Practical Management of Hypertension in Primary Care

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Practical Management of Hypertension in Primary
Care

• Back to Medical School Group
• Dr Rob Sapsford
• Consultant Cardiologist
• Leeds Teaching Hospitals

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Objectives

• Prevalence
• NICE guidance (CG 127 August 2011)
• Investigation
• Treatment
• Resistant Hypertension
• Malignant Hypertension

NICE Clinical Guideline CG 127
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The incidence of hypertension is predicted to
increase dramatically
2000
Population with hypertension ()
2025
25 of all adults hypertensive 50 adults 60yrsgt
hypertensive
Overall
Men
Women
The global incidence of hypertension in the adult
population is predicted to exceed 29 by the year
2025
Kearney PM, et al. 2005
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Pulse pressure
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Cardiovascular risk doubles with each 20/10 mmHg
increment
CV Mortality risk (fold increase)
SBP / DBP (mmHg)
Lewington et al Lancet 2002601903-1913
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Any BP reduction makes a difference
7 reduction in risk of IHD mortality 10
reduction in risk of CVA mortality
2 mmHg decrease in mean SBP
Meta-analysis of 61 prospective observational
studies involving 1 million adults (12.7 million
patient years)
Lewington S et al lancet 20023601903-1913
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Long-term antihypertensive treatment reduces CV
risk
CHD
Stroke
CV event
2021
2128
3039
Relative risk reduction ()
Risk of CV event with ACEI or CCB relative to
placebo CV cardiovascular CHD coronary
heart disease
Neal B, et al. 2000
RAS07000047
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Measuring BP

• Standardise BP measurements
• Never base treatment on an isolated reading
• All adults every 5 Years
• High / normal (130139 / 8589 mmHg) every 1 year

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Measuring BP has improved
Carl Ludwigs kymograph
Riva-Roccis sphygmomanometer
Rev Hales veterinarian
The modern sphygnomanometer
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24 Hour BP Monitoring
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24 Hr BP Diagnosis ?
White coat effect Discrepancy of 20/10 mmHg
gtbetween clinic and average daytime ABPM or
average HBPM at time of diagnosis
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BP Problems

• Unequal arm BPs
• Difference in BP between arms BP difference
  20mmHggt Repeat measurements ? persists
• Action
• Document as higher risk for vascular
  disease Use highest arm for subsequent monitoring

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BP Problems

• Postural Hypotension
• Falls / postural dizziness BP seated /
  standing 1mingt Systolic BP fall on standing
  20mmHggt
• Action
• Review medication
• Measure future BP standing
• Consider referral if symptoms persist

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Blood Pressure
Clinic BP 140 gt / 90 gt
Ambulatory BP Monitor ABPM Minimum 2x readings /
Hr Average 14 daytime readings
Home BP Monitor HBPM 2 readings 1 mingt
apart Minimum 2x recordings / day Average min 4
days 7 days readings (disregard day 1 readings)
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Hypertensive Stages

• Stage 1 Clinic BP 140gt / 90gt
• Daytime ABPM 135gt / 85gt
• Average HBPM 135gt / 85gt
• Stage 2 Clinic BP 160gt / 100gt
• Daytime ABPM 150gt / 95gt
• Average HBPM 150gt / 95gt
• Severe Clinic BP 180gt / 110gt

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Treatment guidelines
BP measurement
160gt /100gt mmHg ABPM 150gt/95gt
lt140 /90 mmHg ABPM lt135/lt85
140159 / 90-99 ABPM 135-149/85-94
Assess risk
Treat (any age)
Annual review
BMJ 2004 328634-640
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Treatment Guidelines
ABPM/HBPM 135-150 / 85-95
No Target Organ Damage (TOD) and No Diabetes
mellitus and No Cardio-vascular disease and No
Renal Disease and 10 yr Cardio-vascular risk lt20
Target Organ Damage (TOD) or Diabetes
mellitus or Cardio-vascular disease or Renal
Disease or 10 yr Cardio-vascular risk 20gt
Lifestyle measures Annual review
Treat
BMJ 2004 328634-640
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Investigations

• Cardio-vascular risk U/Es, FBC, TFTs,
  TCHDL, Glucose
• QRISK2, Framinghm
• Target Organ Damage
• ECG
• Urinalysis / AlbCreat ratio

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CVA
Retinopathy
Target Organ Damage
Nephropathy
LVH
LVH
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Framingham Cardiovascular Risk (morbidity and
mortality)

• Atherosclerotic disease anywhere high risk
• Sex
• Age
• Systolic BP / Diastolic BP
• Smoking history
• Total cholesterol HDL
• ECG evidence of LVH

Calculate 10 year CV risk
Treat 20 gt CV risk
Average male 45 years 1 per annum risk (10 10
year risk)
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QRISK2 Calculator
Variables included in the first version were
Age Sex Smoking status Systolic BP Ratio
TCHDL BMI Family history of IHD (first degree
relatives lt60 yrs) Area measure of deprivation
(Townsend score) Treatment with antihypertensive
agent
A more recent version (QRISK2) has additional
variables Self assigned ethnicity Type 2
diabetes Rheumatoid arthritis Renal
disease Atrial fibrillation
Hippisley-Cox J, Coupland C, Vinogradova Y,
Robson J, May M, Brindle P. BMJ 2007335136.
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When to refer ?

