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Primary Care Series

Hypertension

Presented by:

Mr Innes Eaton

Paramedic Practitioner

18th January 2021

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Primary Care Series | Episode 1 | Hypertension

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Session Plan



• Regulation of blood pressure

• The pathophysiology of hypertension

• Diagnosis of hypertension

• Red flags

• NICE guidelines

• Pharmacodynamics of common medications

• Referral into secondary care

Overview



What is Blood Pressure?



BP

Cardiac Output (Systolic)

Stroke Volume

Preload (EDV)

Blood Volume Venomotor Tone

Afterload (SVR) Contractility

Heart Rate

Systemic Vascular Resistance (Diastolic)

CNS Control



RAAS Control



Renin

Angiotensinogen

Angiotensin I Angiotensin II

Angiotensin Converting Enzyme

(ACE)

Renin

1. Juxtaglomerular Cells

2. Sympathetic NS

3. Macula Densa Cells

RAAS Control



Angiotensin II

Antidiuretic

Hormone

(ADH)

Aldosterone

Angiotensin II: ↑Na+ Reabsorption PCT Aldosterone:↑Na+ Reabsorption DCT/CD

ADH:↑H2O Reabsorption CD

Primary vs Secondary



• Primary/essential hypertension: no identifiable secondary cause

• Glomerulonephritis or coarctation of the aorta in the young

• Renal artery stenosis (bruit, rapid ↑creatinine with ACEi/ARB)

• Renal disease (↑creatinine, ↑urine ACR)

• Primary aldosteronism (↑ARR, hypokalaemia)

• Pheochromocytoma (headaches, diaphoresis, labile BP)

• Cushing’s Syndrome (raised urinary cortisol)

• Thyroid dysfunction (TFTs)

• Obstructive sleep apnoea

• Iatrogenic/drug induced (POP/COCP/NSAIDs, steroids, illicit drugs)

Diagnosing Hypertension



• Check bilateral BP – use the higher reading• Consider differentials and/or referral if gross difference

• If BP consistently ≥140/90mmHg in clinic• Offer ABPM/HBPM for 7-14 days

• During this time, Ix target organ damage and calculate QRISK3

• Consider secondary causes

• If clinic BP ≥180/120mmHg• Ix target organ damage ASAP and repeat clinic BP within 7 days

• Start antihypertensives immediately if target organ damage identified

• If retinal haemorrhage or papilloedema then refer same day (AECU)

• If symptomatic (confusion, CP, HF, AKI) then refer same day (AECU)

Ix Target Organ Damage



• ECG – LVH +/- strain

• Renal & electrolytes, urine ACR – CKD

• Hba1c and lipid profile – associated risk factors

• Fundoscopy – retinopathy, papilloedema

Stages of Hypertension



• Stage 1• Clinic BP 140/90 – 159/99mmHg

• Stage 2• Clinic BP 160/100 – 179/119mmHg

• Stage 3• Clinic BP ≥180/120mmHg

Indications for Antihypertensives



• Any age• Persistent stage 2 hypertension• Caution: frailly and/or multimorbidity (postural hypotension)

• Adults under 80• Persistent stage 1 hypertension with 1 or more of the following:

• Target organ damage• Established cardiovascular disease (CVA/TIA/MI/angina/PAD etc)• Renal disease• DM• QRISK3 ≥10%

• Adults under 40• Additionally consider secondary causes +/- specialist opinion

Treatment Aims



• Age

Non-Pharmacological Options



• Exercise

• Salt restriction

• Weight loss

• Smoking cessation

• Alcohol reduction

• Relaxation techniques

• High potassium diet

• Lipid management (diet)

Step 1


T2DM?

Yes

Are they black African/Afro-Caribbean ?

Yes

ARB

No

ACEi

No

Are they black African/Afro-Caribbean?

Yes

CCB

No

How old?

Step 2


What are they on now?

ACEi or ARB

Add CCB

Or TLD

CCB


Yes

Add ARB

Or TLD

No

Add ACEi

Or TLD

TLD


Yes

Add ARB

No

Add ACEi

• If ACEi is not tolerated – change to ARB

Step 3



• Triple therapy• ACEi

• Or ARB if not tolerated, or if black African/Afro-Carribean

• Plus CCB

• Plus TLD

Step 4


Measure K+

≤4.5mmol

Add spironolactone

(K+ sparing diuretic)

>4.5mmol

Add α blocker

Or β blocker

• Check for postural hypotension before starting

4th line therapy

• Careful monitoring of electrolytes and renal

function

• Refer to cardiology if hypertension remains

uncontrolled

ACE Inhibitors (ACEi)



Common ACE inhibitors include:

• Captopril

• Cilazapril

• Enalapril

• Fosinopril

• Imidapril

• Lisinopril

• Moexipril

• Perindopril

• Quinapril

• Ramipril

• Trandolapril

ACEi



Renin

Angiotensinogen

Angiotensin I Angiotensin II

Angiotensin Converting Enzyme

(ACE)

Renin

1. Juxtaglomerular Cells

2. Sympathetic NS

3. Macula Densa Cells

ACEi



Angiotensin II

Antidiuretic

Hormone

(ADH)

Aldosterone



Angiotensin Receptor Blockers (ARB)



Common ARBs include:

• Candesartan

• Eprosartan

• Irbesartan

• Losartan

• Olmesartan

• Telmisartan

• Valsartan

ARBs



Angiotensin II

Antidiuretic

Hormone

(ADH)

Aldosterone



Calcium Channel Blockers (CCB)



Common CCBs include:

• Amlodipine

• Diltiazem (non-DHP)

• Felodipine

• Lacidipine

• Nifedipine

• Nimodipine

• Verapamil (non-DHP)

CCBs



Alpha Blockers



Common alpha blockers include:

• Alfuzosin

• Doxazosin

• Indoramin

• Prazosin

• Tamsulosin

• Terazosin

Beta Blockers



Common beta blockers include:

• Atenolol

• Betaxolol

• Bisoprolol

• Celiprolol

• Co-tenidone

• Esmolol

• Metoprolol

• Propanolol

• Nebivolol

Alpha & Beta Blockers



Case Study



• 60 y/o female presents with clinic BP of 165/99

• Not known DM, white British

• Average HBPM over 1/52 is 162/95

• ECG = NSR, U&Es/GFR normal range, Hba1c 39, TC 5.2

Next Session



Primary Care Series | Episode 2 | Heart Failure

Monday 25th January 2021

19:00 GMT

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