1. Department of General Practice QUB
Hypertension
Kieran McGlade Nov 2001
Department of General Practice QUB

2. Aetiology of Hypertension
Primary – 90-95% of cases – also termed “essential” of “idiopathic”
Secondary – about 5% of cases
Renal or renovascular disease
Endocrine disease
Phaeochomocytoma
Cusings syndrome
Conn’s syndrome
Acromegaly and hypothyroidism
Coarctation of the aorta
Iatrogenic
Hormonal / oral contraceptive
NSAIDs
Kieran McGlade Nov 2001
Department of General Practice QUB

3. Department of General Practice QUB
This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy.
Kieran McGlade Nov 2001
Department of General Practice QUB

4. Department of General Practice QUB
The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.
Kieran McGlade Nov 2001
Department of General Practice QUB

5. Department of General Practice QUB
H O T
Hypertension Optimal Treatment
Largest intervention trial in hypertension. Published in 1998
Conducted in General Practice. 18,790 patients in 26 countries
Followed up for an average of 3.8 years
Kieran McGlade Nov 2001
Department of General Practice QUB

6. Department of General Practice QUB
H O T Findings
Lowest incidence of major CV events occurred at a mean achieved DBP of 83 mmhg. This target (compared to mean achieved of 105 mmHg was associated with a 30% reduction in main CV events.
In diabetes – Diastolic< or = 80mmhg 51 % lower risk compared to 90 mmHg
Kieran McGlade Nov 2001
Department of General Practice QUB

7. Department of General Practice QUB
Global heart threat from diabetes:
A global explosion in the number of cases of diabetes is threatening to reverse the reduction in deaths from heart disease in many western countries, including the United Kingdom. To coincide with World Diabetes Day on 14 November, Diabetes UK is calling for action to be taken to reduce the 20,000 deaths per year from coronary heart disease (CHD) among people with diabetes in the UK.
Kieran McGlade Nov 2001
Department of General Practice QUB

8. Hypertension and Diabetes
Hypertension co-exists with type II in about 40% at age 45 rising to 60% at age 75.
70% of type II patients die from cardio-vascular disease.
At least 60% of patients will require 2 or 3 antihypertensive agents to achieve tight control.
Kieran McGlade Nov 2001
Department of General Practice QUB

9. Department of General Practice QUB
Stages
Identification of hypertensive patients
Baseline investigations
Initiating therapy
Reviewing patients
Stepping up therapy
Motivation and compliance
Kieran McGlade Nov 2001
Department of General Practice QUB

10. Investigation of the New Hypertensive
History and examination
Exclude secondary Hypertension
Urea and electrolytes
FBP and ESR
ECG
Lipid profile
Chest x-ray no longer routinely indicated
Kieran McGlade Nov 2001
Department of General Practice QUB

11. Clinical clues to renal vascular disease
Hypertension under 50 Yrs of age.
Generalised vascular (esp peripheral) disease.
Mild – moderate renal dysfunction.
Sudden onset pulmonary oedema.
Kieran McGlade Nov 2001
Department of General Practice QUB

12. Department of General Practice QUB
Ladder Approach
Bendrofluazide
Bendrofluazide + Atenolol or ACE
Calcium Channel blocker
Alpha blocker
Kieran McGlade Nov 2001
Department of General Practice QUB

13. Department of General Practice QUB
Tailored Approach
Assessment of overall cardiovascular risk
Recognition of co-morbidities
Lipid profile
Renal function
Existing contra- indications
Kieran McGlade Nov 2001
Department of General Practice QUB

14. Department of General Practice QUB
Kieran McGlade Nov 2001
Department of General Practice QUB

15. Coronary Risk Calculator
Launch risk calculator program
Kieran McGlade Nov 2001
Department of General Practice QUB

16. Department of General Practice QUB
Compelling and possible indications and contrindications for the major classes of antihypertensive drugs
                               
