1.3 240412 Hypertension event-presentation-FINAL · PDF file5/1/2012 · GPwSI Cardiology (MD, PGD Cardiology) Hypertension ... Cardiology , 67:723–7. 2. BP measurement: how...

HYPERTENSION

Lambeth & Southwark

CVD Education Programme Event: CVD Education Programme Event: Hypertension

Wednesday 18th April 2012

Welcome

• Why is CVD a priority?

• Partnership working

• Purpose

– Education

– Promoting dialogue

Why focus on hypertension?

�Key risk factor

August 2011 NICE guidance� August 2011 NICE guidance

�Ethnic views of hypertension – there

are big differences

Health concerns

and ethnicity

WA WI White

Heart disease ��

“It’s 30 years since I’ve been to a

doctor, and I know damn rightly that if I

do go, I know exactly what the HBP ��

Sexual health ��

Mental health ��

Asthma ��

Pollution ��

Drugs / alcohol ��

Sanitation ��

exactly what the answer will be.

Point 1, are you still smoking? Yes.

Point 2, cut back on the food a little bit

and what about your lifestyle?”

White Respondent

West African views

“Most people begin to think about exercise

and health when they are economically

“The bigger you are in size kind of reflects how wealthy you may

be and people are economically

stable … there is food on the table, you have got a permanent job.”

be and people respect you more for being large in size.”

West African Respondent

West African Respondent

Home is healthier than London …

“We come from Africa to the UK, and that makes things very difficult for us. Why? Because of our background that we’re coming from … we have a sort of

“I’m always healthier when I’m in Jamaica … I always come

back … shining. Now I’m brown, then I’m blue black.”

we’re coming from … we have a sort of … lifestyle that we’re not actually used to, not brought up with”

West African Respondent Caribbean Respondent

Event agenda - 17.00pm –7.05pm

Welcome and introduction � Background � Objectives

Dr John BalazsGP/CVD GP commissioning leadDr Brian ClappConsultant Cardiologist/KHP education lead

7.05pm Current position in Lambeth & 7.05pm –7.15pm

Current position in Lambeth & Southwark - Public health data- Key challenges

Dr Hiten Dodhia

Helen Williams

7.15pm -7.50pm

Key updates - diagnosis- NICE Guidance: key changes and

implications - Case study

� Dr Eric Cajeat GP/CVD Clinical lead

Event Agenda - 27.50pm-8.25pm

Key updates – treatment - NICE Guidance: key changes and

implications - Case study

� Helen WilliamsCVD Consultant Pharmacist

BREAK8.35 pm-9.10pm

Case study focussed discussions(continued) � Primary prevention/Risk

� Ruth JeffriesPractice Nurse

� Andrew Webb 9.10pm � Primary prevention/Risk assessment

� Treatment o Drug therapy o Lifestyle advice

Andrew Webb Consultant Clinical Pharmacologist

8.50pm –9.00pm

Panel discussion � What are key challenges for primary

care in managing hypertension � What should future support focus

on?� How should it be delivered? � Sharing of good practice

Dr Eric CajeatCVD Clinical leadHelen WilliamsCVD Consultant PharmacistDr John BalazsGP/CVD GP commissioning leadDr Brian ClappConsultant Cardiologist/KHP education lead

Lambeth & Southwark

CVD Education Programme Event:

Hypertension – Public Health

ContextContext

2012

Hiten Dodhia

Consultant

10

MORTALITY

SOURCE: Global

11

SOURCE: Global health risks: mortality and burden of disease attributable to selected major risks. WHO 2009

MORBIDITY

SOURCE: Global

12

SOURCE: Global health risks: mortality and burden of disease attributable to selected major risks. WHO 2009

13

Franz Messerli et al & Editorial Lancet Aug 2007

• For a person the risk of developing hypertension in developed countries exceeds 90%

• Worldwide estimated numbers of adults with hypertension in 2000 exceeds 972 million (639 live in developed countries)exceeds 972 million (639 live in developed countries)

• By 2025 number is thought to exceed 1.25 billion

• “Lifestyle” factors at the heart of this burden

• Issues in developed countries:– Screening not done systematically

– Diagnosis often at late stage when end-organ damage has already happened

– Optimum time to start treatment remains under debate (most guidelines have treatment thresholds – now scientifically questionable)

– Compliance remains big problem

14

Franz Messerli et al & Editorial Lancet Aug

2007

• Epidemiological evidence suggests a continuous relation

between risk of cardiovascular disease and usual blood-

pressure values of at least 115/75 mm Hgpressure values of at least 115/75 mm Hg

• Irrespective of the level of hypertension, lowering of blood

pressure is always preferable by non-pharmacological means,

such as a low salt diet, weight loss, exercise, and alcohol

restriction (although challenging at an individual level as

compliance is poor).

15

16SOURCE: Global health risks: mortality and burden of disease attributable to selected major risks. WHO 2009

Rationale for choosing QOF Blood pressure as

key Strategic Plan Target

• Blood pressure – key risk factor for cardiovascular disease

– Heart disease and stroke premature mortality remain – Heart disease and stroke premature mortality remain higher than nationally

– Detection remains lower compared to nationally and what would be expected

– Control remains in worst decile compared to national picture

– Refocus on primary prevention (will improve secondary prevention as well)

17

Hypertension

18

Detected prevalence 8.9%

Actual and expected hypertension prevalence by Southwark practice, 2010-11

Concordia Melbourne3-Zero-6 MC

Villa StreetTrafalgar

The Surgery (Lee)The Surgery (East Street)

Sir John Kirk ClosePrincess Street

PenroseOld Kent Road

Manor PlaceMaddock Way

Borough (Sharma)Borough (Misra)

BlackfriarsAylesbury Partnership

Surrey DocksSt James Church

Parkers RowPark Medical

New Mill StreetGrange Road

Falmouth RoadDMC Silverlock

Bermondsey & LansdowneAvicenna

Albion Street

Bor

ough

and

Wal

wor

thB

erm

onds

ey a

nd R

othe

rhith

e

0 1,000 2,000 3,000 4,000 5,000 6,000

Sternhall LaneSt Giles (Virji & Begley)

St Giles (Patel, Rosemam,Vasant)Queens Road

Lister (Ullah)Lister (Hurley Group)

Lister (Hossain)Lister (Aru)

