Kieran McGlade Nov 2001 Department of General Practice QUB Hypertension

Kieran McGlade Nov 2001 Department of General Practice QUB Aetiology of Hypertension Primary – 90-95% of cases – also termed essential of idiopathic Secondary – about 5% of cases –Renal or renovascular disease –Endocrine disease Phaeochomocytoma Cusings syndrome Conns syndrome Acromegaly and hypothyroidism –Coarctation of the aorta –Iatrogenic Hormonal / oral contraceptive NSAIDs

Kieran McGlade Nov 2001 Department of General Practice QUB This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy.

Kieran McGlade Nov 2001 Department of General Practice QUB The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.

Kieran McGlade Nov 2001 Department of General Practice QUB H O T Hypertension Optimal Treatment Largest intervention trial in hypertension. Published in 1998 Conducted in General Practice. 18,790 patients in 26 countries Followed up for an average of 3.8 years

Kieran McGlade Nov 2001 Department of General Practice QUB H O T Findings Lowest incidence of major CV events occurred at a mean achieved DBP of 83 mmhg. This target (compared to mean achieved of 105 mmHg was associated with a 30% reduction in main CV events. In diabetes – Diastolic< or = 80mmhg 51 % lower risk compared to 90 mmHg

Kieran McGlade Nov 2001 Department of General Practice QUB Global heart threat from diabetes: A global explosion in the number of cases of diabetes is threatening to reverse the reduction in deaths from heart disease in many western countries, including the United Kingdom. To coincide with World Diabetes Day on 14 November, Diabetes UK is calling for action to be taken to reduce the 20,000 deaths per year from coronary heart disease (CHD) among people with diabetes in the UK.

Kieran McGlade Nov 2001 Department of General Practice QUB Hypertension and Diabetes Hypertension co-exists with type II in about 40% at age 45 rising to 60% at age % of type II patients die from cardio- vascular disease. At least 60% of patients will require 2 or 3 antihypertensive agents to achieve tight control.

Kieran McGlade Nov 2001 Department of General Practice QUB Stages Identification of hypertensive patients Baseline investigations Initiating therapy Reviewing patients Stepping up therapy Motivation and compliance

Kieran McGlade Nov 2001 Department of General Practice QUB Investigation of the New Hypertensive History and examination Exclude secondary Hypertension Urea and electrolytes FBP and ESR ECG Lipid profile Chest x-ray no longer routinely indicated

Kieran McGlade Nov 2001 Department of General Practice QUB Clinical clues to renal vascular disease Hypertension under 50 Yrs of age. Generalised vascular (esp peripheral) disease. Mild – moderate renal dysfunction. Sudden onset pulmonary oedema.

Kieran McGlade Nov 2001 Department of General Practice QUB Ladder Approach Bendrofluazide Bendrofluazide + Atenolol or ACE Calcium Channel blocker Alpha blocker

Kieran McGlade Nov 2001 Department of General Practice QUB Tailored Approach Assessment of overall cardiovascular risk Recognition of co-morbidities Lipid profile Renal function Existing contra- indications

Kieran McGlade Nov 2001 Department of General Practice QUB

Kieran McGlade Nov 2001 Department of General Practice QUB Coronary Risk Calculator Launch risk calculator program

Kieran McGlade Nov 2001 Department of General Practice QUB Compelling and possible indications and contrindications for the major classes of antihypertensive drugs INDICATIONS CONTRAINDICATIONS CLASSS OF DRUGCOMPELLINGPOSSIBLE COMPELLING -blockers ProstatismDyslipidaemiaPostural HypotensionUnrinary incontinence Angiotensin converting enzyme (ACE) inhibitors Heart failure Left ventricular dysfunction Chronic renal disease * Type II diabetic nephropathy Renal impairment * Peripheral vascular disease Pregnancy Renovascular disease Angiotensin II receptor antagonistsCough induced by ACE inhibitor Heart failure Intolerance of other antihypertensive drugs Peripheral vascular disease Pregnancy Renovascular disease blockers Myocardial infarction Angina Heart failure Heart failure Dyslipidaemia Peripheral vascular disease Asthma or COPD Heart block Calcium antagonists (dihydropyridine)Isolated systolic hypertension (ISH) in elderly patients Angina Elderly patients _ _ Calcium antagonists (rate limiting)AnginaMyocardial infarction Combination with blockade Heart block Heart failure ThiazidesElderly patients including ISH _DyslipidaemiaGout * ACE inhibitors may be beneficial in chronic renal failure but should be used with caution. Close supervision and specialist advice are needed when there is established and significant renal impairment Caution with ACE inhibitors and angiotensin II receptor antagonists in peripheral vascular disease because of association with renovascular disease. If ACE inhibitor indicated -blockers may worsen heart failure, but in specialist hands may be used to treat heart failure British Hypertension Society Guidelines 2000

