1. Hypertension Dr Zaka Haq, MBBS, MRCP Cardiology Registrar Queens Hospital Romford

3. Hypertension Prevalence (UK) NICE Beta Blockers Challenges Primary Care

4. Hypertension-Overview Hypertension itself-Introduction Types Classification Risk Factors Sequels Hypertension in special circumstances Management Follow Up Guidelines Referral to Secondary care

5. Hypertension, Introduction. Hypertension is one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for stroke (ischemic and haemorrhagic), myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension may result in vascular and renal damage that can culminate in a treatment-resistant state. The 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 ischemic heart disease and a 10% increased risk of mortality from stroke.

6. Hypertension, Introduction. Diastolic pressure is more commonly elevated in younger people. With ageing, systolic hypertension becomes a more significant problem. The clinical management of hypertension is one of the most common 22 interventions in primary care, accounting for approximately £1 billion in drug costs alone in 2006. Hypertension is often symptom less, so screening is vital - before damage is done. Many surveys continue to show that hypertension remains under diagnosed, undertreated and poorly controlled in the UK

7. Hypertension, Introduction In many countries, 50% of the population older than 60 years has hypertension. Overall, approximately 20% of the world’s adults are estimated to have hypertension. UK, 1 in every 4 th person has Hypertension and this increases to 1 in every second person aged over 60.

8. Types of hypertension Essential hypertension (Primary)  90%  No underlying cause Secondary hypertension  5%  Underlying cause

9. Causes of Secondary Hypertension Renal disease Approximately 75% are from intrinsic renal disease: glomerulonephritis, polyarteritis nodosa, systemic sclerosis, chronic pyelonephritis, or polycystic kidneys. Approximately 25% are due to Reno vascular disease - most frequently atheromatous (e.g. elderly cigarette smokers with peripheral vascular disease) or fibromuscular dysplasia (more common in younger females). Endocrine disease Cushing’s syndrome, Conn's syndrome, pheochromocytoma, acromegaly, Hyperparathyroidism Others Coarctation, Preeclampsia, Drugs and toxins, e.g. alcohol, cocaine, ciclosporin, tacrolimus, erythropoietin, adrenergic medications, decongestants containing ephedrine and herbal remedies containing liquorice

10. Definitions and Classifications of BP Levels SBPDBP Category*(mm Hg)(mm Hg) Optimal< 120< 80 Normal< 130< 85 High-normal130-13985-89 Grade 1 hypertension (mild)140-15990-99 Grade 2 hypertension (moderate)160-179100-109 Grade 3 hypertension (severe)> 180> 110 ISH> 140< 90 Reading to Remember 140 90 WHO-ISH Guidelines Subcommittee J Hypertens 1999; 17:151

11. Hypertension: Predisposing factors Age > 60 years Sex (men and postmenopausal women) Family history of cardiovascular disease Smoking High cholesterol diet Co-existing disorders such as diabetes, obesity and hyperlipidaemia High intake of alcohol Sedentary life style Remember all these are predisposing factors for HTN but they all including HTN are risk factors for Cardiovascular disease.

12. Diseases Attributable to Hypertension HYPERTENSION Gangrene of the Lower Extremities Heart Failure Left Ventricular Hypertrophy Myocardial Infarction Hypertensive Encephalopathy Aortic Aneurysm Blindness Chronic Kidney Failure Stroke Preeclampsia/ Eclampsia Cerebral Hemorrhage Coronary Heart Disease Adapted from Dustan HP et al. Arch Intern Med. 1996; 156: 1926-1935

13. Hypertension in special circumstances HTN in Young-Causes HTN and Pregnancy-Cautions HTN and Diabetes - Proteinurea HTN and Renal Failure – vice versa Hypertensive Emergencies – urgency, Emergency

14. Management of hypertension: the issues Measurement Classification Investigations Risk assessment Non-pharmacological measures Treatment thresholds - 1st line - sequencing - beyond BP Treatment targets Concomitant therapy

15. Diagnosis and Measurement- 2011 If the first and second blood pressure measurements taken during consultation are 140/90 mmHg or higher, offer 24-hour ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new 2011] When using ABPM to confirm a diagnosis of hypertension, ensure that: Blood pressure is measured for a total of 24 hours. At least two measurements per hour are taken during the day (08:00 to 22:00). At least one measurement per hour is taken during the night (22:00 to 08:00). Use the average daytime blood pressure measurement, [new 2011]

