1. Hypertension Dr Nidhi Bhargava 8/10/13

2. Why Treat Increased risk of cardiovascular death and mortality Increased systolic, diastolic and pulse pressures (associated with arterial wall and haemodynamic changes)- all equally important Prevalence of HT increases with age Initially both systolic and diastolic increase up to 50years of age Thereafter systolic continues to rise but diastolic plateau Diastolic HT most prevalent up to 60years and then either isolated systolic or combined HT- Why?

3. BP, Stroke and CHD For each reduction of 10mmHg in SBP and 5mmHg of DBP-associated reduction of stroke by 28% and 34% resp. HT and LVH Sokolow-Lyon criteria for assessing LVH- ECG-depth of S wave in V1 added to height of R wave in V5 > 35mm- rule applicable to pts > 40years

4. Diagnosing Hypertension Clinic BP ≥ 140/90mmHg Repeat after a few minutes Offer ambulatory BP monitoring (ABPM) ABPM- 24hr BP monitor (2 measurements per hour during pt.'s waking hours and at least 14 measurements to get an average) HBPM- 2 consecutive measurements are taken at least 1-2 mins apart, with pt. seated and record lower of the two readings, twice a day for 4-7 days Discard 1 st day’s readings and then taken an average

5. Stages of Hypertension Stage 1- clinic BP 140/90 or higher And ABPM or HBPM is ≥ 135/85 mmHg Stage 2- Clinic BP ≥ 160/100mmHg And ABPM or HBPM is ≥ 150/95mmHg Stage 3- clinic systolic BP is ≥ 180mmHg or higher or diastolic BP ≥ 110mmHg start treatment immediately

6. Lifestyle Changes Weight reduction- age independent correlation between HT and obesity, 3 fold increased risk in pt. with body weight > 20% Salt intake reduction- recommended intake 5mmHg of diastolic reduction in 30-40% Exercise-aerobic exercise results in wt. reduction and hence BP reduction Reduce excess alcohol intake- < 21 units for men and <14 units for women per week Stop smoking

7. Use of Antihypertensives-1 ClassCompelling indications Possible indications Possible contraindicat ions Compelling Contraindica tions α BlockersProstatismDyslipidaemi a Postural Hypotension Urinary incontinence ß BlockersMI, anginaHFHF, PVD, Dyslipidaemi a Asthma, COPD, Heart block DHP Ca blockers Isolated Systolic HT Angina, elderly Heart failure Non DHP Ca blockers AnginaMIß BlockersHeart Block and heart failure

8. Use of Antihypertensives-2 ClassCompelling Indications Possible Indications Possible Contraindica tions Compelling Contraindica tions ThiazidesIsolated systolic HT, elderly Dyslipidaemi a, acute gout ACEIHeart failure CHD Diabetes CRFSevere renal Impairment RAS Pregnancy ARBSCough with ACEI Type 2 DM with renal disease Severe renal impairment RAS Pregnancy

9. Initiating Treatment Pts < 80yrs with stage 1 HT with 1 or more of the following –Target organ disease –Established CVD –Renal disease –Diabetes –10yrs CVD risk ≥ 20%

10. Offer treatment to pts of any age with stage 2 HT For pts <40 years with stage 1 HT investigate for secondary causes For pts >80 yrs. same as above

11. Assessing Cardiovascular risk Assess target organ damage –Urine acr and urine dip for haematuria –UEs, lipids, glucose, cholesterol and eGFr –Fundi examination for hypertensive retinopathy –Routine ecg

12. Secondary causes of HT Renal US Renin and aldosterone levels 3 × 24 hour urine collections for catecholamine CT/MRI of abdomen to look at adrenals MRA/MRI for renal artery stenosis Investigate if BP not controlled on 3 antihypertensive at any age

13. Treatment options Step 1 If ≤ 55years –ACEI or a low cost ARB –If > 55 and pts of AfroCarribean origin CCB if not suitable or oedema or evidence of HF then thiazides diuretics- prefer indapamide or chlorthalidone

14. Step 2 – If ≤ 55 years –A+C or A+D –If > 55years or Afrocarribean –C+A or C+ARB –B+C rather than D if increased risk of diabetes –Before adding 3 rd medication ensure step 2 treatment is at optimal or best tolerated doses

15. Step 3 – A+C+D –If BP ≥ 140/90mmHg resistant HT –Step 4 Add low dose spironolactone 25mgs if K ≤ 4.5 Higher dose diuretic if K > 4.5, check UEs in a month If UEs worsening consider α or ß blocker and refer if still not controlled

16. BP targets Age < 80years BP<140/90mmHg Age > 80years BP <150/90mmHg ABPM/HBPM –Age <80years- BP<135/85 –Age >80years-BP<145/85mmHg