1210 DIASTOLIC Hypertension[2]

7/30/2019 1210 DIASTOLIC Hypertension[2]

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Hypertension

Dr Moynul Haque

GPST3


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Overview

Background

NICE Guideline

AKT Question


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Epidemiology 15-20% of the adult population (>half of those older than 60) are

hypertensive

Risk associated with increasing blood pressure is continuous

-with each 2 mmHg rise in systolic blood pressureassociated with a 7% increased risk of mortality from IHD and a10% from strokeDiastolic pressure is more commonly elevated in people youngerthan 50

With ageing, systolic hypertension becomes a more significantproblem, as a result of progressive stiffening and loss of

compliance of larger arteries


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Aetiology

Essential / Primary 95%

Secondary (only 5%)

Renal 80%-GLomerulonephritis

-Pyelonephritis

-Adult PCKD-Renal artery stenosis

Endocrine causes 15%-Cushing's syndrome

-Conn's syndrome

-Liddle's syndrome

-Congenital adrenal hyperplasia

-Phaeochromocytoma

- Acromegaly

Others 5%-Pregnancy

-Coarctation of Aorta

-Steroid use

-COC pill

-MAOI


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Definition of Hypertension

Stage 1: Clinic BP 140/90 or higher andABPM daytime / HBPM 135/85 or higher

Stage 2: Clinic BP 160/100 or higher andAMBP daytime / HBPM 150/95

Severe : Clinic SBP 180 or higher or Clinic DBP 110 or higher

Accelerated: Clinic BP 180/110 or higherwith Sign of papilloedema or Retinal haemorrhage


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Clinic BP recording

Measure BP in both arms If difference >20 repeat the

measurements

If remains >20 on 2nd time

Measure BP again in the arm

with the higher reading

If clinic BP140/90

Take a second measurement If 2nd measure is different from

1st , take 3rd

Record the lower of the last 2

measurements as the clinic BP
http://eachthingonline.com/wp-content/uploads/2011/04/high-blood-pressure-remedy.jpg


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Key points

If clinic BP 140/90 (180/110)ABPM/HBPM

If ABPM-At least 2 measurement / hour during waking

hours (eg 08:00 & 22:00)-Use avg value (at least 14 measurement)

If HBPM-2 consecutive BP taken at least 1 min apart & with

the person seated-Ideally twice daily , am & pm-Recording for 7 days ( at least 4 days)-Discard the measurement taken on the 1st day and

use the avg value of all remaining measurements


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Management

Lifestyle interventions


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20112011

1997


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Lifestyle interventions

Diet

Exercise

Cut down of Alcohol consumption

Stop Smoking Low salt intake

Discourage excessive consumption of coffee & other

caffeine-rich products

Relaxation therapy can be advised ( PCT will not provideroutinely)


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Initiating medication

If Stage 1(Clinic BP140/90 + ABPM135/85) +one of the following

-Target organ damage eg, LVH,

-Established CVD disease-Renal disease eg,albuminuria/proteinuria,haematuria

-Diabetes

-A 10 yrs CV risk equivalent to 20%If Stage 2 ( Clinic BP160/100 + ABPM150/95)

Severe hypertension (Clinic SBP180 or DBP110) Start antihypertensive medication immediately


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Investigation

Urine dips for haematuria

Urine for ACR (Albumin: creatinine ratio)

-if DM ACR>2.5 in men and >3.5 in womenIf non-DM ACR> 30 significant proteinuria

Blood for U&Es, glucose, total cholesterol

and HDL cholesterol

Fundoscopy for hypertensive retinopathy

12 lead ECG


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Drugs treatments

Key points

Offer drugs taken only once a day Do not combine ACE inhibitor with ARB If > 55yrs or Afro-Caribbean offer CCB If diuretics considered offer a thiazide-like

diuretics eg, Indapamide (1.5 mg MR od or 2.5 mgod) or Chlortalidone ( 12.5- 25.0 mg od) inpreference to conventional thiazide eg,Bendroflumathiazide or hrdrochlorthiazide ( if

already taken & well controlled then continue tx) In step 4 treatment Consider further diuretics with low dose of Spironolactone 25mg od if

K level 4.5

Consider further diuretic high dose of Thiazide like diuretics if K level4.5


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Drug of choice

HTN + DM ACE/ARB

HTN + IHD B blocker

HTN + HF ACE/ARB HTN + CKD ACE/ARB

HTN + Pregnancy Methyledopa/ B blocker


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MONITORING

When using further diuretics (eg, Spironolactone orhigher dose of Thiazide-like diuretics)

Monitor blood Na, K and U&Es within 1 month and repeat as required

If ACE inhibitor or ARB

Monitor U&Es before and after initiation and also afterincreasing the dose.