DMC ChadwickConcordia ParksideCamberwell Green

Acorn

The Gardens Nunhead

Lordship LaneHambleden

Forest HillElm Lodge

East Dulwich PCCDMC CPR

Concordia Melbourne3-Zero-6 MC

number of patients

Number on register Expected numbers

Dul

wic

hP

eckh

am a

nd C

ambe

rwel

l

Prevalence

Area Registered patients

Number of people on

hypertension register

Unadjusted detected

prevalence

Lambeth 2004-05 344588 26073 7.6

2005-06 339304 27194 8.0

Crude prevalence of hypertension (Source: QMAS Database NHS Information Centre)

Change in population Lambeth:

9.6%National:

4.4%

Average change

20

2006-07 354843 29,737 8.4

2007-08 359,938 30,623 8.5

2008-09 366,664 31,425 8.6

2009-10 375,797 32,730 8.7

2010-11 377,807 33,582 8.9

National 2004-05 52833584 5973062 11.3

2005-06 53211253 6365837 11.9

2006-07 53681098 6705899 12.5

2007-08 54009831 6908055 12.8

2008-09 54310660 7132856 13.1

2009-10 54836561 7321472 13.3

2010-11 55169643 7460497 13.5

4.4% change Lambeth:

0.2%

Average change

National: 0.4%

Prevalence Crude prevalence of hypertension

(Source: QMAS Database NHS Information Center)

Area

Registered

patients

Number of

people on

hypertension

register

Unadjusted

detected

prevalence

Southwark 2004-05 280,231 24,055 8.6%

2005-06 288,878 27,041 9.4%

2006-07 295,503 28,653 9.7%

2007-08 301,020 29,390 9.8%

Change in population Southwark:

14.6%National:

4.4%

Average change

Southwark: 0.2%

21

2007-08 301,020 29,390 9.8%

2008-09 309,666 29,976 9.7%

2009-10 316,613 30,827 9.7%

2010-11 321,036 31,758 9.9%

National 2004-05 52,833,584 5,973,062 11.3%

2005-06 53,211,253 6,365,837 11.9%

2006-07 53,681,098 6,705,899 12.5%

2007-08 54,009,831 6,908,055 12.8%

2008-09 54,310,660 7,132,856 13.1%

2009-10 54,836,561 7,321,472 13.3%

2010-11 55,169,643 7,460,497 13.5%

k: 0.2%

Average change

National: 0.4%

Lambeth: 86.5% (n=5142)

Lambeth: 83.9% (n=3257)

Southwark: 85.5% (n=4749)

Southwark: 81.9% (n=2728)

7580

8590

Per

cent

ach

ieve

men

t (b

ased

on

dise

ase

regi

ster

siz

e)Hypertension management 2010-11

22

Lambeth: 73.2% (n=33582)Lambeth: 74.1% (n=13089)

Lambeth: 66.5% (n=5958)

Southwark: 72.9% (n=11595)

Southwark: 65.6% (n=5347)LambethSouthwark

Southwark: 71.7% (n=31758)

6065

70P

erce

nt a

chie

vem

ent (

bas

ed o

n di

seas

e re

gist

er s

ize)

BP05 register size CHD06 register size Str oke 06 register si ze DM12 register size CKD03 register size

Source: NHS Information Centre QOF Database 2011

Evidence based interventions

Summary of antihypertensive

drug treatment

Aged over 55 years or black person of African or Caribbean family origin of any age

Aged under55 years

C2A Step 1

23

Step 4

A + C2

A + C + D

Resistant hypertension

A + C + D + consider further diuretic 3, 4 or alpha- or

beta-blocker 5

Consider seeking expert advice

Step 2

Step 3

KeyA – ACE inhibitor or angiotensin II receptor blocker (ARB)1

C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic

See slide notes for details of footnotes 1-5

LAMBETH DATANET PROVISIONAL

DATA

The number of people with hypertension following NI CE hypertension guideline (practices n =50/52; people on hypertensi on register with valid BP reading in the last 9 months n = 28,746 – data ex tracted from 31/03/11)

NICE STEP CONTROLLED (150/90 or less)

UNCONTROLLED (>150/90)

Step 1 8,178 1,713

24

Step 1 8,178 1,713

Step 2 4,018 981 Step 3 1,484 452 Step 4 + Beta Blocker 35 10 Step 4 + antagonist 237 70

Non-NICE combinations

5,710 1,312

No prescription recorded

3,572 948

TOTAL 23,234 5,486

LAMBETH DATANET PROVISIONAL

DATAThe number (%) of people with hypertension and othe r co-morbid conditions (practices n =50/52; people on hypertens ion regin = 32,183 data extracted from 31/03/11)

COMORBIDITY Frequency Percent Cumulative %

Hypertension 19,001 59.04 59.04 Hypertension & Diabetes 4,872 15.14 74.18 Hypertension & CKD 2,189 6.80 80.98

25

Hypertension & CKD 2,189 6.80 80.98 Hypertension & CHD 1,402 4.36 85.34 Hypertension, CKD & Diabetes 1,016 3.16 88.49 Hypertension & Stroke 892 2.77 91.27 Hypertension, Diabetes & CHD 708 2.20 93.47 Hypertension, CKD & CHD 405 1.26 94.72 Hypertension, Stroke, Diabetes & CHD 357 1.11 95.83 Hypertension, Stroke & Diabete 351 1.09 96.92 Hypertension, CKD & Stroke 272 0.85 97.77 Hypertension, Stroke & CHD 218 0.68 98.45 Hypertension, CKD, Stroke & Diabetes 177 0.55 99.00 Hypertension, CKD, Stroke, Diabetes & CHD 112 0.35 99.34 Hypertension, CKD, Stroke & CHD 110 0.34 99.69 Hypertension, CKD, Diabetes & CHD 101 0.31 100.00 Hypertension, CKD, Stroke, Diabetes & CHD 0 0 TOTAL 32,183 100.00

Challenges in Hypertension

Management

�Diagnosis – finding your patient, tests and investigations

�Lifestyle changes�Lifestyle changes

�Assessing CV risk

�Drug therapies

�When to use

�What to use

�Monitoring

�Adherence

Hypertension

NICE 2011 - diagnosis update

Dr Eric CAJEAT

NHS Lambeth CVD Lead

GPwSI Cardiology (MD, PGD Cardiology)

HypertensionNICE 2011 - diagnosis update

1. The new diagnosis paradigm: Ambulatory Blood Pressure Monitoring (ABPM):

a. From the old to the new paradigm, understanding the rationaleb. ABPM gives you “a lot more”!c. ABPM: is good or better than CBPM?d. ABPM: technical considerations in briefe. ABPM report: key points

2. Home Blood Pressure Monitoring:a. When to consider?b. HBPM: technical considerations

3. Practical issues:a. Always confirm diagnosis of hypertension with ABPM (or HBPM)?b. Patients with AF: ABPM?c. Monitoring hypertension: how?d. BP thresholds to remember

4. Case studies

From the old to the new paradigm,

understanding the rationale

The old paradigm: a poor estimate of the “real BP”

“To identify hypertension (persistent raised blood pressure, above 140/90 “To identify hypertension (persistent raised blood pressure, above 140/90 mmHg), ask the patient to return for at least two more appointments; check blood pressure twice on each occasion, under the best conditions available.

