1、Hypertension Dr Zaka Haq,MBBS,MRCP Cardiology Registrar Queens Hospital RomfordHypertensionnPrevalence(UK)nNICEnBeta BlockersnChallengesnPrimary CareHypertension,Introduction.nDiastolic pressure is more commonly elevated in younger people.With ageing,systolic hypertension becomes a more significant
2、problem.nThe clinical management of hypertension is one of the most common 22 interventions in primary care,accounting for approximately 1 billion in drug costs alone in 2006.nHypertension is often symptom less,so screening is vital-before damage is done.Many surveys continue to show that hypertensi
3、on remains under diagnosed,undertreated and poorly controlled in the UKHypertension,Introductionn In many countries,50%of the population older than 60 years has hypertension.Overall,approximately 20%of the worlds adults are estimated to have hypertension.n UK,1 in every 4th person has Hypertension a
4、nd this increases to 1 in every second person aged over 60.Types of hypertensionn Essential hypertension(Primary)u90%uNo underlying causen Secondary hypertensionu5%uUnderlying causeCauses of Secondary HypertensionnRenal disease Approximately 75%are from intrinsic renal disease:glomerulonephritis,pol
5、yarteritis nodosa,systemic sclerosis,chronic pyelonephritis,or polycystic kidneys.Approximately 25%are due to Reno vascular disease-most frequently atheromatous(e.g.elderly cigarette smokers with peripheral vascular disease)or fibromuscular dysplasia(more common in younger females).nEndocrine diseas
6、e Cushings syndrome,Conns syndrome,pheochromocytoma,acromegaly,HyperparathyroidismnOthers Coarctation,Preeclampsia,Drugs and toxins,e.g.alcohol,cocaine,ciclosporin,tacrolimus,erythropoietin,adrenergic medications,decongestants containing ephedrine and herbal remedies containing liquorice Definitions
7、 and Classifications of BP LevelsSBPDBPCategory*(mm Hg)(mm Hg)Optimal 120 80Normal 130 180 110ISH 140 60 yearsnSex(men and postmenopausal women)nFamily history of cardiovascular diseasenSmokingnHigh cholesterol dietnCo-existing disorders such as diabetes,obesity and hyperlipidaemianHigh intake of al
8、coholnSedentary life stylenRemember all these are predisposing factors for HTN but they all including HTN are risk factors for Cardiovascular disease.Diseases Attributable to HypertensionHYPERTENSIONGangrene of the Lower ExtremitiesHeart FailureLeft Ventricular HypertrophyMyocardial InfarctionHypert
9、ensive EncephalopathyAortic AneurysmBlindnessChronic Kidney FailureStrokePreeclampsia/EclampsiaCerebral HemorrhageCoronary Heart DiseaseAdapted from Dustan HP et al.Arch Intern Med.1996;156:1926-1935Hypertension in special circumstancesn HTN in Young-Causesn HTN and Pregnancy-Cautionsn HTN and Diabe
10、tes-Proteinurean HTN and Renal Failure vice versan Hypertensive Emergencies urgency,EmergencyManagement of hypertension:the issuesnMeasurement nClassification nInvestigations nRisk assessment nNon-pharmacological measures nTreatment thresholds n-1st line n-sequencing n-beyond BP nTreatment targets n
11、Concomitant therapy Diagnosis and Measurement-2011nIf the first and second blood pressure measurements taken during consultation are 140/90 mmHg or higher,offer 24-hour ambulatory blood pressure monitoring(ABPM)to confirm the diagnosis of hypertension.new 2011 nWhen using ABPM to confirm a diagnosis
12、 of hypertension,ensure that:nBlood pressure is measured for a total of 24 hours.nAt least two measurements per hour are taken during the day(08:00 to 22:00).nAt least one measurement per hour is taken during the night(22:00 to 08:00).nUse the average daytime blood pressure measurement,new 2011 Diag
