HYPERTENSION NMP

How Common? 25% UK adults 25% UK adults > 50% adults over 60 > 50% adults over 60

Hypertension: the silent killer Asymptomatic Asymptomatic Not associated with Not associated with –Headaches –nosebleeds

Complications CVA CVA MI MI CCF CCF CKD CKD PVD PVD Cognitive decline Cognitive decline Premature death Premature death Depends on ethnicity Depends on ethnicity Cf diabetes Cf diabetes

Treatment Life style Life style Drugs Drugs Rarely surgery Rarely surgery –Bariatric surgery –Endocrine surgery –Renal artery angioplasty –Renal denervation

NICE guidelines Aug 2011 Primary care Primary care Excludes Excludes –Diabetes –18 yrs –pregnancy

3 Stages of hypertension 1 clinic BP >140/90 1 clinic BP >140/90 –ABPM is >135/85 2 clinic BP >160/100 2 clinic BP >160/100 –ABPM >150/95 3 SEVERE BP>180/110 3 SEVERE BP>180/110

ABPM Do not start treatment without ABPM unless severe hypertension ie 180/110 Do not start treatment without ABPM unless severe hypertension ie 180/110 Monitor about half the size of the BNF Monitor about half the size of the BNF Home monitoring an alternative but much less data Home monitoring an alternative but much less data Huge resource implications Huge resource implications ?? Save money ?? Save money

Who To Treat? Stage 1 Stage 1 –Under 80 –Target organ damage –Established cardiovascular disease –Renal disease –Diabetes –10 year cardiovascular risk>20% –Think about under 40 Stage 2 treat Stage 2 treat

Relearn your alphabet No longer ABCD No longer ABCD Now ACDD Now ACDD

Step 1 Under 55 Under 55 –A ACE or ARB Ramipril, perindopril Ramipril, perindopril Losarten irbesarten candasarten Losarten irbesarten candasarten –C Over 55, or African or carribean C calcium channel blocker C calcium channel blocker –Amlodipine

Step 2 Add A to C Add A to C

Step 3 Add A to C to D Add A to C to D Now using thiazide like diuretics NOT bendroflumethazide or hydrochlorothiazide Now using thiazide like diuretics NOT bendroflumethazide or hydrochlorothiazide Indapamide or chlortalidone Indapamide or chlortalidone

Step 4 Add in further diuretic Add in further diuretic D Spironolactone D Spironolactone –If Potassium <4.5 –NB low GFR Increase dose of non thiazide Increase dose of non thiazide

Step 5 Free for all Free for all ? Refer ? Refer ? Alpha blocker ? Alpha blocker ? Beta blocker ? Beta blocker

Own Goals Spironolactone does not have a product license for hypertension Spironolactone does not have a product license for hypertension Recommended dose of chlortalidone is 12.5 or 25 and only 50 mg is available. Recommended dose of chlortalidone is 12.5 or 25 and only 50 mg is available.

Pharmacology ACE/ARB ACE 10-20% will have a dry cough ACE 10-20% will have a dry cough ARB is an ACE without the dry cough and without angio oedema ARB is an ACE without the dry cough and without angio oedema First dose hypotension First dose hypotension Bilateral renal artery stenosis Bilateral renal artery stenosis –Worsening U and E High potassium High potassium

Renin angiotensin system Low BP Renin excretion from kidney (enzyme) Angiotensinogen Angiotensin 1 Angiotensin II Inc. aldosterone from adrenals Retention of salt and water from kidney Vasoconstriction Renal retention of salt and water ACE-I Spironalactone ARBs Renin inhibitor

Calcium channel blockers Usually amlodipine but I also use diltiazem and verapamil Usually amlodipine but I also use diltiazem and verapamil Main side effect is ankle oedema with amlodipine Main side effect is ankle oedema with amlodipine –Swop to verapamil or diltiazem –Lower the dose. Try 2.5mg Gum hyperplasia Gum hyperplasia Drug interaction with simvastatin Drug interaction with simvastatin

Spironolactone (Potassium sparing diuretic) (Potassium sparing diuretic) Aldosterone antagonist Aldosterone antagonist Oestrogen like side effects Oestrogen like side effects Gynacomastia and high potassium Gynacomastia and high potassium

Chronic diseases No decision about me without me No decision about me without me

Case study 32 year old city worker 32 year old city worker Presented to GP with headaches Presented to GP with headaches Found to be hypertensive Found to be hypertensive

Referred to a neurologist Referred to a neurologist No cause found for headaches No cause found for headaches Multiple intolerances to BP drugs Multiple intolerances to BP drugs Referred to hypertensive clinic Referred to hypertensive clinic

Full history and examination Full history and examination BP 165/104 BP 165/104 Confirmed on ABPM Confirmed on ABPM Amlodipine 5 mg started Amlodipine 5 mg started

Comes back 4 weeks later complaining of a headache Comes back 4 weeks later complaining of a headache Stopped Amlodipine Stopped Amlodipine BP still high BP still high

Explained that he always has headaches and no serious cause found Explained that he always has headaches and no serious cause found If BP remains high he is at risk of CVA/MI If BP remains high he is at risk of CVA/MI Asked him want he wanted to do Asked him want he wanted to do

I will take the amlodipine I will take the amlodipine

Non Pharmacological management This has not changed This has not changed Alcohol Alcohol Smoking Smoking Diet Diet –Decrease caffeine –decrease salt –(5 a day) –(Low fat dairy products) –Wt loss if appropriate –Exercise

Summary Down load new guidelines Down load new guidelines NB Amlodipine and Simvastatin NB Amlodipine and Simvastatin No decision about me without me. No decision about me without me.