Hypertension

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Hypertension
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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

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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.
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The left ventricle is markedly thickened in this
patient with severe hypertension that was
untreated for many years. The myocardial fibers
have undergone hypertrophy.
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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

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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 Diastoliclt or 80mmhg 51 lower
  risk compared to 90 mmHg

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Hypertension and Diabetes

• Hypertension co-exists with type II in about 40
  at age 45 rising to 60 at age 75.
• 70 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.

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Stages

• Identification of hypertensive patients
• Baseline investigations
• Initiating therapy
• Reviewing patients
• Stepping up therapy
• Motivation and compliance

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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

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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.

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Ladder Approach

• Bendrofluazide
• Bendrofluazide Atenolol or ACE
• Calcium Channel blocker
• Alpha blocker

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Tailored Approach

• Assessment of overall cardiovascular risk
• Recognition of co-morbidities
• Lipid profile
• Renal function
• Existing contra- indications

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Coronary Risk Calculator

• Launch risk calculator program

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Compelling and possible indications and
contrindications for the major classes of
antihypertensive drugs                           
     
INDICATIONS              
CONTRAINDICATIONS
  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 f  b-blockers
may worsen heart failure, but in specialist hands
may be used to treat heart failure  British
Hypertension Society Guidelines 2000
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Therapeutic targets
Therapeutic targets
                          Measured in
clinic               Mean daytime ABPM
                                                 
                   or home
measurement
Blood Pressure            No diabetes     
Diabetes                No diabetes       
Diabetes Optimal                        
lt140/85           lt140/80                 
lt130/80              lt130/75 Audit
Standard             lt150/90            
lt140/85                  lt140/85             
lt140/80
   
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
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Logical Combinations
Verapamil beta-blocker absolute
contra-indication    
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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)

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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)

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Web based references

• British Hypertension Society http//www.hyp.ac.uk
  /bhs/
• Summary Guidelines 2000http//www.hyp.ac.uk/bhs/
  gl2000.htm
• Hypertension audit protocol from
  Leicesterhttp//www.le.ac.uk/genpractice/gpaudit/
  htnprot.html

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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.

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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.

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• 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.
• 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

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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, UE, Lipids.
• Target lt 140/85.
• Bendrofluazide 2.5 mg a good starting point.
• Refer patients needing more than 3 drugs to
  control their hypertension.