13、nosis and Measurement-2011nWhen using home blood pressure monitoring(HBPM)to confirm a diagnosis of hypertension,ensure that:nFor each blood pressure measurement,two consecutive measurements are taken,at least 1 minute apart and with the person seated.nBlood pressure measurements are taken twice dai
14、ly,ideally in the morning and evening.nBlood pressure measurement continues for at least 4 days,ideally for 7 days.nDiscard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of HTN-2011Potential indications for the use of ambul
15、atory blood pressure monitoring Unusual variabilityPossible white coat hypertension Informing equivocal treatment decisionsEvaluation of nocturnal hypertension Evaluation of drug-resistant hypertensionDetermining the efficacy of drug treatment over 24 hours Diagnoses and treatment of hypertension in
16、 pregnancyEvaluation of symptomatic hypotension Why Home or ABPM?n2004 Guideline recommended that BP should not be diagnosed and treated based on one clinic BP measurementnMajority will need repeated clinic visits to confirm or refute the diagnosis nInaccurate clinic measurements may weaken the rela
17、tionship between BP and CVD risk nPeople who do not have sustained BP may be wrongly diagnosed and commenced on treatment with risk of side effects and unnecessary diagnosis and anxiety and cost.EquipmentTraining ServicingInvestigationsnUrinenBiochemistrynBlood GlucosenLipid ProfilenElectrocardiogra
18、m,CXRnUSG-KUB,Urinary catecholamine,TSH,CXR,ECHO,urinary free cortisol,nSpecialist investigationsLife Style Modifications.nMaintain normal weight for adults(BMI 20-25 kg/m2)nReduce salt intake to 100 mmol/day(6g NaCl or 2.4g Na+/day)nLimit alcohol consumption to 3 units/day for men and 30 min per da
19、y nConsume at least five portions/day of fresh fruit and vegetablesnReduce the intake of total and saturated fat nSTOP SMOKINGNextInitiating and monitoring antihypertensive drug treatment,including blood pressure targetsDrug therapy for hypertensionClass of drugExampleInitiating doseUsualmaintenance
20、 doseDiureticsHydrochlorothiazide 12.5 mg o.d.12.5-25 mg o.d.-blockersAtenolol 25-50 mg o.d.50-100 mg o.d.CalciumAmlodipine2.5-5 mg o.d.5-10 mg o.d.channelblockers-blockersDoxazosin1 mg o.d.1-8 mg o.d.ACE-inhibitors Lisinopril2.5-5 mg o.d.5-20 mg o.d.Angiotensin IILosartan25-50 mg o.d.50-100 mg o.d.
21、receptor blockers-Centrally ActingMethyledopaHydralazineAntihypertensive therapy:Side-effects and ContraindicationsClass of drugsMain side-effectsContraindications/Special PrecautionsDiureticsElectrolyte imbalance,Hypersensitivity,Anuria(e.g.Hydrochloro-total and LDL cholesterol thiazide)levels,HDL
22、cholesterollevels,glucose levels,uric acid levels-blockersImpotence,Bradycardia,Hypersensitivity,(e.g.Atenolol)FatigueBradycardia,Conductiondisturbances,Diabetes,Asthma,Severe cardiacfailureClass of drugMain side-effectsContraindications/SpecialPrecautionsCalcium channel blockersPedal edema,Headache
23、Non-dihydropyridine(e.g.Amlodipine,CCBs(e.g diltiazem)Diltiazem)Hypersensitivity,Bradycardia,Conductiondisturbances,Congestive heartfailure,Left ventriculardysfunction.Dihydropyridine CCBsHypersensitivity-blockersPostural hypotensionHypersensitivity(e.g.Doxazosin)ACE-inhibitorsCough,Hypertension,Hyp
24、ersensitivity,Pregnancy,(e.g.Lisinopril)Angioneurotic edemaBilateral renal artery stenosisAngiotensin-II receptorHeadache,DizzinessHypersensitivity,Pregnancy,blockers(e.g.Losartan)Bilateral renal artery stenosisAntihypertensive therapy:Side-effects and Contraindications(Contd.)Factors affecting choi
25、ce of antihypertensive drugn The cardiovascular risk profile of the patientn Coexisting disordersn Target organ damagen Interactions with other drugs used for concomitant conditionsn Tolerability of the drugn Cost of the drug Choosing the right antihypertensiveConditionPreferred drugsOther drugsDrug
