Hypertension

Dr Zaka Haq, MBBS, MRCP

Cardiology Registrar

Queens Hospital Romford

Hypertension

Prevalence (UK)

NICE

Beta Blockers

Challenges

Primary Care

Hypertension-Overview

Hypertension itself-Introduction Types Classification Risk Factors Sequels Hypertension in special circumstances Management Follow Up Guidelines Referral to Secondary care

Hypertension, Introduction. Hypertension is one of the most important preventable

causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for stroke (ischemic and haemorrhagic), myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension may result in vascular and renal damage that can culminate in a treatment-resistant state.

The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischemic heart disease and a 10% increased risk of mortality from stroke.

Hypertension, Introduction.

Diastolic pressure is more commonly elevated in younger people. With ageing, systolic hypertension becomes a more significant problem.

The 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.

Hypertension is often symptom less, so screening is vital - before damage is done. Many surveys continue to show that hypertension remains under diagnosed, undertreated and poorly controlled in the UK

Hypertension, Introduction

In many countries, 50% of the population older than 60 years has hypertension. Overall, approximately 20% of the world’s adults are estimated to have hypertension.

UK, 1 in every 4th person has Hypertension and this increases to 1 in every second person aged over 60.

Types of hypertension

Essential hypertension (Primary)

90%

No underlying cause

Secondary hypertension

5%

Underlying cause

Causes of Secondary Hypertension Renal disease Approximately 75% are from intrinsic renal disease:

glomerulonephritis, polyarteritis 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).

Endocrine disease Cushing’s syndrome, Conn's syndrome, pheochromocytoma,

acromegaly, Hyperparathyroidism Others Coarctation, Preeclampsia, Drugs and toxins, e.g. alcohol, cocaine,

ciclosporin, tacrolimus, erythropoietin, adrenergic medications, decongestants containing ephedrine and herbal remedies containing liquorice

Definitions and Classifications of BP Levels

SBP DBP

Category* (mm Hg) (mm Hg)

Optimal < 120 < 80

Normal < 130 < 85

High-normal 130-139 85-89

Grade 1 hypertension (mild) 140-159 90-99

Grade 2 hypertension (moderate) 160-179 100-109

Grade 3 hypertension (severe) > 180 > 110ISH > 140 < 90Reading to Remember 140 90

WHO-ISH Guidelines Subcommittee J Hypertens 1999; 17:151

Hypertension: Predisposing factors Age > 60 years Sex (men and postmenopausal women) Family history of cardiovascular disease Smoking High cholesterol diet Co-existing disorders such as diabetes, obesity and

hyperlipidaemia High intake of alcohol Sedentary life style Remember all these are predisposing factors for HTN but

they all including HTN are risk factors for Cardiovascular disease.

Diseases Attributable to Hypertension

HYPERTENSION

Gangrene of the Lower Extremities

Heart Failure

Left Ventricular Hypertrophy Myocardial

Infarction

Hypertensive Encephalopathy

Aortic Aneurysm

Blindness

Chronic Kidney Failure

Stroke Preeclampsia/Eclampsia

Cerebral Hemorrhage

Coronary Heart Disease

Adapted from Dustan HP et al. Arch Intern Med. 1996; 156: 1926-1935

Hypertension in special circumstances

HTN in Young-Causes HTN and Pregnancy-Cautions HTN and Diabetes - Proteinurea HTN and Renal Failure – vice versa Hypertensive Emergencies – urgency,

Emergency

Management of hypertension: the issues

Measurement Classification Investigations Risk assessment Non-pharmacological measures Treatment thresholds - 1st line - sequencing - beyond BP Treatment targets Concomitant therapy

Diagnosis and Measurement- 2011 If 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]

When using ABPM to confirm a diagnosis of hypertension, ensure that:

Blood pressure is measured for a total of 24 hours. At least two measurements per hour are taken during the

day (08:00 to 22:00). At least one measurement per hour is taken during the

night (22:00 to 08:00). Use the average daytime blood pressure measurement,

[new 2011]

Diagnosis and Measurement- 2011

When using home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension, ensure that:

For each blood pressure measurement, two consecutive measurements are taken, at least 1 minute apart and with the person seated.

Blood pressure measurements are taken twice daily, ideally in the morning and evening.

Blood pressure measurement continues for at least 4 days, ideally for 7 days.

Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of HTN-2011

Potential indications for the use of ambulatory blood pressure monitoring 

•Unusual variability

•Possible white coat hypertension

•Informing equivocal treatment decisions

•Evaluation of nocturnal hypertension

•Evaluation of drug-resistant hypertension

•Determining the efficacy of drug treatment over 24 hours

•Diagnoses and treatment of hypertension in pregnancy

•Evaluation of symptomatic hypotension

Why Home or ABPM?

2004 Guideline recommended that BP should not be diagnosed and treated based on one clinic BP measurement

Majority will need repeated clinic visits to confirm or refute the diagnosis

Inaccurate clinic measurements may weaken the relationship between BP and CVD risk

People 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.

Equipment

Training

Servicing

Investigations

Urine Biochemistry Blood Glucose Lipid Profile Electrocardiogram, CXR USG-KUB, Urinary catecholamine, TSH, CXR, ECHO,

urinary free cortisol, Specialist investigations

Life Style Modifications.

Maintain normal weight for adults (BMI 20-25 kg/m2) Reduce salt intake to <100 mmol /day (<6g NaCl or

<2.4g Na+/day) Limit alcohol consumption to <3 units/day for men and

<2 units/day for women Engage in regular aerobic physical exercise (brisk

walking rather than weightlifting) for >30 min per day Consume at least five portions/day of fresh fruit and

vegetables Reduce the intake of total and saturated fat STOP SMOKING

Next

Initiating and monitoring antihypertensive drug treatment, including blood pressure

targets

Drug therapy for hypertension

Class of drug Example Initiating dose Usualmaintenance dose

Diuretics Hydrochlorothiazide 12.5 mg o.d. 12.5-25 mg o.d.

-blockers Atenolol 25-50 mg o.d. 50-100 mg o.d.

Calcium Amlodipine 2.5-5 mg o.d. 5-10 mg o.d.channelblockers

-blockers Doxazosin 1 mg o.d. 1-8 mg o.d.

ACE- inhibitors Lisinopril 2.5-5 mg o.d. 5-20 mg o.d.

Angiotensin II Losartan 25-50 mg o.d. 50-100 mg o.d.receptor blockers -Centrally Acting Methyledopa Hydralazine

Antihypertensive therapy:Side-effects and Contraindications

Class of drugs Main side-effects Contraindications/Special Precautions

Diuretics Electrolyte imbalance, Hypersensitivity, Anuria(e.g. Hydrochloro- total and LDL cholesterol thiazide) levels, HDL cholesterol

levels, glucose levels, uric acid levels

-blockers Impotence, Bradycardia, Hypersensitivity, (e.g. Atenolol) Fatigue Bradycardia, Conduction

disturbances, Diabetes,Asthma, Severe cardiacfailure

Class of drug Main side-effects Contraindications/ Special

Precautions

Calcium channel blockers Pedal edema, Headache Non-dihydropyridine(e.g. Amlodipine, CCBs (e.g diltiazem)– Diltiazem) Hypersensitivity,

Bradycardia, Conductiondisturbances, Congestive heartfailure, Left ventriculardysfunction.Dihydropyridine CCBs–Hypersensitivity

-blockers Postural hypotension Hypersensitivity(e.g. Doxazosin)

ACE-inhibitors Cough, Hypertension, Hypersensitivity, Pregnancy,(e.g. Lisinopril) Angioneurotic edema Bilateral renal artery stenosis

Angiotensin -II receptor Headache, Dizziness Hypersensitivity, Pregnancy,blockers (e.g. Losartan) Bilateral renal artery stenosis

Antihypertensive therapy: Side-effects and Contraindications (Contd.)

Factors affecting choice of antihypertensive drug

The cardiovascular risk profile of the patient

Coexisting disorders

Target organ damage

Interactions with other drugs used for concomitant conditions

Tolerability of the drug

Cost of the drug

Choosing the right antihypertensive

Condition Preferred drugs Other drugs Drugs to be that can be used avoided

Asthma Calcium channel -blockers/Angiotensin -II -blockersblockers receptor blockers/Diuretics/

ACE-inhibitors

Diabetes -blockers/ACE Calcium channel blockers Diuretics/mellitus inhibitors/ -blockers