Kieran McGlade Nov 2001 Department of General Practice QUB Therapeutic targets Therapeutic targets * Measured in clinic Mean daytime ABPM or home measurement Blood Pressure No diabetes Diabetes No diabetes Diabetes Optimal <140/85 <140/80 <130/80 <130/75 Audit Standard <150/90 <140/85 <140/85 <140/80 The audit standard reflects the minimum recommended levels of BP control. Despite best practice, it may not be achievable in some treated hypertensive patients. NB: Both systolic and diastolic targets should be reached British Hypertension Society Guidelines

Kieran McGlade Nov 2001 Department of General Practice QUB Logical Combinations Diuretic - blocker CCB ACE inhibitor - blocker Diuretic blocker - * - CCB - * - ACE inhibitor blocker - * Verapamil + beta-blocker = absolute contra-indication

Kieran McGlade Nov 2001 Department of General Practice QUB ACE Inhibitor Side Effects Cough (15% of patients. Is reversible) Taste disturbance (reversible) Angiodema First-dose hypotension Hyperkalaemia ( esp. in patients with type II diabetes and renal dysfunction)

Kieran McGlade Nov 2001 Department of General Practice QUB Follow-up For patients with BP stabilised by management, follow up should normally be three monthly (interval should not exceed 6 months), at which the following should be assessed by a trained nurse: * Measurement of BP and weight * Reinforcement of non-pharmacological advice * General health and drug side-effects * Test urine for proteinuria (annually)

Kieran McGlade Nov 2001 Department of General Practice QUB Web based references British Hypertension Society: Summary Guidelines 2000: Hypertension audit protocol from Leicester prot.html prot.html

Kieran McGlade Nov 2001 Department of General Practice QUB Drug Treatment of Essential Hypertension in Older People Hypertension is very common, occuring in over 50% of older people, and is a major risk factor for stroke and ischaemic heart disease. Drug treatment of hypertension in older people saves lives and prevents unnecessary morbidity. Treating isolated systolic hypertension also saves lives.

Kieran McGlade Nov 2001 Department of General Practice QUB Drug Treatment of Essential Hypertension in Older People There is strong evidence to support the use of diuretics as first-line agents. Antihypertensive treatments are most cost- effective when targeted at older patients. There is evidence of under detection and under treatment of hypertension. Factors influencing patient adherence with treatment are not well understood and require further research.

Kieran McGlade Nov 2001 Department of General Practice QUB RECOMMENDATIONS (for the treatment of the elderly) Through the wider use of antihypertensive therapies more older people would be able to maintain a healthy and active lifestyle. For first-line agents there is strong evidence to support the use of diuretics and some evidence for the use of beta-blockers. Systems to ensure that older people with hypertension are diagnosed, treated and followed up need to be developed. A system of audit should be cultivated to assure adequate treatment. High quality research on patient adherence with antihypertensive medications is needed. NHS Centre for reviews and dissemination 1999

Kieran McGlade Nov 2001 Department of General Practice QUB Practical Points 15 – 20% of adult western population. Isolated systolic hypertension just as dangerous. Primary cause identified in only 5%. Investigate – Urine, FBP, ESR, ECG, U&E, Lipids. Target < 140/85. Bendrofluazide 2.5 mg a good starting point. Refer patients needing more than 3 drugs to control their hypertension.