Practical Management of Hypertension in Primary

Care

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Dr Rob SapsfordConsultant Cardiologist

Leeds Teaching Hospitals

Objectives

Prevalence NICE guidance (CG 127 August 2011)

Investigation Treatment Resistant Hypertension Malignant Hypertension

NICE Clinical Guideline CG 127

Kearney PM, et al. 2005

The incidence of hypertension is predicted to increase dramatically

Population with hypertension (%)

30

Overall

26

28

Men Women

20002025

24

The global incidence of hypertension in the adult population is predicted to exceed 29% by the year 2025

25% of all adults hypertensive50% adults 60yrs> hypertensive

Pulse pressure

Cardiovascular risk doubles with each 20/10 mmHg increment

0

2

4

6

8

115/75 135/85 155/95 175/105

SBP / DBP (mmHg)

CV Mortality risk (fold increase)

Lewington et al Lancet 2002:60;1903-1913

Any BP reduction makes a difference

2 mmHg decrease in mean SBP

7% reduction in risk of IHD mortality

10% reduction in risk of CVA

mortality

Lewington S et al lancet 2002:360;1903-1913

Meta-analysis of 61 prospective observational studies involving 1 million adults (12.7 million patient years)

Relative risk reduction (%)

−50

−40

−30

−20

−10

0CHDStrokeCV event

20–21

21–28

30–39

Risk of CV event with ACEI or CCB relative to placeboCV: cardiovascular CHD: coronary heart disease

Long-term antihypertensive treatment

reduces CV risk

Neal B, et al. 2000RAS07000047

Measuring BP

Standardise BP measurements Never base treatment on an isolated

reading All adults every 5 Years High / normal (130–139 / 85–89 mmHg) every 1

year

Measuring BP has improved

The modern sphygnomanometer

Rev Hales – veterinarian

Carl Ludwig’s kymograph Riva-Rocci’s sphygmomanometer

24 Hour BP Monitoring

24 Hr BP – Diagnosis ?

‘White coat effect’Discrepancy of 20/10 mmHg >between clinic and average daytime ABPM

or average HBPM at time of diagnosis

BP Problems

Unequal arm BP’sDifference in BP between arms

BP difference 20mmHg> Repeat measurements ?

persists

ActionDocument as higher risk for vascular

disease Use highest arm for subsequent monitoring

BP Problems Postural Hypotension

Falls / postural dizziness BP seated / standing 1min>Systolic BP fall on standing 20mmHg>

ActionReview medicationMeasure future BP standingConsider referral if symptoms persist

Blood Pressure Clinic BP

140 > / 90 >

Ambulatory BP MonitorABPM

Minimum 2x readings / HrAverage 14 daytime readings

Home BP MonitorHBPM

2 readings 1 min> apartMinimum 2x recordings / day

Average min 4 days – 7 days readings(disregard day 1 readings)

Hypertensive Stages

Stage 1 Clinic BP 140> / 90>Daytime ABPM 135> / 85>Average HBPM 135> / 85>

Stage 2 Clinic BP 160> / 100>Daytime ABPM 150> / 95>Average HBPM 150> / 95>

Severe Clinic BP 180> / 110>

Treatment guidelines

160> /100> mmHgABPM 150>/95>

Treat(any age)

BMJ 2004 328:634-640

<140 /90 mmHgABPM <135/<85

Annual review

140–159 / 90-99 ABPM 135-149/85-94

Assess risk

BP measurement

Treatment Guidelines

No Target Organ Damage (TOD) and

No Diabetes mellitusand

No Cardio-vascular diseaseand

No Renal Diseaseand

10 yr Cardio-vascular risk <20%*

BMJ 2004 328:634-640

Lifestyle measures Annual

review

Target Organ Damage (TOD) or

Diabetes mellitusor

Cardio-vascular diseaseor

Renal Diseaseor

10 yr Cardio-vascular risk 20%>

Treat

ABPM/HBPM 135-150 / 85-95

Investigations

Cardio-vascular risk U/E’s, FBC, TFT’s, TC:HDL, Glucose

QRISK2, Framinghm

Target Organ DamageECGUrinalysis / Alb:Creat ratio

Target Organ Damage

CVA

Nephropathy

Retinopathy

LVHLVH

Framingham Cardiovascular Risk

(morbidity and mortality)

Atherosclerotic disease anywhere – high risk

Sex

AgeSystolic BP / Diastolic BPSmoking historyTotal cholesterol : HDLECG – evidence of LVH

Calculate 10 year CV risk

Treat 20% > CV risk

Average male 45 years 1% per annum risk (10% 10 year risk)

QRISK2 Calculator

Variables included in the first version were

AgeSexSmoking statusSystolic BPRatio TC:HDLBMIFamily history of IHD (first degree relatives <60 yrs)Area measure of deprivation (Townsend score)Treatment with antihypertensive agent

Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, May M, Brindle P. BMJ 2007;335:136.