16. Diagnosis and Measurement- 2011 When using home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension, ensure that: For each blood pressure measurement, two consecutive measurements are taken, at least 1 minute apart and with the person seated. Blood pressure measurements are taken twice daily, ideally in the morning and evening. Blood pressure measurement continues for at least 4 days, ideally for 7 days. Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of HTN-2011

17. Potential indications for the use of ambulatory blood pressure monitoring Unusual variability Possible white coat hypertension Informing equivocal treatment decisions Evaluation of nocturnal hypertension Evaluation of drug-resistant hypertension Determining the efficacy of drug treatment over 24 hours Diagnoses and treatment of hypertension in pregnancy Evaluation of symptomatic hypotension

18. Why Home or ABPM? 2004 Guideline recommended that BP should not be diagnosed and treated based on one clinic BP measurement Majority will need repeated clinic visits to confirm or refute the diagnosis Inaccurate clinic measurements may weaken the relationship between BP and CVD risk People who do not have sustained BP may be wrongly diagnosed and commenced on treatment with risk of side effects and unnecessary diagnosis and anxiety and cost.

19. Equipment Training Servicing

20. Investigations Urine Biochemistry Blood Glucose Lipid Profile Electrocardiogram, CXR USG-KUB, Urinary catecholamine, TSH, CXR, ECHO, urinary free cortisol, Specialist investigations

21. Life Style Modifications. Maintain normal weight for adults (BMI 20-25 kg/m2) Reduce salt intake to <100 mmol /day (<6g NaCl or <2.4g Na+/day) Limit alcohol consumption to <3 units/day for men and <2 units/day for women Engage in regular aerobic physical exercise (brisk walking rather than weightlifting) for >30 min per day Consume at least five portions/day of fresh fruit and vegetables Reduce the intake of total and saturated fat STOP SMOKING

22. Next Initiating and monitoring antihypertensive drug treatment, including blood pressure targets

23. Drug therapy for hypertension Class of drugExampleInitiating doseUsual maintenance dose DiureticsHydrochlorothiazide 12.5 mg o.d.12.5-25 mg o.d.  -blockersAtenolol 25-50 mg o.d.50-100 mg o.d. CalciumAmlodipine2.5-5 mg o.d.5-10 mg o.d. channel blockers  -blockersDoxazosin1 mg o.d.1-8 mg o.d. ACE- inhibitors Lisinopril2.5-5 mg o.d.5-20 mg o.d. Angiotensin IILosartan25-50 mg o.d.50-100 mg o.d. receptor blockers - Centrally ActingMethyledopaHydralazine

24. Antihypertensive therapy: Side-effects and Contraindications Class of drugsMain side-effectsContraindications/ Special Precautions DiureticsElectrolyte imbalance,Hypersensitivity, Anuria (e.g. Hydrochloro-  total and LDL cholesterol thiazide) levels,  HDL cholesterol levels,  glucose levels,  uric acid levels  -blockers Impotence, Bradycardia,Hypersensitivity, (e.g. Atenolol)FatigueBradycardia, Conduction disturbances, Diabetes, Asthma, Severe cardiac failure

25. Class of drugMain side-effectsContraindications/ Special Precautions Calcium channel blockersPedal edema, HeadacheNon-dihydropyridine (e.g. Amlodipine,CCBs (e.g diltiazem)– Diltiazem)Hypersensitivity, Bradycardia, Conduction disturbances, Congestive heart failure, Left ventricular dysfunction. Dihydropyridine CCBs– Hypersensitivity  -blockersPostural hypotensionHypersensitivity (e.g. Doxazosin) ACE-inhibitorsCough, Hypertension,Hypersensitivity, Pregnancy, (e.g. Lisinopril)Angioneurotic edemaBilateral renal artery stenosis Angiotensin -II receptorHeadache, DizzinessHypersensitivity, Pregnancy, blockers (e.g. Losartan)Bilateral renal artery stenosis Antihypertensive therapy: Side-effects and Contraindications (Contd.)

26. Factors affecting choice of antihypertensive drug The cardiovascular risk profile of the patient Coexisting disorders Target organ damage Interactions with other drugs used for concomitant conditions Tolerability of the drug Cost of the drug

27. Choosing the right antihypertensive ConditionPreferred drugsOther drugsDrugs to be that can be usedavoided Asthma Calcium channel  -blockers/Angiotensin -II  -blockers blockersreceptor blockers/Diuretics/ ACE-inhibitors Diabetes  -blockers/ACECalcium channel blockersDiuretics/ mellitus inhibitors/  -blockers Angiotensin -II receptor blockers High cholesterol  -blockersACE inhibitors/ Angiotensin -II  -blockers/ levelsreceptor blockers/ CalciumDiuretics channel blockers Elderly patientsCalcium channel  -blockers/ACE- (above 60 years)blockers/Diuretics inhibitors/Angiotensin -II receptor blockers/  - blockers BPH  -blockers  -blockers/ ACE inhibitors/ Angiotensin -II receptor blockers/ Diuretics/ Calcium channel blockers