Take measurements at monthly intervals – but if the patient has severe

hypertension re-evaluate him or her earlier.” NICE CG34 –June 2006

1. Physiological BP variability:

a. Circadian pattern:

– peak around 6am,

– gradual diurnal decline and further decline at night.

– BP lowest between 2-4am with night systolic and diastolic

From the old to the new

paradigm, understanding the rationale

– BP lowest between 2-4am with night systolic and diastolic

reduction respectively of 13 and 17%.

a. Other factors influencing BP variability:

– Physical activity,

– Consumption of alcohol, caffeine and food,

– Emotional states, such as anxiety, anger….

– Sleep–wake routine

Staessen JA, Fagard RH, Lijnen PJ et al. (1991), Mean and range of the ambulatory pressure in normotensive subjects from a meta–analysis of 23 studies. Am J Cardiology, 67:723–7

2. BP measurement: how accurate in real-world clinical setting?

a. Do we always follow proper BP measurement technique?

• Environment: quiet, comfortable location at normal room temperature

• Patient:� not need to pass urine, not recently have eaten, smoked or taken caffeine or exercise for

at least 30mn before

� Seated calmly for 5mn, back supported and feet flat on the floor,

� Arm: out-stretched, in line with mid-sternum and supported



• Cuff size - inflatable part:� Should encircle at least 80% of the arm

� Width: encircle 40% of arm at midpoint

• Initial BP check: in both arms� BP difference of <10mmHg normal

� If difference >20 mmHg, repeat measurements

� use the arm with the higher reading for subsequent BP measurements

• Subsequent BP check:� 2 readings, at least 1mn apart,

� If more than 5mmHg difference take at least one additional reading, ?average the 2 bestreadings

• If pulse irregular check BP manually

ABPM: understanding the rationale:

Pater Cornel (2005), Beyond the evidence of the new hypertension guidelines. Blood pressure measurement – is it good enough for accurate diagnosis of hypertension? Time might be in for a paradigm shift (I) Additional file: factors that can interfere with accuracy of BP measurement (after McAlistar and Strauss), Current Controlled Trials in Cardiovascular Medicine, 6:6.

Pickering, T.G. at al. (2005), Recommendations for blood pressure measurement in humans and experimental animals, part1: blood pressure measurement in humans, Hypertension, 45, 142-161.

– Cuff size:

� too small: over-estimate

� too large: risk of under-estimate

� Unsupported back: may increase DBP

� Crossing the legs: may increase SBP

b. Other sources of measurement bias:

– Observer bias & large inter-observer variations,

– Improperly maintained or calibrated equipment,

– Rounding error: manual BP reading to nearest 2mmHg upward

– Automated manometer errors: algorithm “vulnerability” with

dependence of the cuff deflation rate to the heart rate

ABPM: understanding the rationale:

dependence of the cuff deflation rate to the heart rate

� Deflation too rapid or heart rate too slow (e.g., in patients treated

with beta-blockers)

� Irregular HR (e.g. AF)

� Elderly individuals with stiff arteries

�Clinical perspective: in VALUE & ALLHAT a BP difference of +/- 2mmHg was clinically significant in terms of cardiovascular outcomes

Julius, S. et al. (2004), outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial, Lancet, 363, 2022-2031.The HALLHAT collaborative group (2002), major outcomes in high risk hypertensive patients randomised to angiotensin converting enzyme inhibitor or calcium channel blocker vs. diuretic: the Antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT), JAMA, 288, 1981-1997.

“If the clinic blood pressure is 140/90 mmHg or

higher, offer Ambulatory Blood Pressure

The new paradigm :



Monitoring (ABPM) to confirm the diagnosis of

hypertension

or Home Blood Pressure Monitoring (HBPM) if

ABPM is declined or not tolerated”

NICE CG 127 – August 2011

1. Provides a BP “profile”

– Multiple measurements over 24 hours

– Mean day time, night time and mean 24 hour systolic & diastolic

ABPM: gives you “a lot more”!

O’Brien E (2010) Ambulatory blood pressure monitoring: 24-hour blood pressure control as a therapeutic goal for improving cardiovascular prognosis, Medicographia, 32, 241-249.

2. Allows identification of:

a. White coat hypertension:

– Def.: Office BP ≥ 140/90 but normal ABMP (<135/85mmHg)

– Prevalence:

� 15-30% of general population

� Especially common in the elderly & pregnant women

– No clinical characteristics to assist in clinical suspicion


b. White coat effect:

� Def.:

�CBPM > mean daytime BP, regardless of actual levels

�By at least 20 mmHg systolic and/or 10 mmHg diastolic

� Leads to over estimate of hypertension severity & over treatment

� Prevalence1:

�More frequent in women / men

� In as many as 73% of treated hypertensive populations


c. Nocturnal hypertension - “dippers & non-dippers”1

– Dippers:

� Normal average difference diurnal/nocturnal BP: 10-20%

� Pattern usually preserved in hypertensive subjects

– Non-dippers:

� Nocturnal fall <10%

� Marker of increased CVD risk� Marker of increased CVD risk

� More common in Blacks

� Multiple causes:

• High day level of activity,

• Poor sleep pattern

• High sympathetic nervous system activity

• Secondary hypertension:

o Use of glucocorticoids,

o Renal disease

1 Pickering, T.G. et all (2006), Current concepts: Ambulatory blood pressure monitoring, NEJM, 354 (22), 2368-2374

d. Masked hypertension:

– Def.:

� Reverse of white coat hypertension

� Normal CBP and raised ABPM

– Prevalence:

� At least 10% of general population1


� At least 10% of general population1

� Tendency to decrease with age

– Higher rate of TOD & higher CV morbidity

– When to suspect2:

� raised CBP at some time,

� FH of hypertension in both parents,

� patient with multiple risk factors for CVD,

� ?diabetic.

