2.  Edmond 75 years presented with ‘shocking” blood pressure recordings of 184/102 in the morning. His afternoon and night readings were in the ‘acceptable target ranges”He has atrial fibrilliation and is on warfarin 5 mg daily. In addition he is on prazosin 5 mg, atenolol 50 mg, coversyl 10 mg and valsaltan

3.  What is the prevalence rate of under achieving target blood pressures?  List 5 cause of failure to achieve target blood pressures ? How can we reach blood pressure targets?  What is the choice of antihypertensives in angina, post myocardial infarct, post stroke, heart failure, diabetes with proteinuria or microalbuminuria,gout, chronic kidney disease, atrial fibrilliation ?  What are the potentially harmful antihypertensives in asthma/COPD, bradycardia 2 nd or 3 rd atrioventricular failure,depresion,gout,heart failure, bilatral renal artery stenosis + diabetes with proteinuria or microalbuminuria?  List 3 effective antihypertensive combination therapies + 3 combinations to avoid.

4. Patient groupTarget ( mm Hg) Proteinuria > 1 gm / day ( with or without diabetes) <125/75 Associated conditions of end organ damage: (coronary heart disease, stroke, diabetes, chronic kidney disease, proteinuria >300 mg / day) <130/80 None of the above<140/90 or lower if tolerated

5. TrialsPrevalence of underachieving target blood pressures AusDiab study( The Australian Diabetes, Obesity + Lifestyle) 40% ALLHAT(The Antihypertensive + Lipid Lowering Treatment to Prevent Heart Attack Trial) 66% CONVINCE( Controlled Onset Verapamil Investigation of Cardiovascular Endpoints) 70%

6. (1) Lifestyle factors not implemented (2) Adherence medication poor: costs, side effects (3) Substances increasing BP: NSAIDs, prednisolone, alcohol, caffeine, salt intake (4) Systems issues: social or economic barriers, recall or reminder systems (5) Secondary hypertension: (6) Therapeutic inertia: need to increase a current agent or add another agent (7) Measurement issues: white coat effect, inappropriate cuff size

7. ConditionPotentially beneficial AnginaACEI,Beta blockers(except oxprenolol,pindolol),CCBs Post myocardial infarctACEI, Beta blockers(except oxprenolol, pindolol),Eplerone Post strokeACEI,A2RA,low dose thiazide-like diuretics Heart failureACEI,A2RA,Thiazide diuretics,Beta blockers(bisoprolol,carvedilol,metopr olol controlled release) spironolactone Type 1 or 2 Diabetes with proteinuria or microalbuminuria ACEI,A2RA GoutLosartan Chronic kidney diseaseACEI,A2RA Atrial fibrilliationACEI,A2RA

8. ConditionCautionContraindicated Asthma/COPDCardioselective BB use in mild/moderate asthma/COPD only BB(except cardioselective agents) Bradycardia,2 nd /3 rd AV block BB,verapamil,diltiazem DepressionBB, clonidine,methyldopa, minoxidine GoutThiazide diuretics Heart failureCCBs(verapamil,dilthiaz em) Alpha blockes in AS,BB in uncontoled HF Bilateral RAS( Unilateral solitary kidney) ACEI,A2RA Type 1 /2 diabetes with proteinuria or microalbuminuria BB,Thiazide diuretics

9. First drugAdditional drugRecommendation ACEI or A2RACCBDiabetes or lipid abnormalities ACEI or A2RAThiazide diureticHeart failure or post stroke ACEI or A2RABBPost MI or heart failure BBDihydrpyridine CCBCoronary heart disease Thiazide DiureticsCCB,BB( not recommended in glucose intolerance, metabolic syndrome or established diabetes

10. First drugAdditional drugRecommendation ACEI or A2RAPotassium sparing diuretics Risk of hyperkalaemia VerapamilBeta blockerRisk of heart block ACEIA2RALarge trial did not reduce cardiovascular death or morbidity in vascular disease or diabetes but increased risk of hypotensive symptoms, syncope + renal dysfunction