28. Limitations on use of antihypertensives in patients with coexisting disorders CoexistingDiuretic  -blockerACEAllCCB   -blocker Disorderinhibitorantagonist DiabetesCaution/xCaution/x     Dyslipidaemiaxx     CHD       Heart failure  3/Caution   Caution  Asthma/COPD  x  /Caution    Peripheral  CautionCautionCaution   vascular disease Renal artery   xx   stenosis

31. WHICH PATIENTS NEED TREATMENT Concentrate Bp Reading Target Organ Damage 10 Year CVD Risk Diabetes Young Hypertensives

32. Initiating Treatment Offer people older than 80 years the same antihypertensive drug treatment as people aged 55–80 years, taking into account any comorbidities 2011 Offer Stage 1 Hypertensive's treatment if they have target organ damage or 86 established cardiovascular disease or renal disease or diabetes or a 10-year cardiovascular risk equivalent to 20% or greater. [new 2011]

33. Initiating Treatment Hypertension is not controlled with monotherapy in at least 50% of patients; in these patients combination therapy is required Offer antihypertensive drug treatment to people with stage 2 hypertension. [new 2011] For people younger than 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular (CV) disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10- year CV risk assessments can underestimate the lifetime risk of CV events in these people -new 2011

37. Choosing drugs for patients newly diagnosed with hypertension: NICE/BHS

38. Antihypertensive Drug Treatment - 2011

39. Treatment Recommendations – General Concepts Offer people with isolated systolic hypertension (systolic BP 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure. [2004] Offer people older than 80 years the same antihypertensive treatment as people aged 55–80 years, taking into account any co morbidities. [new 2011] Offer step 1 antihypertensive treatment with an ACE inhibitor or a low-cost ARB to people aged under 55 years. If an ACE inhibitor is used and not tolerated, offer an ARB. [new 2011] Do not combine an ACE inhibitor with an ARB to treat hypertension. [new 2011]

40. Step 1 Treatment Recommendations Offer step 1 antihypertensive treatment with a CCB to people aged 55 years and older and to black people of African and Caribbean descent of any age. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure, or a high risk of heart failure, offer a thiazide -like diuretic. [new 2011] If a diuretic is required, choose a thiazide -like diuretic, such as chlortalidone (12.5 mg–25.0mg once daily) or indapamide (2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [new 2011]

41. Step 2 Treatment Recommendations If step 2 antihypertensive treatment is required, offer a CCB in combination with either an ACE Inhibitor or a low-cost ARB. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic [new 2011]

42. Step 3 Treatment Recommendations If treatment with three drugs is required, the combination of ACE inhibitor or angiotensin II receptor blocker, calcium-channel blocker and thiazide-like diuretic should be used. [2006]

43. Step 4 Treatment Recommendations Resistant Hypertension For treatment of resistant hypertension at step 4, consider further diuretic therapy with low-dose spironolactone (25 mg once daily) if blood potassium levels are lower than 4.5 mmol/l and eGFR is higher than 60 ml/min/1.73m2. If blood potassium levels are higher than 4.5 mmol/l, consider therapy with a higher- dose thiazide-like diuretic treatment. [new 2011] When using further diuretic therapy for resistant hypertension at step 4, monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter. [new 2011]

44. Step 4 Treatment Recommendations Resistant Hypertension If further diuretic therapy for resistant hypertension at step 4 is not tolerated, contraindicated or ineffective, consider an alpha- or beta-blocker. [new 2011] If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained. new 2011]

45. BP Targets in Various Guidelines Guidelines Uncomp.HTN DM C RF USA (JNC VII [2003]) <140/90 mmHg <130/80 mmHg <130/80 mmHg Europe (ESH 2007) <140/90 mmHg <130/80 mmHg <130/80 mmHg China (CSH 2005) <140/90 mmHg <130/80 mmHg <130/80 mmHg Russia <140/90 mmHg <130/80 mmHg <130/80 mmHg Korea (KSH 2004) <140/90 mmHg <130/80 mmHg <130/80 mmHg WHOISH SBP <140 mmHg <130/80 mmHg <130/80 mmHg BHS IV 2004 <140/85 mmHg <130/80 mmHg <130/80 mmHg