1 Pickering TG (2003), Effects of stress and behavioral intervention in hypertension: what is masked hypertension?, Journal of Clinical Hypertension, 5, 171-174.2 O’ Brien E. (2003), Ambulatory blood pressure monitoring in the management of hypertension, Heart, 89, 571-576.

3. Better in “therapeutic challenges”:a. Resistant hypertension:

– Def.: BP consistently above 150/90 mmHg despite being on 3 or more drugs of different pharmacological class (ideally including a diuretic) and at optimal dose

– ABPM could allow identification of:

� White coat phenomenon


� White coat phenomenon

� Absence of nighttime drop which could suggest secondary hypertension

a. Hypertension & pregnancy: high prevalence of white coat hypertension

c. Hypertension in the elderly: various BP patterns are more frequent

» White coat hypertension & white coat effect

» Isolated Systolic hypertension

» Postural hypotension

» Postprandial hypertension


» Postprandial hypertension

» Daytime hypotension / nocturnal hypertension

» Drug induced hypotension

» Autonomic failure


ABPM suggests:- white-coat hypertension (175/95 mm Hg), - normal day time BP (133/71 mmHg)- Optimal nighttime (119/59 mmHg)- Normal dipping pattern.

O’Brien E (2010) Ambulatory blood pressure monitoring: 24-hour blood pressure control as a therapeutic goal for improving cardiovascular prognosis, Medicographia, 32, 241-249.

ABPM suggests:- low daytime PB (100/59 mmHg)- moderate nighttime hypertension (146/89 mmHg)- white-coat effect (181/102 mmHg)- reverse dipping pattern.

ABPM: is it good or better than CBPM?

1. ABPM: good at predicting clinical outcomes

� NICE: ABPM versus CBPM - 9 studies

�ABPM superior to CBPM in 8 studies

�No difference in 1 study

� NICE: ABPM versus HBPM & CBPM - 2 studies

�ABPM & HBPM similar but superior to CBPM in 1 study�ABPM & HBPM similar but superior to CBPM in 1 study

�No difference in 1 study

NICE: “ABPM never inferior at predicting clinical outcomes

& most often the best predictor of clinical outcomes”

� Day or night-time average in predicting outcomes? no conclusive evidence

suggesting superiority of either

� For practical reason: ABPM daytime average preferred

2. Better sensitivity / specificity:

Compared to ABPM as gold standard1:– CBPM sensitivity:

Overall population “restricted” population

� 74.6% (CI 60.7 – 84.8) 85.6% (CI 81.0 – 89.2)

� False negative: 25.4% 14.4%

ABPM: is it good or better than CBPM?

� False negative: 25.4% 14.4%

– CBPM specificity:

Overall population “restricted” population

� 74.6% (CI 47.9 – 90.4) 45.9% (CI 33.0 – 59.3)

� False positive: 25.4% 54.1%

1 Hodgkinson, J. et al. (2011), Relative effectiveness of clinic and home blood pressure monitoring compared to ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review, BMJ, 342:d3621.

ABPM:

technical considerations in brief….

1. Prepare the patient:• Explain the procedure: frequency of inflation, repeat measurement if failed,

how to manually deflate cuff,

• Instruct patient: engage with normal activities between measurements, keep arm steady during measurement and at heart level, not to shower with monitor fitted…monitor fitted…

2. Prepare the monitor:• Frequency of measurements: daytime every 30mns, night time every hour

• Patient’s details

3. Fitting monitor: with appropriate size cuff!!!• Non-dominant arm or ?patient’s preference

• But if BP difference >10mmHg, on the arm with highest BP reading

ABPB report: key points

1. Ensure you have:

� Daytime & Night time BP average

� Minimum data requirement: at least 14 daytime & 7 night time

2. Look at:

� White coat window: ?white coat effect� White coat window: ?white coat effect

� >10% day/night BP reduction: Dipping pattern or not?

� Overall BP variability: any� BP drop

� Large variations

� Rx gap in BP control

QUIZ:

1. When selecting the correct cuff size, the bladder should be large enough (the shorter dimension) to encircle at least what % of the upper arm at mid point?

a. 30%

b. 40%

c. 50%c. 50%

d. 80%

2. Which of the following is true?

a. If you take 2 BP readings and SBP are 134 & 141, the average should be recorded as the SBP?

b. The cuff should encircle 60% of arm circumference?

c. In the absence of a hard surface to rest arm, the patient can hold up the arm during BP reading?

d. Urinary bladder distension can cause significant error in BP reading?

HBPM: when to consider?

“If the clinic blood pressure is 140/90 mmHg or higher,

offer ambulatory blood pressure monitoring

(ABPM) to confirm the diagnosis of hypertension

or home blood pressure monitoring (HBPM)

if ABPM is declined or not tolerated”

HBPM: as good as ABPM?

Pickering, T.G. et al (2006), Ambulatory Blood-Pressure Monitoring, NEJM, 354, 2368-74.

HBPM: as good as ABPM?

Compared to ABPM as gold standard1:

1. HBPM & CBPM have similar sensitivity:

� 85.7% (CI 78.0 – 91.0) versus 85.6% (CI 81.0 – 89.2)

� False negative: 14.3% vs. 14.4%

2. HBPM is more specific than CBPM:

� 62.4% (CI 48.0 – 75.0) versus 45.9% (CI 33.0 – 59.3)

� False positive: 37,6% vs. 54%

3. HBPM has better prognostic value than CBPM.

Overall, ABPM should always be preferred, unless declined or not tolerated

1 Hodgkinson, J. et al. (2011), Relative effectiveness of clinic and home blood pressure monitoring compared to ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review, BMJ, 342:d3621.

HBPM:

technical considerations in brief….

1. Importance of standardised approach:

� Patient seated & relaxed� 2 measurements at 1 minute apart per check� Every morning and evening� Over 4 consecutives days at least (optimally over 7 days)� Over 4 consecutives days at least (optimally over 7 days)

� But also don’t forget to:� Provide right cuff size� Teach patient how to use the monitor….

1. Data analysis:

� Discard 1st day readings� Use all other readings to calculate HBPM average

Always confirm diagnosis with

ABPM (or HBPM)?