Rise in Creatinine up to 30% from base line

Reduce eGFR up to 20% from base line

Increase K level up to 5.5


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Specialty referrals

If stage1 hypertension and 20) +

symptoms persist eg, fall, postural dizzy


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Target BP

Under 80yrs Clinic BP140/90

Daytime avg ABPM/ HBPM 135/85

Over 80yrs-Clinic BP 150/90

-Daytime avg ABPM/ HBPM 145/85

Hypertension with diabetes Clinic BP 140/80

If target organ damage 130/80

9/6/11


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MCQ

AKT


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You review a 67-year-old woman who has a history of

chronic obstructive pulmonary disease and hypertension.

She has develop cor pulmonale and her current

medications include frusemide 80 mg bd, amlodipine 10mg

od and atenolol 50 mg od. You want to initiate an ACEinhibitor. What is the most appropriate action?

A. Stop frusemide for 2 days + start ramipril 1.25 mg od + checkU&Es in 2 weeks

B. Start ramipril 1.25 mg od + check U&Es in 2 weeks

C. Refer to secondary care

D. Reduce frusemide to 80mg od + start ramipril 1.25mg od + check U&Es in 2 weeks

E. Start ramipril 1.25 mg od + check U&Es in 5 days


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C

Both the BNF and Clinical Knowledge

Summaries recommend referring people on

larger doses of diuretics to specialists for

initiation of ACE inhibitors.


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You review an 81-year-old man with regards to his

hypertensive therapy. He is currently taking a

combination of losartan and amlodipine which is

failing to keep his blood pressure withing target.

What is the most appropriate next step assuming

he has no relevant contraindications?

A. Add indapamide MR 1.5mg odB. Add atenolol 50mg od

C. Add ramipril 1.25mg od

D. Add doxazosin 1mg od

E. Add bendroflumethiazide 2.5mg od


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NICE now advise using alternatives to

bendroflumethiazide. Patients already taking

bendroflumethiazide should however not be

switched over to alternative thiazide-typediuretics.

A

This patient is taking an angiotensin 2

receptor blocker (losartan), possibly due to

having problems with ACE inhibitor therapy

previously, for example a dry cough. Patients

should not normally take an ACE inhibitor and

A2RB at the same time.

A 65 ld f l ith k hi t f h t


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A 65 year old female with a known history of heart

failure presents to her GP for an annual check-up.

She is found to have a blood pressure of 170/100

mmHg. Her current medications are furosemide and

aspirin. What is the most appropriate medication toadd?

A. Bendroflumethiazid

B. SpironolactonC. Bisoprolol

D. Verapamil

E. Enalapril


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E

Both enalapril and spironolactone have been

shown to improve prognosis in patients with

heart failure.

NICE guidelines recommend the introductionof an ACE inhibitor prior to a beta-blocker in

patients with chronic heart failure

A 71-year-old woman is reviewed in her local GP surgery She has


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A 71-year-old woman is reviewed in her local GP surgery. She has

recently changed practices and is having a routine new patient

medical. Her blood pressure is 146/ 94 mmHg. This is confirmed on a

second reading. In line with recent NICE guidance, what is the most

appropriate management?

A. Ask her to come back in 6 months for a blood pressurecheck

B. Arrange 3 blood pressure checks with the practicenurse over the next 2 weeks with medical review following

C. Arrange ambulatory blood pressure monitoring

D. Reassure her this is acceptable for her age

E. Start treatment with a calcium channel blocker


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C

Hypertension - NICE now recommend

ambulatory blood pressure monitoring toaid diagnosis

The 2011 NICE guidelines recognise that

in the past there was overtreatment of

'white coat' hypertension. The use of

ambulatory blood pressure monitoring

(ABPM) aims to reduce this.


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A 52-year-old man is seen in the hypertension clinic. He was

diagnosed around three months ago and started on ramipril. This

has been titrated up to 10mg od but his blood pressure remains

around 156/92 mmHg. What is the most appopriate next step in

management?

A. Add bendroflumethiazide

B. Add bisoprolol

C. Switch ramipril to perindopril

D. Add amlodipine

E. Add losartan


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D

Calcium channel blockers are nowpreferred to thiazides in the treatment of

hypertension

The 2011 NICE guidelines reflected the

changing evidence base supporting theuse of calcium channel blockers in

preference to thiazide-type diuretics in

the management of hypertension.