46. Hypertension in DRAFT NICE Big changes with impact on Primary Care Hypertension as a disease Primary not Essential hypertension At least ¼ of adult UK population have a BP > = 140/90 or hypertension More than ½ of those 60 or more

47. Hypertension in NICE ( DRAFT) Strong emphasis on diagnosis and measuring blood pressure Ensuring training for those taking blood pressure measurements Validation, maintenance and calibration of devices and correct cuff size Standard procedure for measurement resting 5-10 min Check pulse rhythm for AF Check for postural drop If first and second readings are both higher than 140/90 to arrange an ABPM If blood pressure > 180/110 start treatment

48. Suggested indications for specialist referral Urgent treatment needed Accelerated hypertension (severe hypertension and grade III-IV retinopathy) Particularly severe hypertension ( > 220/120 mm Hg) Impending complications (for example, transient ischemic attack, left ventricular failure) Possible underlying cause Any clue in history or examination of a secondary cause, such as hypokalaemia with increased or high normal plasma sodium (Conn’s syndrome) Elevated serum creatinine Suspected phaeochromocytome with labile BP or postural hypotension, headache, palpitations, pallor

49. Suggested indications for specialist referral Proteinuria or haematuria Sudden onset or worsening of hypertension Resistant to multidrug regimen ( ≥ 3 drugs) Young age (any hypertension < 20 years; needing treatment < 30 years) Therapeutic problems Multiple drug intolerance Multiple drug contraindications Persistent non-adherence or non-compliance Special situations Unusual blood pressure variability Possible white coat hypertension Hypertension in pregnancy

50. Groups that will not be covered 420 People with diabetes. Children and young people (younger than 18 years). Pregnant women. Secondary causes of hypertension (for example, Conn's adenoma, phaeochromocytoma and renovascular hypertension). People with accelerated hypertension (that is, severe acute hypertension 426 associated grade III retinopathy and encephalopathy). People with acute hypertension or high blood pressure in emergency care

51. Drugs in special conditions Condition Pregnancy Coronary heart disease Congestive heart failure Preferred Drugs Nifedipine, labetalol, hydralazine, beta-blockers, methyldopa, prazosin Beta-blockers, ACE inhibitors, Calcium channel blockers ACE inhibitors, beta-blockers 1999 WHO-ISH guidelines

52. HTN and Pregnancy Chronic hypertension (2-4%) Hypertension first identified in early pregnancy Hypertension that persists postpartum Gestational hypertension (2-4%) Non- proteinuric hypertension Pre- eclampsia 3% primigravida at term and 0.5% pre-term

53. HTN and Pregnancy During pregnancy, BP target; 130/80 - 150/100mmHg If BP ≥150/100; start labetolol/methyldopa/nifedipine SR Avoid ACE-I and ARBs during pregnancy Consider secondary hypertension in women with severe hypertension especially in early pregnancy and postpartum Consider prophylactic low-dose aspirin from 12 weeks Both systolic and diastolic hypertension important Early onset pre-eclampsia, a serious threat to mother and foetus Long-term follow up is essential for future woman’s health

54. CKD and Diabetes  In people with CKD aim for: systolic blood pressure below 140 mmHg (target range 120–139 mmHg) diastolic blood pressure below 90 mmHg  In people with CKD and diabetes - or when ACR  70mg/mmol, aim for: systolic blood pressure below 130 mmHg (target range 120–129 mmHg) diastolic blood pressure below 80 mmHg

55. Place Of Beta blockers Beta-blockers are not a preferred initial therapy for hypertension. However, beta-blockers may be considered in younger people, particularly: those with an intolerance or contraindication to ACE inhibitors and angiotensin -II receptor antagonists or women of child-bearing potential or people with evidence of increased sympathetic drive. In these circumstances, if therapy is initiated with a beta-blocker and a second drug is required, add a calcium-channel blocker rather than a thiazide -type diuretic to reduce the person’s risk of developing diabetes.

56. Other medications for hypertensive patients Primary prevention (1) Aspirin: use 75mg daily if patient is aged  50 years with blood pressure controlled to <150/90 mm Hg and either; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of  20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart) (2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years, with a 10 year risk of cardiovascular disease of  20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart) and with total cholesterol concentration  3.5mmol/l (3) Vitamins—no benefit shown, do not prescribe

57. Secondary prevention (including patients with type 2 diabetes) (1)Aspirin: use for all patients unless contraindicated (2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years with a total cholesterol concentration  3.5 mmol/l (3) Vitamins— no benefit shown, do not prescribe Other medications for hypertensive patients