1. What if: Systolic BP ≥180 mmHg and/or diastolic BP ≥110 mmHg?

� Do not delay treatment � Do confirm with ABPM or HBPM if not tolerated/declined

� Important to detect possible: � significant white-coat effect� significant white-coat effect� or even masked hypertension

� Significant impact on both treatment & monitoring decision

1. What if: evidence of Target Organ Damage?

� Not always due to hypertension: e.g. LVH & HCM� Could be 2nd to masked hypertension� Higher risk group and ABPM better at prognostic value

Patients with AF: ABPM?

• If good rate control some ABPM monitor might work effectively

• Need for specific validation protocol

• NICE: “Until then MANUAL BP measurement ONLY • NICE: “Until then MANUAL BP measurement ONLY alternative if significant arrhythmia”

Monitoring hypertension: how?

• ALL clinical trials outcomes based on CBPM

• CBPM vs. HBPM: �Meta-analysis: often significant heterogeneity in studies

design & populations

� Interesting “trend”:o Lower achieved CBPM:o Lower achieved CBPM:

• Systolic -3.82 mmHg (CI -5.61 to -2.03), diastolic -1.45 mmHg (CI -1.95 to -0.94)1

• Systolic -2.63 mmHg (CI -4.24 to -1.02), diastolic -1.68 mmHg (CI -2.58 to -0.79)2

• Systolic -2.2 mmHg (CI -0.9 to 5.3), diastolic -1.9 mmHg (CI 0.6 to 3.2)3

o Higher likelihood of achieving CBP target• 9% (CI 1.02 - 1.16)1

• 11% but not SS2

• But high cost

• NICE: use CBPM, except in patients with identified white coat effect consider ABPM/HBPM

1 Bray E.P. at al. (2010), Does self-monitoring reduce blood pressure? Meta-analysis with meta-regression of randomized controlled trials.Annals of Medicine, 42(5):371-862 Agarwal R. et al. (2011), Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension, 57:29-383 Cappuccio F.P. et al. (2004), Blood pressure control by home monitoring: meta-analysis of randomised trials. BMJ, 329:145-151.

Hypertension:

BP thresholds to remember!

1. Diagnosis:

� CBPM: ≥ 140/90 mmHg� ABPM / HBPM: ≥ 135/85 mmHg

2. Treatement Target BP:

� CBPM: � People aged under 80 yo: <140/90 mmHg� People aged 80 yo and over: <150/90 mmHg

� ABPM / HPBM:� People aged under 80 yo: <135/85 mmHg� People aged 80 yo and over: <145/85 mmHg

Case study 1: Martha

• 40 YO woman, white British

• High BMI (44.38)

– BP check for POP:179/105mmHg (08/09/11)

– Previous BP values:� 135/93 mmHg (07/10/08)� 135/93 mmHg (07/10/08)

� 175/10 mmHg (08/10/09)

� 149/96 mmHg (12/01/10)

� 142/87 mmHg (05/02/10)

� 169/101 mmHg (01/08/11)

� 179/122 & 180/106 mmHg (30/08/11)

• Previously on COC but changed to POP in view of BP readings:

� 151/94 mmHg (25/05/06)

� 140/98 mmHg (30/06/06)

� What do you do next?

a. Start hypertension treatment with ACE-Inhibitor

b. Start hypertension treatment with ARBc. Start hypertension treatment with calcium

antagonistd. Request ABPM


Step 4


drug treatment


Aged under55 years

C2A

A + C2

A + C + D



beta-blocker 5


Step 1

Step 2

Step 3





• 179/105mmHg (08/09/11)

– Previous BP values:

� 135/93 mmHg

� 175/10 mmHg

� 149/96 mmHg

� 142/87 mmHg

� 169/101 mmHg

� 179/122 & 180/106 mmHg

• Previously BP while on COC:

� 151/94 mmHg

� 140/98 mmHg

Only 8 daytime readings!Only 8 daytime readings!And 7 nighttime readings…

White coat hypertension or not?

Case study 2: Mary

• 50 YO woman, newly registered

• White british

• PMH:

� Hypertension (2009)

� CKD 2 (2009)

� Right Nephrectomy (2000) following sepsis &

Kidney stones

� TIA in 2009 but unproven?

� Severe depression / agoraphobia / panic

� Rx: � Amlodipine 10mg (but not taking)

� Atenolol 75mg

� Doxazosin 2mg

� Ramipril 10mg

� Simvastatin 40mg

� Citalopram 40mg

� BP readings:� Severe depression / agoraphobia / panic

attacks

� Smoker (10/day)

• FH:

� Premature IHD (sister, brother)

� Stroke (brother)

� Hypertension (mother, brother, uncle)

� Diabetes (mother, maternal grandmother)

� BP readings:� 208/99 mmHg, pulse 89 (1st practice BP reading)

� Subsequent readings:

165/95 mmHg,182/99 mmHg, 167/69 mmHg

� Bloods:� eGFR: 67mL/min, Creat 79umol/L

� Glucose: normal, TSH normal

� Lipids: TC 6.4 mmol/L, HDL-C 1.24 mmol/L, direct LDL-C 3.92 mmol/L, TG 3.92 mmol/L


a. Increase Atenolol to 100mg OD

b. Increase Doxazosinc. Change ACE-inhibitor for an ARBd. Start a diuretice. Re-start a calcium antagonist

Aged over 55 years

• 50 YO woman, White british

– Rx:

Step 4


drug treatment


Aged under55 years

C2A

A + C2

A + C + D



beta-blocker 5


Step 1

Step 2

Step 3




– Rx: � Amlodipine 10mg (but not taking)

� Atenolol 75mg

� Doxazosin 2mg

� Ramipril 10mg

� Simvastatin 40mg

� Citalopram 40mg

– BP readings:� 208/99 mmHg, pulse 89 (1st

practice BP reading)

� Subsequent readings:

165/95 mmHg,182/99 mmHg, 167/69 mmHg

1. Initial management:

� Reinforce life-style advice

� Referred to practice stop smoking advisor

� Compliance discussed

� Declined diuretic, Amlodipine re-started (5mg) > notes checked “not tolerated” > agreed after discussion with patient of benefit of new trial at lower dose

� Recheck fasting lipid profile

2. Subsequent follow-up:

� BP: 215/86 & 160/80 mmHg > Atenolol stopped, changed for Nebivolol 5mg OD

� BP: 164/81 mmHg & 150/69 mmHg > dose Amlodipine increased to 10 mg

� Renal physician review > Nebivolol increased to 10mg OD

� BP:163/81 &187/105mmHg > Compliance discussed / switch to dosette box & ABPM requested

� DNA ABPM twice and then left due to panic attack….

