start medications Offer antihypertensive treatment if the person is: Younger than 80 years with stage 1 hypertension and has one or more of the following: Target organ damage, established cardiovascular disease, renal disease, diabetes, and/or a 10 year cardiovascular risk of 20% or more. Any age with stage 2 hypertension.

Starting antihypertensives If 55 years of age or older and of black African or Caribbean ethnic origin (any age): Offer a CCB, or A low-dose thiazide-type diuretic, if: A CCB is not suitable (e.g. Oedema or intolerant), There is heart failure, or A high risk of heart failure.

Starting antihypertensives If younger than 55 years of age (not of black African or Caribbean ethnic origin) start: An angiotensin-converting enzyme (ACE) inhibitor, or A low-cost angiotensin II receptor antagonist (AIIRA). If ace inhibitors or aiiras are not suitable: Start a low-dose thiazide-type diuretic or a calcium channel blocker (CCB).

Target BP Aim for a BP lower than 140/90 mmhg for people under 80 years. Aim for a bp lower than 150/90 mmhg for people 80 years and older.

Adjusting treatment If on monotherapy, add a second drug. If on an ace inhibitor or an aiira: Add a CCB. If the person cannot take a ccb, add a thiazide diuretic. If on a ccb or a thiazide diuretic: Add an ACE inhibitor or an AIIRA. If the person cannot take an ace inhibitor or an aiira consider combining a ccb with a thiazide diuretic. If on dual therapy prescribe a third antihypertensive such as: An ACE inhibitor or an AIIRA A calcium-channel blocker, and A thiazide-type diuretic.

PATHWAY 2 STUDY The recent PATHWAY-2 study compared drug choices for step 4 of the A+C+D algorithm. It randomised 335 patients with resistant hypertension (clinic blood pressure more than 140 mmhg and home blood pressure more than 130 mmhg after at least three months on three drugs in maximum tolerated doses) to spironolactone, bisoprolol, doxazosin, or placebo. Resulting reductions in blood pressure with spironolactone were superior to placebo (-8.7 mmhg; 95%CI - 9.7 to -7.7), and to the mean reductions with either bisoprolol or doxazosin (-4.3 mmhg, -5.1 to -3.4). All drugs were well tolerated, with only six (2%) of patients treated with spironolactone exhibiting a hyperkalaemia of more than 6.0 mmmol/L on single occasions.

Risk Risk associated with increasing blood pressure is continuous, with each 2 mmhg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke

SPRINT Trial (Nov 15) Trial from US looked at intensive treatment Systolic BP 120 vs 140 Trial stopped early Reductions in rates of cardiovascular mortality (43%), all cause mortality (27%), and heart failure (38%) in the intensive treatment group. SPRINT found that the intensive group experienced acute kidney injury three times as often, hypotension two and a half times as often, and falls resulting in injury twice as often, irrespective of age, as the control group

Treatment Targets For people who are hypertensive without diabetes, NICE guidance sets a treatment target for blood pressure of 140/90 mmhg, or 150/90 mmhg for people aged over 80 years.

Group Clinic target (mmHg) Suggested ambulatory or home target (mmHg) Guideline (year) Elderly people (over 80 years) 150/90 145/85 NICE CG127(2011) Diabetes 140/80 135/75 NICE NG28(2015) Diabetes with retinopathy, cerebrovascular, or renal disease 130/80 125/75 NICE NG28(2015) NICE CG182(2014) Stroke RCP (2012)* Chronic kidney disease 140/90 135/85 NICE CG182(2014) Chronic kidney disease with albuminuria

Summary Be cautious with lower blood pressure treatment targets, as intense treatment regimens can be associated with increased adverse events Intensive lowering of blood pressure is associated with greater incidence of postural hypotension and related morbidity Safely treating patients to lower blood pressure targets requires periodic checking of sitting and standing blood pressure

Hypertension and primary prevention In 2014 NICE lowered its recommended 10 year threshold for drug treatment with statins in primary prevention, using qrisk2, from 20% to 10%

White Coat Hypertension Following is true regarding white coat hypertension It is a benign condition It is associated with higher rate of target organ damage as compare to normotensive patients Nurses induce higher white coat effect as compare to doctors It doesn’t need monitoring At least 20mm of hg drop in systolic BP required at same sitting to predict white coat hypertension.

Secondary Hypertension Renal disorders (chronic pyelonephritis, diabetic nephropathy). Vascular disorders (Coarctation of the aorta). Endocrine disorders (Primary hyperaldosteronism). Drugs (Alcohol, cocaine) Miscellaneous causes (Scleroderma, obstructive sleep apnoea).

Secondary Hypertension hypertension with a possible underlying cause (1) patients with hypokalaemia/increased plasma sodium (e.g. Conn's syndrome) haematuria or proteinuria raised serum creatinine young age (any hypertension under 20 years: needing treatment < 30 years) sudden-onset or worsening hypertension hypertension that is resistant to multi-drug regimen, that is, >= 3 drugs