Hypertension the Community - Overview HYPERTENSION IN THE COMMUNITY: OVERVIEW.
How Should We Investigate the Young Person with Hypertension? · How Should We Investigate the...
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How Should We Investigate the Young Person with Hypertension?
Dr Aled Lewis
Consultant Nephrologist
BCULHB
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Why Investigate?
1. Confirm correct diagnosis of hypertension
2. Identify end organ damage
3. Evaluate the cardiovascular risk
4. Exclude secondary causes
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1. Confirm Correct Diagnosis
• Trained professional
• Validated machine and appropriate cuff size
• Temperate, relaxed environment
• Quiet, seated with arm outstretched and supported
• Both arms, repeat reading in arm with highest BP
• If BP >140/90 offer automated BP monitor
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Automated Blood Pressure Monitor (ABPM)
• 2 readings per hour in usual waking hours
• Average of at least 14 measurements
• If unable to perform ABPM, offer Home BPM – 2 consecutive readings, 1 minute apart
– Repeat morning and evening, 4 to 7 days
– Ignore first day readings then average all other readings
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What is Hypertension?
• NICE CG127 (2011) • Stage 1 BP 140/90 or 135/85 • Stage 2 BP 160/100 or 150/95 • Stage 3 BP >180/ or > /110
• JNC 7 (2004)
• Normal <120 <80 • Pre Hypertension 120-139 80-89 • Stage 1 140-159 90-99 • Stage2 >160 >100
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Chronic kidney disease Hypertension
Wales 109922 492386
Wales Betsi Cadwaladr University Local Health Board 27894 113265
Powys Teaching Local Health Board 6277 23467
Hywel Dda Local Health Board 13960 63962
Abertawe Bro Morgannwg University Local Health Board 19091 82002
Cwm Taf Local Health Board 10183 51095
Cardiff and Vale University Local Health Board 10952 63000
Aneurin Bevan Local Health Board 21565 95595
2011 population >16 years: 2,507,917 (StatsWales)= 19.6% hypertensive
2010 'Health Survey for England‘ hypertension prevalence= 31.5% in men and 29.0% in women.
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What is a Young Person?
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2. Identify End Organ Damage
• Urine Dipstick • Blood urea and electrolytes +/- eGFR • 12 lead ECG • Fundoscopy • Blood glucose • Serum total and HDL cholesterol • Age, sex, smoking, family history
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3. Cardiovascular Risk Prediction
• Diastolic pressure
• Systolic pressure
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Diastolic Pressure
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• Lancet 2002; 360 (9349): 1903-1913 • BP reduction of 20/10 reduced death from cerebro-
and cardiovascular disease by 50%
• Lancet 1990; 335 (8692): 765-774
• Diastolic BP reduction of 5mmHg reduced cerebrovascular accidents by 34% and coronary events by 21%
• Lancet 1990; 335 (8693): 827-838 • Diastolic BP reduction by 5-6mmHg reduced
cerebrovascular accidents by 42% and coronary heart disease by 14%
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Lancet 2002; 360 (9349): 1903-1913
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Cardiovascular Risk
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4. Exclude Secondary Causes
• <40 years
• Sudden worsening
• Uncontrolled on 3 medications
• Accelerated hypertension – >180/110 + papilloedema or haemorrhage
• CVA <50 years
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Medications
• Immunosuppressants • NSAIDs and COX-2 • Oestrogens and testosterone • Fludrocortisone • Bromocriptine • Carbamazepine, Fluoxetine, Lithium, TCAs • Sodium bicarbonate • Erythropoietin • Nicotine, amphetamines, cocaine • Ephedra/ma huang, ginseng
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History
• Palpitations, facial flushing, headache, sweating, constipation • Oedema, palpitations, muscle weakness • Weight gain, weakness, fatigue, backache, thirst, depression,
hyperpigmentation • Lethargy, fatigue, weight gain, hair loss • Palpitations, oedema, dry skin, hair loss • Sweating, tiredness, weakness, arthralgia
Phaeochromocytoma
Cushing’s
Hyperthyroid
Acromegaly
Conn’s
Hypothyroid
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Other Symptoms
• Nocturia, oliguria
• Somnolence, snoring
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Examination
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Examination 2
• Renal bruits
• Radio-femoral delay
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Probability of Disease
• 5% drugs
• 5% renal/ renovascular disease
• <1% endocrine – Thyroid
– Conn’s (0.01-0.03%)
– Cushing’s (0.1-0.6%)
– Phaeochromocytoma (0.1%)
– Acromegaly (<0.1%)
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Investigation 1
• Thyroid Function Tests
• Aldosterone : Renin ratio
• 24hr urinary metadrenaline/normetadrenaline
• 24hr urinary free cortisol and dexamethasone suppression test
• Glucose tolerance test
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Concurrent Medications
• Aldosterone : Renin ration – ACEI/ARBs- decrease ARR (raised renin)
– Beta blockers- elevate ARR (suppress renin>aldosterone)
– Calcium channel blockers- decrease aldosterone and renin variably
– Diuretics- increase aldosterone and renin in parallel
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Investigation 2
• Ultrasound renal tract
• MRA Renal Arteries +/- angiogram
• Polysomnograph
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Am Fam Physician, 2010; 82(12): 1471-1478
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‘Common’ Causes
• Renal Disease – Chronic Glomerulonephritis
– Fibromuscular dysplasia
– Polycystic kidney disease
• Endocrine – Thyroid disorders
– Conn’s Syndrome
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1180 patients: 54 had adenoma (4.6%) 72 had idiopathic hyperaldosteronism (6.4%)
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PA suggested in 63 of 609, confirmed in 37 (6.1%) K+ normal in 36 of 37. CT showed bilateral adrenal hyperplasia in 7 and nodule in 2
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Summary
• Investigate: – Lifetime cardiovascular risk high
– Diagnosis can guide treatment
– Could offer cure
• Tailor investigations dependent on cause
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A. Accuracy; Apnea; Aldosteronism
B. Bad kidneys; Bruits
C. Catecholamines; Coarctation; Cushing’s
D. Drugs; Diet
E. Endocrine disease
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References
• National Institute for Health and Clinical Excellence. NICE CG127 Hypertension- the clinical management of primary hypertension in adults, August 2011
• The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BloodPressure. JAMA 2003;289:2560–71.
• Hammer, F., Stewart, P.P.. Investigating hypertension in a young person. BMJ 2009; 338:b10432
• Onusko, E. Diagnosing secondary hypertension. Am Fam Physician 2003; 67:67-74
• Viera, A.J., Neutze, D.M.. Diagnosis of secondary hypertension: An age based approach. Am Fam Physician 2010; 82(12):1471-1478