1. Resistant hypertension:

� Always exclude white coat effect & poor compliance

� Address lifestyle factors

2. Management plan:

� Chlorthalidone 25mg OD started� Chlorthalidone 25mg OD started

� If necessary: � Up titrate Doxazosin

� Introduce low dose spironolactone

Case study 3: Dennis

• 46 YO man, afro-caribbean

• PMH:

� Hypertension (1999)

� Chest pain & SOB (2006) > normal

angiography

� Gout (2009)

� Rx:

� Amlodipine & Valsartan 10/160mg OD� Bisoprolol 2.5mg OD� Simvastatin 40mg OD� Aspirin 75mg OD� Olanzapine 7.5mg OD� Gout (2009)

� Hep B carrier

� Single episode psychotic depression (2009)

� ED

� CVD risk 26% (2006 calculation based on pre-Rx BP values

& actual lipids)

� Ex-smoker (stopped 12 years ago)

� Olanzapine 7.5mg OD� Allopurinol 100mg OD� Citalopram 20mg OD

� Recent BP readings:� 143/96 mmHg� 154/98 mmHg� 146/96 mmHg


a. Increase beta-blocker

b. Stop beta-blocker

c. Add a thiazide like diureticd. Add doxazosine. Add spironolactonef. Review compliance & re-

enforce lifestyle adviceg. Request ABPM

� Rx:

� Amlodipine & Valsartan 10/160mg OD� Amlodipine & Valsartan 10/160mg OD� Bisoprolol 2.5mg OD� Simvastatin 40mg OD� Aspirin 75mg OD� Olanzapine 7.5mg OD� Allopurinol 100mg OD� Citalopram 20mg OD

� Recent BP readings:� 143/96 mmHg� 154/98 mmHg� 146/96 mmHg

Step 4


drug treatment


Aged under55 years

C2A

A + C2

A + C + D



beta-blocker 5


Step 1

Step 2

Step 3




� No detailed report sent

� BP on treatment target� Non-dipper

How to get your hypertension

QOF target? QOF upper threshold: 80%

1. Clear you register from ghost patients!

2. Medications:� On repeat once “happy” & no SE

� Do not use nbr of issues > ?PCS but use “0”

� Reduce quantity for late/poor attender once medication review over due

3. Medication review date: 3. Medication review date: � Every 6 months (QOF every 9/12 BUT this will allows for late or poor attender!)

� Set up at “1st” of a month

4. Recall system:� Use clinical system follow-up review date for hypertension

� But mainly using medication review as a prompt

5. Up titration: every 3-4 weeks, keep the momentum going!

6. White coat hypertension / WCE:� Once formally documented use clinical judgement when doing CBPM values

� Use HBPM/ABPM as per NICE guidance

� ?Exception reporting

Hypertension and Prescribing

An Update An Update

Helen Williams

Consultant Pharmacist for CV Disease

South London

Hypertensive patients are at increased risk of

cardiovascular events Framingham Heart Study – Risk of cardiovascular events by hypertensive status in patients aged 35-64 years; 36-year follow-up

45.4

40

50

Normotensive

Coronary

diseaseStroke Peripheral artery

diseaseCardiac failure

ate

pe

r 1

00

0

9.5

3.3 2.45

23.5

2.1

21.3

12.4

6.2

9.97.3

13.9

6.3

22.7

0

10

20

30

Men Women Men Women Men Women Men Women

Normotensive

Hypertensive

Bie

nn

ial a

ge

-ad

just

ed

ra

te p

er

10

00

Blood pressure as a risk factor for CHD mortalityBlood pressure as a risk factor for CHD mortality

256

128

64

32

(floating abso

lute risk an

d 96%

CI) 256

128

64

32

Systolic blood pressure Diastolic blood pressureAge at risk:

80–89 yrs

70–79 yrs

60–69 yrs

50–59 yrs

Age at risk:

80–89 yrs

70–79 yrs

60–69 yrs

50–59 yrs

75Lewington et al. Lancet 2002

16

8

4

2

1

120 140 160 180

Usual systolic blood

pressure (mm Hg)

IHD m

ortality

(floating abso

lute risk an

d 96%

CI

16

8

4

2

1

70 80 90 100

Usual diastolic blood

pressure (mm Hg)

110

40–49 yrs 40–49 yrs

NICE 2011 – Drug Therapy

• Antihypertensive drug therapy should be used if:

– BP >160/100mmHg or more

– BP > 140/90mmHg and high CV risk – BP > 140/90mmHg and high CV risk

• High CV risk:

– CVD risk > 20% (CHD risk > 15%)

– Or established CV disease

– Or target organ damage (i.e. HF, MI, stroke, retinopathy)

– Or diabetes

Summary of

antihypertensive

drug treatment

Aged over 55 years or

black person of African

or Caribbean family

origin of any age Aged under

55 years

C2A

A + C2

Step 1

Step 2Key

A – ACE inhibitor or low-cost

angiotensin II receptor blocker

Step 4

A + C + D


A + C + D + consider further diuretic3, 4

or alpha- or

beta-blocker5


Step 3


(ARB)1

C – Calcium-channel blocker

(CCB)

D – Thiazide-like diuretic

ACE inhibitors or

‘Low Cost’ ARBs at Step One

� Three new head to head RCTs demonstrating equivalent efficacy with fewer drug withdrawals with ARBs

� Patent expiry has improved the cost-effectiveness of ARBs

� ARBs currently make up >50% of the costs of anti-hypertensive � ARBs currently make up >50% of the costs of anti-hypertensive therapy ; but constitute <10% of the total volume of prescribing

� What is a ‘low cost ‘ARB?