Angiotensin -IIreceptor blockers

High cholesterol -blockers ACE inhibitors/ Angiotensin -II -blockers/levels receptor blockers/ Calcium Diuretics

channel blockers

Elderly patients Calcium channel -blockers/ACE- (above 60 years)blockers/Diuretics inhibitors/Angiotensin -II

receptor blockers/- blockers

BPH -blockers -blockers/ ACE inhibitors/

Angiotensin -II receptor

blockers/ Diuretics/

Calcium channel blockers

Limitations on use of antihypertensives in patientswith coexisting disorders

Coexisting Diuretic -blocker ACE All CCB -blockerDisorder inhibitor antagonist

Diabetes Caution/x Caution/x

Dyslipidaemia x x

CHD

Heart failure /Caution Caution

Asthma/COPD x /Caution

Peripheral Caution Caution Caution vasculardisease

Renal artery x x stenosis

Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs Class of drug

Compelling indications

Possible indications

Caution

Compelling contra-indications

Alpha-blockers

Benign prostatic hypertrophy

Postural hypotension, heart failure

Urinary incontinence

ACE-inhibitors

Heart failure, LV dysfunction, post MI or established CVD, Type I diabetic nephropathy, 2o stroke prevention

Chronic renal disease, Type II diabetic nephropathy, proteinuric renal disease

Renal impairment

PVD Pregnancy, renovascular disease

ARBs ACE inhibitor-intolerance, Type II diabetic nephropathy, hypertension with LVH, heart failure in ACE-intolerant patients, post MI

LV dysfunction post MI, intol-erance of other antihypertensive drugs, proteinuric renal disease, chronic renal disease,

heart failure

Renal impairment PVD

Pregnancy, renovascular disease

Compelling 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,

Diabetes (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 TREATMENT

Concentrate Bp Reading Target Organ Damage 10 Year CVD Risk Diabetes Young Hypertensives

Initiating Treatment

Offer people older than 80 years the same antihypertensive drug treatment as people aged 55–80 years, taking into account any comorbidities 2011

Offer Stage 1 Hypertensive's treatment if they have target organ damage or 86 established cardiovascular disease or renal disease or diabetes or a 10-year cardiovascular risk equivalent to 20% or

greater. [new 2011]

Initiating Treatment

Hypertension is not controlled with monotherapy in at least 50% of patients; in these patients combination therapy is required

Offer antihypertensive drug treatment to people with stage 2 hypertension. [new 2011]

For 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 causes 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

  

Target organ damageor

cardiovascular complicationsor

diabetesor

10 year CVD risk† 20%

>180/110 160 179100 109

140 15990 99

130 13985 89

<130/85

160/100 140 15990 99

<140/90

No target organ damageand

no cardiovascular complicationsand

no diabetesand

10 year CVD risk† <20%

* ** ***

Treat Treat Treat Observe, reassessCVD risk yearly

Reassessyearly

Reassessin 5 years

* Unless malignant phase of hypertensive emergency confirm over 1 2 weeks then treat** If cardiovascular complications, target organ damage or diabetes is present, confirm over 3 4 weeks then treat; if absent re-measure

weekly and treat if blood pressure persists at these levels over 4 12*** If cardiovascular complications, target organ damage, or diabetes is present, confirm over 12 weeks then treat: if absent re-measure

monthly and treat if these levels are maintained and if estimated 10 year CVD risk is 20%† Assessed with CVD risk chart

THRESHOLDS FOR INTERVENTIONInitial blood pressure (mmHg)

Choosing drugs for patients newly diagnosed with hypertension: NICE/BHS

Antihypertensive Drug Treatment - 2011

Treatment Recommendations – General Concepts

Offer 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]

Offer people older than 80 years the same antihypertensive treatment as people aged 55–80 years, taking into account any co morbidities. [new 2011]

Offer 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]

Do not combine an ACE inhibitor with an ARB to treat hypertension. [new 2011]

Step 1 Treatment Recommendations

Offer 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 heart failure, or a high risk of heart failure, offer a thiazide -like diuretic . [new 2011]

If a diuretic is required, choose a thiazide -like diuretic, such as chlortalidone (12.5 mg–25.0mg once daily) or indapamide (2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [new 2011]

Step 2 Treatment Recommendations

If 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 a high risk of heart failure, offer a thiazide-like diuretic [new 2011]

Step 3 Treatment Recommendations

If 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 Recommendations Resistant Hypertension

For 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 than 4.5 mmol/l, consider therapy with a higher-dose thiazide-like diuretic treatment. [new 2011]

When 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 Recommendations Resistant Hypertension

If further diuretic therapy for resistant hypertension at step 4 is not tolerated, contraindicated or ineffective, consider an alpha- or beta-blocker. [new 2011]

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert 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 <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 <130/80 mmHg

Hypertension in DRAFT NICE

Big changes with impact on Primary Care

Hypertension as a disease

Primary not Essential hypertension

At least ¼ of adult UK population have a BP > = 140/90 or hypertension

More than ½ of those 60 or more

Hypertension in NICE ( DRAFT)

