Edmond 75 years presented with ‘shocking” blood pressure recordings of 184/102 in the morning....
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Transcript of Edmond 75 years presented with ‘shocking” blood pressure recordings of 184/102 in the morning....
UNCONTROLLED HYPERTENSION
Case history
Edmond 75 years presented with ‘shocking” blood pressure recordings of 184/102 in the morning. His afternoon and night readings were in the ‘acceptable target ranges”He has atrial fibrilliation and is on warfarin 5 mg daily. In addition he is on prazosin 5 mg, atenolol 50 mg , coversyl 10 mg and valsaltan
Questions
What is the prevalence rate of under achieving target blood pressures?
List 5 cause of failure to achieve target blood pressures? How can we reach blood pressure targets?
What is the choice of antihypertensives in angina, post myocardial infarct, post stroke, heart failure, diabetes with proteinuria or microalbuminuria,gout, chronic kidney disease, atrial fibrilliation ?
What are the potentially harmful antihypertensives in asthma/COPD, bradycardia 2nd or 3rd atrioventricular failure,depresion,gout,heart failure, bilatral renal artery stenosis + diabetes with proteinuria or microalbuminuria?
List 3 effective antihypertensive combination therapies + 3 combinations to avoid.
Blood pressure treatment targets
Patient group Target ( mm Hg)
Proteinuria > 1 gm / day ( with or without diabetes)
<125/75
Associated conditions of end organ damage: (coronary heart disease, stroke, diabetes, chronic kidney disease, proteinuria >300 mg / day)
<130/80
None of the above <140/90 or lower if tolerated
Prevalence of underachieving
Trials Prevalence of underachieving target blood pressures
AusDiab study( The Australian Diabetes, Obesity + Lifestyle)
40%
ALLHAT(The Antihypertensive + Lipid Lowering Treatment to Prevent Heart Attack Trial)
66%
CONVINCE( Controlled Onset Verapamil Investigation of Cardiovascular Endpoints)
70%
Reaching blood pressure targets
(1) Lifestyle factors not implemented(2) Adherence medication poor: costs, side effects(3) Substances increasing BP: NSAIDs,
prednisolone, alcohol, caffeine, salt intake(4) Systems issues: social or economic barriers,
recall or reminder systems(5) Secondary hypertension:(6) Therapeutic inertia: need to increase a
current agent or add another agent(7) Measurement issues: white coat effect,
inappropriate cuff size
Choice of Antihypertensives
Condition Potentially beneficial
Angina ACEI,Beta blockers(except oxprenolol,pindolol),CCBs
Post myocardial infarct ACEI, Beta blockers(except oxprenolol, pindolol),Eplerone
Post stroke ACEI,A2RA,low dose thiazide-like diuretics
Heart failure ACEI,A2RA,Thiazide diuretics,Beta blockers(bisoprolol,carvedilol,metoprolol controlled release) spironolactone
Type 1 or 2 Diabetes with proteinuria or microalbuminuria
ACEI,A2RA
Gout Losartan
Chronic kidney disease ACEI,A2RA
Atrial fibrilliation ACEI,A2RA
Potentially harmful Antihypertensives
Condition Caution Contraindicated
Asthma/COPD Cardioselective BB use in mild/moderate asthma/COPD only
BB(except cardioselective agents)
Bradycardia,2nd/3rd AV block
BB,verapamil,diltiazem
Depression BB, clonidine,methyldopa, minoxidine
Gout Thiazide diuretics
Heart failure CCBs(verapamil,dilthiazem)
Alpha blockes in AS,BB in uncontoled HF
Bilateral RAS( Unilateral solitary kidney)
ACEI,A2RA
Type 1 /2 diabetes with proteinuria or microalbuminuria
BB,Thiazide diuretics
Effective combination therapies
First drug Additional drug Recommendation
ACEI or A2RA CCB Diabetes or lipid abnormalities
ACEI or A2RA Thiazide diuretic Heart failure or post stroke
ACEI or A2RA BB Post MI or heart failure
BB Dihydrpyridine CCB Coronary heart disease
Thiazide Diuretics CCB,BB( not recommended in glucose intolerance, metabolic syndrome or established diabetes
Combinations to avoid
First drug Additional drug Recommendation
ACEI or A2RA Potassium sparing diuretics
Risk of hyperkalaemia
Verapamil Beta blocker Risk of heart block
ACEI A2RA Large trial did not reduce cardiovascular death or morbidity in vascular disease or diabetes but increased risk of hypotensive symptoms, syncope + renal dysfunction