INDICATIONS               CONTRAINDICATIONS
CLASSS OF DRUG
COMPELLING
POSSIBLE
a-blockers
Prostatism
Dyslipidaemia
Postural Hypotension
Unrinary incontinence
Angiotensin converting enzyme (ACE) inhibitors
Heart failure Left ventricular dysfunction
Chronic renal disease * Type II diabetic nephropathy
Renal impairment * Peripheral vascular disease †
Pregnancy Renovascular disease
Angiotensin II receptor antagonists
Cough induced by ACE inhibitor ‡ 
Heart failure Intolerance of other antihypertensive drugs
Peripheral vascular disease
b-blockers
Myocardial infarction Angina
Heart failure  
Heart failure Dyslipidaemia Peripheral vascular disease
Asthma or COPD Heart block
Calcium antagonists (dihydropyridine)
Isolated systolic hypertension (ISH) in elderly patients
Angina Elderly patients
  _
   _
Calcium antagonists (rate limiting)
Angina
Myocardial infarction
Combination with b-blockade
Heart block Heart failure
Thiazides
Elderly patients including ISH
Gout
*  ACE inhibitors may be beneficial in chronic renal failure but should be used with caution. Close supervision and specialist  advice are needed when there is established and significant renal impairment †   Caution with ACE inhibitors and angiotensin II receptor antagonists in peripheral vascular disease because of association         with renovascular disease. ‡   If ACE inhibitor indicated f  b-blockers may worsen heart failure, but in specialist hands may be used to treat heart failure   British Hypertension Society Guidelines 2000
Kieran McGlade Nov 2001
Department of General Practice QUB

17. Department of General Practice QUB
Therapeutic targets *
Therapeutic targets
                          Measured in clinic               Mean daytime ABPM                                                                     or home measurement
Blood Pressure            No diabetes      Diabetes                No diabetes        Diabetes Optimal                         <140/85           <140/80                  <130/80              <130/75 Audit Standard             <150/90             <140/85                  <140/85              <140/80
   
The audit standard reflects the minimum recommended levels of BP control.  Despite best practice, it may not be achievable in some treated hypertensive patients.
NB: Both systolic and diastolic targets should be reached
British Hypertension Society Guidelines
Kieran McGlade Nov 2001
Department of General Practice QUB

18. Department of General Practice QUB
Logical Combinations
Diuretic
b-blocker
CCB
ACE inhibitor
a-blocker
         -
  ü
  ü*
* Verapamil + beta-blocker = absolute contra-indication    
Kieran McGlade Nov 2001
Department of General Practice QUB

19. ACE Inhibitor Side Effects
Cough (15% of patients. Is reversible)
Taste disturbance (reversible)
Angiodema
First-dose hypotension
Hyperkalaemia ( esp. in patients with type II diabetes and renal dysfunction)
Kieran McGlade Nov 2001
Department of General Practice QUB

20. Department of General Practice QUB
Follow-up
For patients with BP stabilised by management, follow up should normally be three monthly (interval should not exceed 6 months), at which the following should be assessed by a trained nurse:
*   Measurement of BP and weight  *   Reinforcement of non-pharmacological advice *   General health and drug side-effects  *   Test urine for proteinuria (annually)
Kieran McGlade Nov 2001
Department of General Practice QUB

21. Drug Treatment of Essential Hypertension in Older People
Hypertension is very common, occuring in over 50% of older people, and is a major risk factor for stroke and ischaemic heart disease.
Drug treatment of hypertension in older people saves lives and prevents unnecessary morbidity.
Treating isolated systolic hypertension also saves lives.
Kieran McGlade Nov 2001
Department of General Practice QUB

22. Drug Treatment of Essential Hypertension in Older People
There is strong evidence to support the use of diuretics as first-line agents.
Antihypertensive treatments are most cost-effective when targeted at older patients.
There is evidence of under detection and under treatment of hypertension.
Factors influencing patient adherence with treatment are not well understood and require further research.
Kieran McGlade Nov 2001
Department of General Practice QUB

23. Department of General Practice QUB
RECOMMENDATIONS (for the treatment of the elderly)
Through the wider use of antihypertensive therapies more older people would be able to maintain a healthy and active lifestyle.
For first-line agents there is strong evidence to support the use of diuretics and some evidence for the use of beta-blockers.
Systems to ensure that older people with hypertension are diagnosed, treated and followed up need to be developed.
A system of audit should be cultivated to assure adequate treatment.
High quality research on patient adherence with antihypertensive medications is needed.
NHS Centre for reviews and dissemination 1999
Kieran McGlade Nov 2001
Department of General Practice QUB

24. Department of General Practice QUB
Practical Points
15 – 20% of adult western population.
Isolated systolic hypertension just as dangerous.
Primary cause identified in only 5%.
Investigate – Urine, FBP, ESR, ECG, U&E, Lipids.
Target < 140/85.
Bendrofluazide 2.5 mg a good starting point.
Refer patients needing more than 3 drugs to control their hypertension.
Kieran McGlade Nov 2001
Department of General Practice QUB