Strong emphasis on diagnosis and measuring blood pressure Ensuring training for those taking blood pressure

measurements Validation, maintenance and calibration of devices and

correct cuff size Standard procedure for measurement resting 5-10 min Check pulse rhythm for AF Check for postural drop If first and second readings are both higher than 140/90 to

arrange an ABPM If blood pressure > 180/110 start treatment

Suggested indications for specialistreferral

Urgent treatment needed • Accelerated hypertension (severe hypertension and grade III-IV retinopathy) • Particularly severe hypertension ( > 220/120 mm Hg) • Impending complications (for example, transient ischemic attack, left ventricular failure)

Possible underlying cause • Any clue in history or examination of a secondary cause, such as hypokalaemia with increased or high normal plasma sodium (Conn’s syndrome) • Elevated serum creatinine • Suspected phaeochromocytome with labile BP or postural hypotension,

headache, palpitations, pallor

Suggested indications for specialistreferral

• Proteinuria or haematuria • Sudden onset or worsening of hypertension • Resistant to multidrug regimen ( ≥ 3 drugs) • Young age (any hypertension < 20 years; needing treatment < 30 years)

Therapeutic problems • Multiple drug intolerance • Multiple drug contraindications • Persistent non-adherence or non-compliance

Special situations • Unusual blood pressure variability • Possible white coat hypertension • Hypertension in pregnancy

Groups that will not be covered 420

People with diabetes. Children and young people (younger than 18 years). Pregnant women. Secondary causes of hypertension (for example, Conn's

adenoma, phaeochromocytoma and renovascular hypertension).

People with accelerated hypertension (that is, severe acute hypertension 426 associated grade III retinopathy and encephalopathy).

People with acute hypertension or high blood pressure in emergency care

Drugs in special conditions

Condition

Pregnancy

Coronary heart disease

Congestive heart failure

Preferred Drugs

Nifedipine, labetalol, hydralazine, beta-blockers, methyldopa, prazosin

Beta-blockers, ACE inhibitors, Calcium channel blockers

ACE inhibitors,beta-blockers

1999 WHO-ISH guidelines

HTN and Pregnancy

•Chronic hypertension (2-4%)

•Hypertension first identified in early pregnancy

•Hypertension that persists postpartum

•Gestational hypertension (2-4%) Non- proteinuric hypertension

•Pre- eclampsia 3% primigravida at term and 0.5% pre-term

HTN and Pregnancy

•During pregnancy, BP target; 130/80 - 150/100mmHg •If BP ≥150/100; start labetolol/methyldopa/nifedipine SR •Avoid ACE-I and ARBs during pregnancy •Consider secondary hypertension in women with severe

hypertension especially in early pregnancy and postpartum •Consider prophylactic low-dose aspirin from 12 weeks •Both systolic and diastolic hypertension important •Early onset pre-eclampsia, a serious threat to mother and

foetus •Long-term follow up is essential for future woman’s

health

CKD and Diabetes

In people with CKD aim for:

•systolic blood pressure below 140 mmHg(target range 120–139 mmHg)

•diastolic blood pressure below 90 mmHg

In people with CKD and diabetes - or when ACR 70mg/mmol, aim for:

•systolic blood pressure below 130 mmHg(target range 120–129 mmHg)

•diastolic blood pressure below 80 mmHg

Place Of Beta blockers

Beta-blockers are not a preferred initial therapy for hypertension. However, beta-blockers may be considered in younger people, particularly:

those with an intolerance or contraindication to ACE inhibitors and angiotensin -II receptor antagonists or

women of child-bearing potential or people with evidence of increased sympathetic drive. In these circumstances, if therapy is initiated with a

beta-blocker and a second drug is required, add a calcium-channel blocker rather than a thiazide -type diuretic to reduce the person’s risk of developing diabetes.

Other medications for hypertensive patients

Primary prevention

(1) Aspirin: use 75mg daily if patient is aged 50 years with blood pressure controlled to <150/90 mm Hg and either; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart)

(2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years, with a 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart) and with total cholesterol concentration 3.5mmol/l

(3) Vitamins—no benefit shown, do not prescribe

Secondary prevention (including patients with type 2 diabetes)

(1) Aspirin: use for all patients unless contraindicated

(2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years with a total cholesterol concentration 3.5 mmol/l

(3) Vitamins— no benefit shown, do not prescribe

Other medications for hypertensive patients