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You review a 60-year-old man in the hypertension clinic. His past

medical history includes depression and peripheral arterial disease. He

is currently prescribed aspirin, simvastatin, citalopram and co-codamol

8/500. Two weeks ago he was started on ramipril 1.25 mg od. His bloodpressure has decreased from 160/100 mmHg to 114/ 72 mmHg and the

creatinine has increased from 102 mol/l to 230 mol/l. Which one of

the following is most likely to explain the rise in creatinine?

A.Medication-induced urinary retention with

secondary obstructive nephropathyB. Concurrent paracetamol overdose

C. ACE-related nephropathy

D. Normal, acceptable rise in creatinine forpatients taking an ACE inhibitor

E. Underlying renovascular disease


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You admit a woman who is 34 weeks pregnant to the obstetric ward.

She has been monitored for the past few weeks due to pregnancy-

induced hypertension but has now developed proteinuria. Her blood

pressure is 162/94 mmHg. Which one of the following

antihypertensives is she most likely to be commenced on?

A. Moxonidine

B. Atenolol

C. Methyldopa

D. Losartan

E. Verapamil


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C

Consensus guidelines recommend treating bloodpressure > 160/110 mmHg although many clinicians have

a lower threshold

Oral methyldopa is often used first-line with oral labetalol,

nifedipine and hydralazine also being used

For severe hypertension IV labetalol and IV hydralazine

are used

Addition to the above

Delivery of the baby is the most important and definitive

management step. The timing depends on the individual

clinical scenario.

A 74 year old man presents to his GP for a medication


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A 74-year-old man presents to his GP for a medication

review. Blood pressure is recorded as 184/72. This is

confirmed on two further occasions. What is the most

appropriate first line therapy?

A. Ramipril

B. Losartan

C. BendroflumethiazideD. Amlodipine

E. Atenolol


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DThe 2011 NICE guidelines

recommended treating isolated

systolic hypertension the same wayas standard hypertension. In this age

group calcium channel blockers

would be first-line.

The use of beta-blockers in treating hypertension has


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The use of beta-blockers in treating hypertension has

declined sharply in the past five years. Which one of the

following best describes the reasons why this has

occurred?

A. Less likely to prevent stroke + potential impairment ofglucose tolerance

B. Less likely to prevent myocardial infarctions + potentialimpairment of glucose tolerance

C. High rate of interactions with other commonlyprescribed medications (e.g. Calcium channel blockers)

D. Increased incidence of reported adverse effects

E. Increased incidence of chronic obstructive pulmonarydisease


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AThis was demonstrated in the

Anglo-Scandinavian Cardiac

Outcomes Trial-BloodPressure Lowering Arm

(ASCOT-BPLA).


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You review an 82-year-old woman in clinic. Last month she had

a one-off blood pressure reading of 150/92 mmHg and was

offered ambulatory blood pressure monitoring. This shows an

average reading of 146/94 mmHg. She has no significant pastmedical history of note other than hypothyroidism. What is the

most appropriate management?

A. Arrange further ambulatory blood pressure monitoring

B. Start a thiazide-type diureticC. Give lifestyle advice and repeat blood pressure in 6

months

D. Start an ACE inhibitor

E. Start a calcium channel blocker


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C

NICE now only recommend

diagnosing people over the age of

80 years as hypertensive if they

have stage 2 hypertension (ABPM

daytime average or HBPM average

BP >= 150/95 mmHg).


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Your next appointment is with a 47-year-old woman. She has come

for the results of her ambulatory blood pressure monitoring

(ABPM). This was arranged as a clinic reading one month ago was

noted to be 146/92 mmHg. The results of the ABPM show an

average reading of 126/78 mmHg. What is the most appropriatecourse of action?

A. Make the final decision based on a clinic blood pressurereading today

B. Offer repeat ABPM in 6 months time

C. Offer repeat ABPM in 12 months timeD. Reassure her that she does not need another blood pressure

check for 10 years

E. Offer to measure the patient's blood pressure at least every 5years


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EIn this situation where the ABPM has

shown a sub-threshold average blood

pressure

NICE recommend offering to measure

the patient's blood pressure at least

every 5 years.


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An 83-year-old woman is reviewed in the

hypertension clinic. What should her target blood

pressure be once on treatment?

A. 140/80 mmHg

B. 140/90 mmHg

C. 130/80 mmHgD. 140/85 mmHg

E. 150/90 mmHg


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E

Blood pressure target (based

on clinic readings) forpatients > 80 years - 150/90

mmHg


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Many Thanks

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1210 DIASTOLIC Hypertension[2]

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