A more recent version (QRISK2) has additional variables

Self assigned ethnicityType 2 diabetes Rheumatoid arthritis Renal diseaseAtrial fibrillation

When to refer ?

Stage 1 hypertension in young (<40 yrs) :even if low estimated 10 yr risk (under-estimation of lifetime risk)

Target organ damage (LVH / albuminria / proteinuria) : but no evidence of hypertension

Accelerated Hypertension (BP usually 180/110 > with papilloedema / retinal changes) – urgent admission

Supected phaeochromocytoma (labile BP, headache, palpitations, sweating) – urgent admission

Secondary cause supected on signs or symptoms (RAS – bruit, young female, PVD, Renal dysfunction)

Treatment Lifestyle advice

Diet / exerciseAlcohol reductionCaffeine reductionReduce dietary Sodium Smoking cessation

NICE / BHS guidelines

Step 1

Step 2

Step 3

Step 4

Age (<55) Older(>55) or black any age

A C

A + C

A C D+ +Resistant Hypertension

A+C+D+further diuretic / alpha or BB

Key :

A = ACE-I / ARB

B = Beta-blocker

C = Calcium antagonist

D = Diuretic (chlortalidone / indapamide)

NICE CG 127

Spironolactone 25mg if K<4.5 Higher dose thiazide if K higher

Treatment - ? Beta-blockers

If co-morbidity benefiting from use (angina / systolic heart failure)

Younger patient (<55yrs) intolerance or contra-indication to ACE/ARB

Women of child bearing potential Evidence increased sympathetic drive Avoid BB with thiazide like diuretic

Optimal BP Targets

Patients <80yrs

Patients 80yrs >

<140 / <90 mmHg

<150 / <90 mmHg

Clinic BP

<145 / <85 mmHg

<135 / <85 mmHg

NICE CG 127 2011

ABPM / HBPM

Resistant Hypertension

Failure to achieve goal BP despite optimal doses of 3 or more agents from different classes (ideally one a diuretic)

Prevalence around 10%

True resistance: secondary causes, OSA, Volume overload, Drug induced, obesity, alcohol excess

Apparent resistance – non compliance, cuff related artefacts, white coat resistance (25-37% reclassified)

Heart 2012;98:254-261

Malignant Hypertension

Sudden / rapid hypertension with diastolic 130mmHg>

1% hypertensives (particularly african-americans) Associated CTD, CKD, pregnancy toxaemia, RAS Symptoms – retinal / cerebral / renal / cardiac Signs – retinal / +/- oedema Treatment – IV / oral (aim diastolic <110 within 24

hrs)

Aspirin in Hypertensives Recommended : Primary prevention

75mg / day if Patientaged >50 yrsBP controlled <150 / 90target organ damageDiabetic10 CV risk >20%

And one of

BMJ 2004 328:634-640

Statin Trials: ASCOT - LLAP

erce

nta

ge

wit

h C

HD

eve

nt

Primary prevention

Pravastatin

Lovastatin

Modified from Kastelein JJP. Atherosclerosis. 1999; 143(suppl 1): S17-S21

Atorvastatin

10

5.4 (210)2.3 (90) 2.8 (110) 3.4 (130) 3.9 (150) 4.4 (170) 4.9 (190)

WOSCOPS-S WOSCOPS-P

0

5AFCAPS-S AFCAPS-P

9

8

7

6

4

3

2

1

ASCOT-P

ASCOT-S

LDL-C, mmol/L (mg/dL)

S = statin treated; P = placebo treated ASCOT 10 yr CV risk 9%

Conclusion

Treatment of BP dependent on level and assessment of baseline CV risk

Individualise treatment accepting several agents will be required

Compliance important Treat all CV risk factors – statins usually

indicated

NICE Guidelines: Primary Prevention

Statins are recommended as part of management strategy for primary prevention of CVD for adults who have a 20% 10-year risk of developing CVD

Statins for the prevention of cardiovascular events. NICE Technology Appraisal 94. January 2006

24 Hour Ambulatory BP

Ambulatory BP measurement

Unusual variation Possible white coat hypertension Equivocal treatment decisions Evaluation nocturnal hypertension Evaluation of drug resistant hypertension Evaluation 24 hour treatment control Diagnosis and treatment of pregnancy

hypertension Evaluation of symptomatic hypotension

BP thresholds 10 / 5 mmHg lower than clinic BP’s