26、s to be that can be usedavoidedAsthmaCalcium channel-blockers/Angiotensin-II-blockersblockersreceptor blockers/Diuretics/ACE-inhibitorsDiabetes-blockers/ACECalcium channel blockersDiuretics/mellitusinhibitors/-blockersAngiotensin-IIreceptor blockersHigh cholesterol-blockersACE inhibitors/Angiotensin
27、-II-blockers/levelsreceptor blockers/CalciumDiureticschannel blockersElderly patientsCalcium channel-blockers/ACE-(above 60 years)blockers/Diuretics inhibitors/Angiotensin-IIreceptor blockers/-blockersBPH-blockers-blockers/ACE inhibitors/Angiotensin-II receptorblockers/Diuretics/Calcium channel bloc
28、kersLimitations on use of antihypertensives in patientswith coexisting disordersCoexistingDiuretic-blockerACEAllCCB 1 1-blockerDisorderinhibitorantagonistDiabetesCaution/xCaution/x Dyslipidaemiaxx CHD Heart failure 3/Caution Caution Asthma/COPD x /Caution Peripheral CautionCautionCaution vasculardis
29、easeRenal artery xx stenosisCompelling and possible indications,contraindications,and cautions for the major classes of antihypertensive drugs Class of drug Compelling indications Possible indications Caution Compelling contraindications Beta-blockers MI,Angina Heart failure Heart failure,PVD,Diabet
30、es(except with CHD)Asthma/COPD,Heart block CCBs(dihydropyridine)Elderly,ISH Angina-CCBs(rate limiting)Angina Elderly Combination with beta-blockade Heart block Heart failure Thiazide/thiazide-like diuretics Elderly ISH Heart failure 2 o stroke prevention Gout WHICH PATIENTS NEED TREATMENTn Concentra
31、ten Bp Readingn Target Organ Damagen 10 Year CVD Riskn Diabetesn Young HypertensivesInitiating TreatmentnOffer people older than 80 years the same antihypertensive drug treatment as people aged 5580 years,taking into account any comorbidities 2011nOffer Stage 1 Hypertensives treatment if they have n
32、target organ damage or 86 nestablished cardiovascular disease or nrenal disease orndiabetes or na 10-year cardiovascular risk equivalent to 20%or greater.new 2011 Initiating TreatmentnHypertension is not controlled with monotherapy in at least 50%of patients;in these patients combination therapy is
33、requirednOffer antihypertensive drug treatment to people with stage 2 hypertension.new 2011 nFor people younger than 40 years with stage 1 hypertension and no evidence of target organ damage,cardiovascular(CV)disease,renal disease or diabetes,consider seeking specialist evaluation of secondary cause
34、s of hypertension and a more detailed assessment of potential target organ damage.This is because 10-year CV risk assessments can underestimate the lifetime risk of CV events in these people-new 2011 n Choosing drugs for patients newly diagnosed with hypertension:NICE/BHS Antihypertensive Drug Treat
35、ment-2011Treatment Recommendations General ConceptsnOffer people with isolated systolic hypertension(systolic BP 160 mmHg or more)the same treatment as people with both raised systolic and diastolic blood pressure.2004 nOffer people older than 80 years the same antihypertensive treatment as people a
36、ged 5580 years,taking into account any co morbidities.new 2011 nOffer step 1 antihypertensive treatment with an ACE inhibitor or a low-cost ARB to people aged under 55 years.If an ACE inhibitor is used and not tolerated,offer an ARB.new 2011 nDo not combine an ACE inhibitor with an ARB to treat hype
37、rtension.new 2011 Step 1 Treatment Recommendations nOffer step 1 antihypertensive treatment with a CCB to people aged 55 years and older and to black people of African and Caribbean descent of any age.If a CCB is not suitable,for example because of oedema or intolerance,or if there is evidence of he