� Currently generic losartan is equivalent in cost to ACEI

� Patent expiries: valsartan (2011); candesartan (2012), irbesartan(2012)

� (Do not combine ACEi and ARB for hypertension treatment)

Calcium Channel Blockers preferred to

thiazide-type diuretics

� In most scenarios modelled Calcium Channel blockers are the most cost-effective option first-line� Most CCBs have become generic since 2006 guidance –� Most CCBs have become generic since 2006 guidance –

higher cost CCBs not cost-effective

� ACEi plus CCB preferred at Step 2� reduced MI further than ACEi plus diuretics and was

better tolerated

� Thiazide-like diuretics should be considered as an alternative in patients at high risk of oedema / heart failure

Low Cost ARBs preferred at Step 2 for People of

Black African or Caribbean Family Origin

� Increased risk of angioedema with ACEi

� Although risk is still small; a low-cost ARB is suggested as preferable to an ACEI in this group of patients (at Step 2)

Thiazide-Like Diuretics

(Indapamide / Chortalidone) Preferred

� Bendroflumethazide used routinely in the UK and rarely in the rest of the world� Low doses used to minimise electrolyte and metabolic

disturbances with therapydisturbances with therapy

� BDZ outcome studies used higher doses (10mg) – no evidence for 2.5mg low dose which is used routinely

� Evidence of an outcomes benefit with low dose indapamide or chlortalidone

� New patients should be initiated on a thiazide-like diuretic – but no need to switch well-controlled pts

Resistant Hypertension

• Likely to affect 500,000 people in the UK– Older with co-morbidities and therefore high CV risk

– Paucity of clinical data

• Low-dose spironolactone effectively reduces BP in resistant hypertension, but no data on outcomesresistant hypertension, but no data on outcomes– Caution: gynaecomastia, hyperkalaemia, renal

dysfunction

• If spironolactone unsuitable consider:

– high dose thiazide like diuretic

– alpha-blockers

– beta-blockers

Don’t Forget.......

• CV risk assessment

• Appropriate use of statins• Appropriate use of statins

• Lifestyle advice

• Adherence counselling

Summary of

antihypertensive

drug treatment



or Caribbean family


55 years

C2A

A + C2

Step 1

Step 2Key



Step 4

A + C + D



or alpha- or

beta-blocker5


Step 3


(ARB)1


(CCB)


James

� Aged 84yrs old

� Black Caribbean origin

� Untreated blood pressure: 182/110mmHg

� Started on amlodipine 5mg daily, � Started on amlodipine 5mg daily, and increased to 10mg one month ago

� Also on diclofenac 50mg tds for joint pain

� Review today:

� BP 164/96mmHg

What next?

Ethnicity and Hypertension

� Increased prevalence in people of black African and Caribbean family origin

� Higher stroke incidence as a result

� Earlier onset – not uncommon in 30’s / 40’s� Earlier onset – not uncommon in 30’s / 40’s

�Respond less well to renin-angiotensin system blockers (low renin levels)

�Often resistant to treatment and require multiple therapies

� But also check adherence!

Summary of

antihypertensive

drug treatment



or Caribbean family


55 years

C2A

A + C2

Step 1

Step 2Key



Step 4

A + C + D



or alpha- or

beta-blocker5


Step 3


(ARB)1


(CCB)


Next Steps

• On a ‘C’ drug; so add an ‘A’ drug

– Which one?

• Increased risk of angioedema with ACEi in

black peopleblack people

– Use a ‘low cost ARB’ instead

– Started losartan 50mg daily

– Monitor renal function and electrolytes in 2 weeks

– Review in one month

James

• One month review� BP 152/89mmHg

�What is the BP target

here?

Epidemiological Evidence

� Studies have suggested that blood pressure and

risk of death are inversely related in older people

� low systolic blood pressure (BP) was associated with

risk of death (Rastas et al 2006)

� In men age 85 and older, higher systolic blood pressure

is associated with better survival (Satish et al 2001)

� ...a fall in diastolic pressure of 5 mm Hg was associated

with poor survival in men after age 75. This risk was

strongest in men who took antihypertensive

medication (Langer et al 1993)

RCT Data

Until recently. RCT data for elderly patients has

been limited as either:

�Older people (>80 years) have been excluded�Older people (>80 years) have been excluded

�The numbers of older people recruited have

been too small to show any treatment effect

in the sub-group

+ Perindopril 4 mg

The Trial:

International, multi-centre, randomised double-blind placebo controlled

Inclusion Criteria: Exclusion Criteria:

Aged 80 or more, Standing SBP < 140mmHgSystolic BP; 160 -199mmHg Stroke in last 6 months+ diastolic BP; <110 mmHg, DementiaInformed consent Need daily nursing care

Primary Endpoint:All strokes (fatal and non-fatal)

Placebo

Placebo

+ Placebo

+ Placebo

Indapamide SR 1.5 mg

+ Perindopril 2 mg

M-2 M-1 M0 M3 M6 M9 M12 M18 M24 M60

Target blood pressure

150/80 mmHg

Blood pressure separation

130

140

150

160

170

180B

lood

Pre

ssur

e (m

mH

g)

Placebo

15 mmHg

70

80

90

100

110

120

0 1 2 3 4 5

Follow-up (years)

Blo

od P

ress

ure

(mm

Hg)

Indapamide SR +/-perindoprilIMedian follow-up 1.8 years

6 mmHg

All stroke(30% reduction)

P=0.055

PlaceboIndapamideSR ±perindopril

Indapamide SR

± perindopril

Total Mortality(21% reduction)

P=0.019

Indapamide SR

±perindopril


Heart Failure(64% reduction)

P<0.0001

IndapamideSR

±perindopril


James

• One month review� BP 152/89mmHg

�What is the BP target

here?here?

� Aim for <150/90mmHg

� Increase losartan to 100mg

daily

�Reinforce adherence

�Drugs and lifestyle

The Scale of the Problem

An estimated 50% of medicines for chronic conditions are not for chronic conditions are not taken as prescribed

There are many reasons why people don’t get the most out of medicines

Barriers to optimal use of medicine

Professional

Practical

Examples

Inappropriate prescribingMistakes in dispensing or administration

ForgetfulnessInability to open containers

Information

Lifestyle choices

Beliefs about

medicine

Instructions not understoodPoor understanding of condition/treatment

Unpleasant side effectsInconvenienceNo perceived benefit

UnnaturalAddictivePoisonousDiminishing efficacy

• Those heart tablets make me go to the toilet too often – its really inconvenient if I want to go out, so I only take them every other day

• I can’t do without the pain killers, laxatives or inhalers, but my heart feels fine so I don’t take those heart pills everyday, just if don’t take those heart pills everyday, just if I feel a little ‘off-colour’

• I don’t think medicines are a good idea, they are so unnatural and only cause problems in the long-term – the body can heal itself if it is given time

Health professionals instruct more than

elicitPerceived and actual frequency %

Provide instructions

for taking the

medication

62

87

40

Communication

Discuss side-effects

GP Estimate

Observed

Doctors

underestimate

the degree to

which they

‘instruct’

31

49

34

Discuss side-effects

of the medication

Discuss patient’s

ability to follow

treatment plan

Find out what

patient thinks about

treatment plan

49

8

Doctors

overestimate the

degree to which

they consult and

elicit their

patient’s views

Source: Makoul G, Arntson P, Schofield T. (1995) Health promotion in primary care: physician-patient communication and

decision making about prescription medications. Soc Sci Med ; 41 (9): 1241-1254.

