Practical Management of Hypertension in Primary Care Back to Medical School Group Dr Rob Sapsford Consultant 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 The incidence of hypertension is predicted to increase dramatically Population with hypertension (%) 30 Overall MenWomen The global incidence of hypertension in the adult population is predicted to exceed 29% by the year % of all adults hypertensive 50% adults 60yrs> hypertensive

Pulse pressure

Cardiovascular risk doubles with each 20/10 mmHg increment SBP / DBP (mmHg) CV Mortality risk (fold increase) Lewington et al Lancet 2002:60;

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; Meta-analysis of 61 prospective observational studies involving 1 million adults (12.7 million patient years)

Relative risk reduction (%) −50 −40 −30 −20 −10 0 CHDStrokeCV event 20–21 21–28 30–39 Risk of CV event with ACEI or CCB relative to placebo CV: cardiovascular CHD: coronary heart disease Long-term antihypertensive treatment reduces CV risk Neal B, et al RAS

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 kymographRiva-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’s Difference in BP between arms BP difference 20mmHg> Repeat measurements ? persists Action Document 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> Action Review medication Measure future BP standing Consider referral if symptoms persist

Blood Pressure Clinic BP 140 > / 90 > Ambulatory BP Monitor ABPM Minimum 2x readings / Hr Average 14 daytime readings Home BP Monitor HBPM 2 readings 1 min> apart Minimum 2x recordings / day Average min 4 days – 7 days readings (disregard day 1 readings)

Hypertensive Stages Stage 1 Clinic BP 140> / 90> Daytime ABPM135> / 85> Average HBPM 135> / 85> Stage 2 Clinic BP160> / 100> Daytime ABPM150> / 95> Average HBPM150> / 95> Severe Clinic BP180> / 110>

Treatment guidelines 160> /100> mmHg ABPM 150>/95> Treat (any age) BMJ : <140 /90 mmHg ABPM <135/<85 Annual review 140–159 / ABPM /85-94 Assess risk BP measurement

Treatment Guidelines No Target Organ Damage (TOD) and No Diabetes mellitus and No Cardio-vascular disease and No Renal Disease and 10 yr Cardio-vascular risk <20%* BMJ : Lifestyle measures Annual review Target Organ Damage (TOD) or Diabetes mellitus or Cardio-vascular disease or Renal Disease or 10 yr Cardio-vascular risk 20%> Treat ABPM/HBPM / 85-95

Investigations Cardio-vascular risk U/E’s, FBC, TFT’s, TC:HDL, Glucose QRISK2, Framinghm Target Organ Damage ECG Urinalysis / Alb:Creat ratio

Target Organ Damage CVA Nephropathy Retinopathy LVH

Framingham Cardiovascular Risk (morbidity and mortality) Atherosclerotic disease anywhere – high risk Sex Age Systolic BP / Diastolic BP Smoking history Total cholesterol : HDL ECG – 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 Age Sex Smoking status Systolic BP Ratio TC:HDL BMI Family 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 ethnicity Type 2 diabetes Rheumatoid arthritis Renal disease Atrial 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 / exercise Alcohol reduction Caffeine reduction Reduce dietary Sodium Smoking cessation

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 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:

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 Patient aged >50 yrs BP controlled <150 / 90 target organ damage Diabetic 10 CV risk >20% And one of BMJ :

Statin Trials: ASCOT - LLA Percentage with CHD event Primary prevention Pravastatin Lovastatin Modified from Kastelein JJP. Atherosclerosis. 1999; 143(suppl 1): S17-S21 Atorvastatin (210) 2.3 (90) 2.8 (110) 3.4 (130) 3.9 (150)4.4 (170) 4.9 (190) WOSCOPS-S WOSCOPS-P 0 5 AFCAPS-S AFCAPS-P 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