EXAM 1.A normal adult should have their BP checked at least how often? 2.What level of CVD risk over 10 years is considered high risk for primary prevention? 3.In an otherwise low risk patient with hypertension, at what BP should drug therapy be initiated? 4.10kg of weight loss will result in what reduction in BP (in mmHg)? 5.What two groups of people are considered as “low-renin”?

Why important CVD Greatest mortality worldwide WHO “one of the most important preventable causes of premature morbidity and mortality in developed and developing countries” 50% of people >45 will die of it CVA commonest aquired disability £1.75 billion CHD £1.65 billion CVA Suboptimal management Primary and secondary prevention reduces risk 18QOF 2 NSFs

Levels –Optimum <120/80 –Normal <130/85 –High normal <140/90 –Mild hypertension <160/100 –Mod hypertension <180/110 –Sev hypertension >180/110 Recommendation –All adults measure every 5 years –High normal every year

Clinic –Both arms then pick highest –Also after 2 min standing in diabetes and elderly –Cuff >80% circ –At least two, the second being at the end of the clinic, discard first and do third if first two very different –To nearest 2mm –Do at two subsequent clinics ideally month apart Home –Add 10/5 –Do for 7 days morning and evening and take average Ambulatory –Add 10/5

Causes of secondary Contributory factors Target organ damage CVD risk Investigations The Assessment

CVD risk 20 fold range in the same BP depending on other risk factors Best estimated with epidemiological data Framingham (pros and cons) cf ASSIGN –Indian subcontinent CVD risk is about 1.4 times –A family history of premature CVD, and especially CHD (men, 55 years and women, 65 years) in a first degree relative increases the risk of developing CVD by about 1.3. –Given up smoking with 5 years count as smokers –Untreated Those who don’t need formal risk assessment: Diabetes >40, secondary prevention and familial dyslipidaemia

Screening All adults from 40 years onwards, who have no history of CVD or diabetes, and who are not already on treatment for blood pressure or lipids, should be considered for an opportunistic comprehensive CVD risk assessment in primary care. Younger adults (40 years) with a family history of premature atherosclerotic disease should also have their cardiovascular risk factors measured.

AcceleratedAdmit >220/120Immediate >180/110Assess two weeks. Treat if persistent >160/100Assess 3-12 weeks. Treat if persistent >140/90Assess 12 weeks. Treat if diabetic/TOD/risk

single drug therapy will reduce BP by, on average, no more than about 7– 8%; hypertension can be broadly classified as ‘high renin’ or ‘low renin’ younger people 55 years) or the black population (of African descent) Management of hypertension in the UK remains suboptimal for the majority Monotherapy for hypertension is usually inadequate therapy

ASCOT 2005 (Lancet 2005:366;869) –19,000 people over 5.4 years –Amlodipine (C) and perindopril (A) v. Atenolol (B) v. Bendrofluazide (D) –A +C better and less diabetes –B slightly reduced BP but not deaths of MIs – same as placebo –New guidelines scrap B as first line and consider once on A,C and D

Others 75mg aspirin >50 with BP controlled and CVD risk > 20% Statin CVD risk > 20%, all diabetics > 40, diabetics <40 with additional risk factor In diabetes hypertension twice as common, twice as risky and twice as hard to treat but twice as beneficial