The Management of Hypertension in Primary Care

1
The Management of Hypertension in Primary Care

• Alison Elliott
• (November 2007)

2
Resources

• NICE Guideline 34 (2006) - Hypertension
  management of hypertension in adults in primary
  care
• National Collaborating Centre for Chronic
  Conditions
• British Hypertension Society
• British Hypertension Society Website
• SIGN Guideline 49 (2001) - Hypertension in older
  people
• Dr. John Dick (Sept 2007) Dragging hypertension
  management into the 21st century

3
Patient-centred Care

• Diagnosis of Hypertension
• BP gt140/90mmHg (over 2 months or less)
• Refer urgently if - malignant hypertension
  - ?phaeochromocytoma
• Consider referral if - signs/symptoms unusual
  or suggest 2o cause
• - postural hypotension
• Beware automated BP monitors (?underestimate BP
  by 10/5mmHg)

4
Lifestyle advice

• Weight (BMI 20-25Kg/m2)
• Exercise (30mins/day at least 3/7)
• Diet (reduce sat fat 5 portions fresh FV /day)
• Salt (lt6g NaCl (2.4g Na) /day)
• Alcohol (men 3 units/day women 2 units/day
• Smoking
• Local initiatives

5
Assessing CV risk

• Urinalysis (?protein/blood) /microalbumin
• ECG (?LVH) / ?ECHO
• UEs / glucose (fasted) / cholesterol (total
  HDL / triglycerides - fasted)
• Fundoscopy
• Foot pulses (re. correlation with renal artery
  stenosis)

6
Threshold for antihypertensive

• 160/100mmHg (moderate/severe)
• 140/90 (mild)- 10yr CV risk 20
• - CV disease/organ damage
• - Diabetes /CKD
• 130-139/85-89 - Reassess yearly
• 130/85 - Reassess 5 yearly

7
Treatment targets

• lt140/85mmHg
• Audit Standard lt150/90mmHg
• lt130/80mmHg Diabetes
• Audit Standard lt140/80mmHg
• NNT to prevent one death
• age lt60yrs 167
• age gt60yrs 72
• Review annually once BP controlled

8
Which Class of Antihypertensive?

• 1) lt55yrs A 55yrs (or black) C or D
• 2) AC or AD
• 3) ACD
• 4) Add
• - additional diuretic
• - a-blocker
• - ß-blocker
• A ACEI C Ca ch blocker D Thiazide diuretic

9
Which Class of Antihypertensive? (contd.)

• Consider titrating A drugs (SEs not
  dose-dependent)
• Angiotensin II receptor blockers have fewest
  side-effects
• Dont titrate C D drugs
• Consider 2nd A drug (incl. DRI spironolactone)
• a-Blockers exacerbate postural drop in BP
• Dont use ß-blockers if no Hx cardiac disease
• drugs affecting the renin-angiotensin-aldosterone
  system

10
ß-blockers

• Consider if young female, ?symp drive or
  ACEI/angiotensin-II receptor blocker intolerant
  (or contraindicated)
• Use a ß-blocker with vasodilator properties
• Add Ca channel blocker if patient on ß-blocker
  needs 2nd drug
• Can continue on ß-blocker if BP controlled (if
  not,consider current AHD guidelines)
• If withdrawing, reduce dose gradually

11
Additional Therapy for Primary CV Risk Reduction

• Aspirin if aged 50 BP lt150/90mmHg
• Statin if 10 year CV risk 20
• - Target - Total cholesterol lt4mM (5mM)
• - LDL cholesterol lt2mM (3mM)
• - 25? in Total cholesterol
• - 30 ? in LDL cholesterol

12
Refer

• Refractory hypertension - i.e. uncontrolled on 3
  antihypertensives

13
(No Transcript)
14
NaCl / ECF volume / Arterial blood
pressure
H2O conserved
Adrenal cortex
Liver
Kidney
Lungs
Kidney
Na (and CI) osmotically hold more H2O in ECF
Na (and CI) conserved
Angiotensin- converting enzyme
Renin
Na reabsorption by kidney tubules (
CI reabsorption follows passively)
Angiotensinogen
Angiotensin I
Angiotensin II
Aldosterone
Vasopressin
Thirst
Arteriolar vasoconstriction
H2O reabsorption by kidney tubules
Fluid intake