38、art failure,or a high risk of heart failure,offer a thiazide-like diuretic.new 2011nIf a diuretic is required,choose a thiazide-like diuretic,such as chlortalidone(12.5 mg25.0mg once daily)or indapamide(2.5 mg once daily)in preference to a conventional thiazide diuretic such as bendroflumethiazide o
39、r hydrochlorothiazide.new 2011 Step 2 Treatment RecommendationsnIf step 2 antihypertensive treatment is required,offer a CCB in combination with either an ACE Inhibitor or a low-cost ARB.If a CCB is not suitable,for example because of oedema or intolerance,or if there is evidence of heart failure or
40、 a high risk of heart failure,offer a thiazide-like diuretic new 2011 Step 3 Treatment RecommendationsnIf treatment with three drugs is required,the combination of ACE inhibitor or angiotensin II receptor blocker,calcium-channel blocker and thiazide-like diuretic should be used.2006 Step 4 Treatment
41、 Recommendations Resistant Hypertension nFor treatment of resistant hypertension at step 4,consider further diuretic therapy with low-dose spironolactone(25 mg once daily)if blood potassium levels are lower than 4.5 mmol/l and eGFR is higher than 60 ml/min/1.73m2.If blood potassium levels are higher
42、 than 4.5 mmol/l,consider therapy with a higher-dose thiazide-like diuretic treatment.new 2011 nWhen using further diuretic therapy for resistant hypertension at step 4,monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter.new 2011 Step 4 Treatment Re
43、commendations Resistant HypertensionnIf further diuretic therapy for resistant hypertension at step 4 is not tolerated,contraindicated or ineffective,consider an alpha-or beta-blocker.new 2011 nIf blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs,seek expe
44、rt advice if it has not yet been obtained.new 2011 BP Targets in Various Guidelines Guidelines Uncomp.HTN DM C RF USA(JNC VII 2003)140/90 mmHg 130/80 mmHg 130/80 mmHg Europe(ESH 2007)140/90 mmHg 130/80 mmHg 130/80 mmHg China(CSH 2005)140/90 mmHg 130/80 mmHg 130/80 mmHg Russia 140/90 mmHg 130/80 mmHg
45、 130/80 mmHg Korea(KSH 2004)140/90 mmHg 130/80 mmHg 130/80 mmHg WHOISH SBP 140 mmHg 130/80 mmHg 130/80 mmHg BHS IV 2004 140/85 mmHg 130/80 mmHg =140/90 or hypertension nMore than of those 60 or more Hypertension in NICE(DRAFT)nStrong emphasis on diagnosis and measuring blood pressurenEnsuring traini
46、ng for those taking blood pressure measurementsnValidation,maintenance and calibration of devices and correct cuff size nStandard procedure for measurement resting 5-10 min nCheck pulse rhythm for AF nCheck for postural drop nIf first and second readings are both higher than 140/90 to arrange an ABP
47、M nIf blood pressure 180/110 start treatment Suggested indications for specialistreferralnUrgent treatment neededn Accelerated hypertension(severe hypertension andngrade III-IV retinopathy)n Particularly severe hypertension(220/120 mm Hg)n Impending complications(for example,transientnischemic attac
48、k,left ventricular failure)nPossible underlying causen Any clue in history or examination of a secondaryncause,such as hypokalaemia with increased or highnnormal plasma sodium(Conns syndrome)n Elevated serum creatininen Suspected phaeochromocytome with labile BP or postural hypotension,headache,palp
49、itations,pallor Suggested indications for specialistreferraln Proteinuria or haematurian Sudden onset or worsening of hypertensionn Resistant to multidrug regimen(3 drugs)n Young age(any hypertension 20 years;needingntreatment 30 years)nTherapeutic problemsn Multiple drug intolerancen Multiple drug
50、contraindicationsn Persistent non-adherence or non-compliancenSpecial situationsn Unusual blood pressure variabilityn Possible white coat hypertensionn Hypertension in pregnancyGroups that will not be covered 420nPeople with diabetes.nChildren and young people(younger than 18 years).nPregnant women.
