Illustrative Cases and Summary

A 50 year old European woman who is new to your practice comes to see you late on Friday afternoon with a sore throat which is probably viral. She has a past history of hypertension, but is not on antihypertensives currently. You take her blood pressure and it is 230/130. After 15 minutes quiet rest your nurse remeasures the blood pressure at 210/110. How should she be managed from here?

Hypertensive Urgency or Emergency? Hypertensive Emergency Very high BP with evidence of rapidly progressive target organ damage retinopathy heart failure rapidly progressive renal impairment neurological -TIA/ stroke/ reduced level of consciousness Medical emergency – requiring hospital admission

Hypertensive Urgency Very high BP without evidence of rapidly progressive target organ damage Does not require urgent hospital admission, but does require careful management, close supervision, and review within 1-3 days

This patient needs:- careful physical examination including fundoscopy 12-lead ECG urine Dipstick And send off FBC urea creatinine, electrolytes urine microscopy and spot urine albumin/creatinine ratio

Assuming no evidence of “hypertensive emergency”, start on medication and see again on Monday Start on 2 drugs, either ACE-inhibitor/ thiazide or ACE- inhibitor/CCB eg lisinopril 10mg/ chlorthalidone 12.5mg stat and daily until reviewed or lisinopril 10mg/ amlodipine 5mg stat and daily until reviewed

You see her again on Monday afternoon:- Lab tests have come back normal She feels OK Resting BP 170/100 (on lisinopril 10mg and amlodipine 5mg) Where to from here?

Leave on same meds and review in 2 weeks ↓ BP 160/95 ↓ Increase lisinopril to 20mg and review in 2 weeks ↓ BP 155/92 ↓ Increase amlodipine to 10mg and review in 2 weeks ↓ BP 148/90 ↓ Add chlorthlalidone 12.5mg and review in 2 weeks ↓ BP 143/88 ↓ Increase chlorthalidone to 25mg and review in 2 weeks ↓ BP 137/85 (at target)

You take over the care of a 37 year old Indian man. He has a bad family history of diabetes and premature cardiovascular disease. His father (who was not known to be diabetic) died at 43 of an apparent heart attack. You are only seeing him because his wife forces him to come in for a checkup because she is worried about his family history. He is a non-smoker and currently on no medication Examination BMI 27, abdominal girth 95cm, BP 134/90 Investigations Fasting glucose 5.6mmol/l, cholesterol 4.4mmol/l HDL 0.8mmol/l LDL 3.0mmo/l triglyceride 2.2mmol/l creatinine 75umol/l spot urine albumin-creatinine ratio 5mg/mmol (N < 2.5) What are his prospects for the future, and how should he be managed?

Superficially: Not overweight Not hypertensive Non-diabetic Total cholesterol year cardiovascular risk on NZ CV risk calculator < 5% So – is there a problem? What is your advice?

Yes – he has a big problem – he is genetically programmed to die of cardiovascular disease in his 40’s or 50’s Why? Taking a less superficial look at him…

Being South Asian (on its own) is an important risk factor for type 2 diabetes and cardiovascular disease History of MI or stroke in family members < 55 (men) and <65 (women) is a separate cardiovascular risk factor Abdominal girth 95cm (normal for S.Asians < 90)* Impaired fasting glucose* Prehypertension* Low HDL, elevated triglyceride (atherogenic lipid profile)** Microalbuminuria* - all of the above are separate, quantifiable, and cumulative cardiovascular risk factors in addition he has 6 features* of the metabolic syndrome which confers: x increased risk of cardiovascular events than a simple cumulation of his individial risk factors - substantial (5-10x) higher risk of developing type 2 diabetes

Aims of treatment BMI < 25 Abdominal girth < 90cm BP < 130/80 Fasting glucose < 5.4 LDL cholesterol < 2 Resolution of microalbuminuria How to achieve these goals DASH-Sodium diet High levels of physical activity ACE-inhibitor +/- CCB As much statin as he can tolerate Aspirin Consider metformin

An 83 year old female patients of yours has a long history of systolic hypertension. She had a minor stroke a year ago with good recovery. Recently her BP has been less well-controlled. You see her for a check:- resting seated BP is 180/85, standing 170/82, heart rate 60 bpm. Renal function is normal for age. Her current antihypertensive medications are: metoprolol CR 95mg daily, diltiazem CD 120mg /day, candesartan 32mg daily She is intolerant of thiazides (hyponatraemia – proven on rechallenge) At this age – is more aggressive treatment warranted? If so, how can you improve her blood pressure?

Mean Blood Pressure, Measured while Patients Were Seated, in the Intention-to-Treat Population, According to Study Group Beckett NS et al. N Engl J Med 2008;358:

Treatment Group had: - 30% reduction in in rate of fatal or non-fatal stroke - 39% reduction in rate of death from stroke - 21% reduction in rate of death from any cause - 23% reduction in rate of death from cardiovascular causes - 64% reduction in rate of heart failure

Therapeutic options – Can’t increase metoprolol or diltiazem doses (HR 60) Options (1) Diuretic likely beneficial but can’t tolerate thiazide spironolactone 12.5 – 25mg daily or frusemide 10-20mg BD or TDS …with close monitoring of electrolytes (2) Add amlodipine at 2.5mg daily increasing as tolerated (3) Doxazosin 1mg nocte increasing dose weekly as required

Take Home Messages (1)Hypertension is common in all age groups and is the leading cause of preventable death and disability (2) Most of the excess risk associated with hypertension can be obviated by treating blood pressure to target levels (3)Treatment is complex and time-consuming and patient expectations need to be adjusted accordingly (4) Multi-drug regimens are the norm, and an algorithmic approach to medication adjustment is more likely to be successful than a haphazard one (5) Global cardiovascular risk is an important concept, but don’t get bogged down in the NZ Cardiovascular Risk Guideline which has serious limitations (6)Lifestyle modification is important but (almost) never obviates the need for drugs (7) Any regimen which contains > 2 classes of antihypertensive medication should (almost) always include a diuretic (8) Chlorthalidone is (by far) the most effective thiazide