• Stage 1 hypertension in young (lt40 yrs) even if
  low estimated 10 yr risk (under-estimation of
  lifetime risk)
• Target organ damage (LVH / albuminria /
  proteinuria) but no evidence of hypertension
• Accelerated Hypertension (BP usually 180/110 gt
  with papilloedema / retinal changes) urgent
  admission
• Supected phaeochromocytoma (labile BP, headache,
  palpitations, sweating) urgent admission
• Secondary cause supected on signs or symptoms
  (RAS bruit, young female, PVD, Renal
  dysfunction)

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Treatment

• Lifestyle advice
• Diet / exercise
• Alcohol reduction
• Caffeine reduction
• Reduce dietary Sodium
• Smoking cessation

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Spironolactone 25mg if Klt4.5 Higher dose
thiazide if K higher
NICE CG 127
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Treatment - ? Beta-blockers

• If co-morbidity benefiting from use (angina /
  systolic heart failure)
• Younger patient (lt55yrs) intolerance or
  contra-indication to ACE/ARB
• Women of child bearing potential
• Evidence increased sympathetic drive
• Avoid BB with thiazide like diuretic

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Optimal BP Targets
Clinic BP
ABPM / HBPM
lt140 / lt90 mmHg
lt135 / lt85 mmHg

• Patients lt80yrs
• Patients 80yrs gt

lt150 / lt90 mmHg
lt145 / lt85 mmHg
NICE CG 127 2011
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Resistant Hypertension

• Failure to achieve goal BP despite optimal doses
  of 3 or more agents from different classes
  (ideally one a diuretic)
• Prevalence around 10
• True resistance secondary causes, OSA, Volume
  overload, Drug induced, obesity, alcohol excess
• Apparent resistance non compliance, cuff
  related artefacts, white coat resistance (25-37
  reclassified)

Heart 201298254-261
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Malignant Hypertension

• Sudden / rapid hypertension with diastolic
  130mmHggt
• 1 hypertensives (particularly african-americans)
• Associated CTD, CKD, pregnancy toxaemia, RAS
• Symptoms retinal / cerebral / renal / cardiac
• Signs retinal / /- oedema
• Treatment IV / oral (aim diastolic lt110 within
  24 hrs)

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Aspirin in Hypertensives

• Recommended Primary prevention
• 75mg / day if Patient
• aged gt50 yrs
• BP controlled lt150 / 90
• target organ damage
• Diabetic
• 10 CV risk gt20

BMJ 2004 328634-640
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Statin Trials ASCOT - LLA
10
9
8
7
WOSCOPS-P
WOSCOPS-S
6
Percentage with CHD event
5
AFCAPS-S
AFCAPS-P
Primary prevention
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Pravastatin
3
ASCOT-P
Lovastatin
2
Atorvastatin
ASCOT-S
1
0
2.3 (90)
2.8 (110)
3.4 (130)
3.9 (150)
4.4 (170)
5.4 (210)
4.9 (190)
LDL-C, mmol/L (mg/dL)
ASCOT 10 yr CV risk 9
S statin treated P placebo treated
Modified from Kastelein JJP. Atherosclerosis.
1999 143(suppl 1) S17-S21
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Conclusion

• Treatment of BP dependent on level and assessment
  of baseline CV risk
• Individualise treatment accepting several agents
  will be required
• Compliance important
• Treat all CV risk factors statins usually
  indicated

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NICE Guidelines Primary Prevention

• Statins are recommended as part of management
  strategy for primary prevention of CVD for adults
  who have a ?20 10-year risk of developing CVD

Statins for the prevention of cardiovascular
events. NICE Technology Appraisal 94. January 2006
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24 Hour Ambulatory BP
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Ambulatory BP measurement

• Unusual variation
• Possible white coat hypertension
• Equivocal treatment decisions
• Evaluation nocturnal hypertension
• Evaluation of drug resistant hypertension
• Evaluation 24 hour treatment control
• Diagnosis and treatment of pregnancy hypertension
• Evaluation of symptomatic hypotension

BP thresholds 10 / 5 mmHg lower than clinic BPs