Hypertension and the Practice

NurseNurse

Wednesday 18th April 2012

Ruth Jeffery

Nurse Practitioner

The Practice Nurse’s role

Diagnosis

Correct technique!!!technique!!!

Aneroid or electronic?

24hr ambulatory or 4-7/7 HBPM?

To palpate or not?

Algorithm

Irreg pulse?

Investigations

+ ACR

Risk

MI

Practice-based hypertension clinic?Experience

Confidence

Familiarity

Follow up

TimeLifestyleReferralsSp. adviceDNAsFollow up Sp. advice

Prescriber?de facto prescribing?

DNAs

Nurse Prescriber

Case management

• ACD (resist Bendroflumethiazide)

• Follow up• Follow up

• ADRs – try another brand in same drug group?

• Combinations and ethnicity

• Resistant hypertension

• Women of childbearing age

Case Study – why?

30 year old male Asian

Married

Smokes 20/daySmokes 20/day

BMI 27

TATT

BP 147/94mmHg

24hr ambulatory confirms hypertension

Case Study - difficult choices

42 year old female Black African

New diagnosis T2DM

BP 168/100mmHg

HbA1c 11%

BMI 40

Cholesterol 7mmol/L

Non smoker

Case Study – resistant hypertension?

72 year old female Black Caribbean

Medications:Medications:

Ramipril 10mg

Amlodipine 10mg

Bendroflumethiazide 2.5mg

BP 176/98mmHg

CVD Education Programme:

HypertensionHypertension

Dr Andrew Webb

Senior Lecturer/ Consultant

Clinical Pharmacology

Challenges in Hypertension

Management

�Diagnosis – finding your patient, tests and investigations

�Lifestyle changes�Lifestyle changes

�Assessing CV risk

�Drug therapies

�When to use

�What to use

�Monitoring

�Adherence

CVD Education Programme:

HypertensionHypertension

Dr Andrew Webb

Senior Lecturer/ Consultant

Clinical Pharmacology

Case 1

• 31 y.o. Ghanaian

• Pre-eclampsia 2007,

• Hypertension continued:

• Rx nifedipine – headaches – amlodipine 5 mg • Rx nifedipine – headaches – amlodipine 5 mg

• then bendroflumethiazide – but stopped due

to low K+

• Amlodipine increased to 10 mg

Case 1

• S/B Prof Ritter 2008:

• Renin <0.2 pmol/mL/H (2.8-4.5)

• aldosterone 460 pmol/L (200-800)

• 24h ABPM: Day mean 135/87, night 123/82• 24h ABPM: Day mean 135/87, night 123/82

– +White coat; Clinic BP 152/82

• CT adrenals – normal

• ...Lost to follow-up...

Case 1

• Did not attend GP surgery until Nov 2011:

• BP 200/110;

• K+ 2.5;

• Had stopped amlodipine 2010 • Had stopped amlodipine 2010

– headaches + home SBP ?90 on Rx

• Amlodipine 5 mg od restarted, on norgeston

• Re-referred...

Case 1

• Dr Webb: 9 Feb 2012:

• Fluid intake: 4 L bottled water + 500 mL orange juice, + 330 mL coke/ day!

• Episodes of tiredness, weakness, aching

• BP: L: 181/115, 180/114, 181/106, 172/105• BP: L: 181/115, 180/114, 181/106, 172/105

• R: 180/113, 176/109, 162/104, 173/114; HR82

• soft 1st HS + ESM Aortic – carotids/precordium,

• +/- bruit: aortic/ renal

• AV nipping (Grade II)

• 2+ pr, 2+ blood

Case 1

• ECG – QTc 495 ms

• K+ 2.7, Cr 68

• MRI adrenals + MRA renal arteries requested,

• Sando K 2 bd for 3 days• Sando K 2 bd for 3 days

• Spironolactone 25 mg od, to start

Case 1

• Dr Webb: 29 Feb 2012: K+ 3.1,

• Spiro only started 4 days prior, BP still 170/120

• Aldosterone 866 (100-800 pmol/L)

• Renin 1 mU/L (5.4-60)• Renin 1 mU/L (5.4-60)

Case 1

• MRI Adrenal Both :

• 17 mm nodule - left adrenal

• shows marked signal drop out on the in and out of phase sequences but does not enhance.

• Appearances in keeping with an adrenal • Appearances in keeping with an adrenal adenoma

• MRA Renal artery:

• Single right and single left renal artery.

• normal calibre.

Case 1

• Amlodipine 10 mg

• Home BPs 129-158/92-100

• Clinic BP 164/99

• Discussion at endocrine/radiol MDT 17/04/12 • Discussion at endocrine/radiol MDT 17/04/12

– for adrenalectomy

Case 2

• Referred Oct 2010,

• Age 37 Severe resistant hypertensive 2006

• Headache - ? Nifedipine, leg cramps

• Multiple pathology: Takayasu’s arteritis, +veanticardiolipin Abs, anticardiolipin Abs,

• Bilat internal carotid artery + subclavian stenosis

• Osteoporosis

• K+ fell from 4.2 to 3.2 after 1 week BFZ

• Cr 56, eGFR 108

• MRA - renal arteries N

Case 2

• Ramipril 10 mg od, Nifedipine LA 20 mg od (max

tolerated), BFZ 2.5 mg od, Doxazosin 16 mg bd,

• Azathioprine, prednisolone, ASA 75 od,

omeprazole, Ca + vit D, omeprazole, Ca + vit D,

• Mycophenolate stopped - considering pregnancy

• Clinic BP 182-209/98-112,

• HBPM: 165-212/90-95

• What next...?

Case 2

• ?Na retention – steroids, low K

• Amiloride 20 mg (not to become pregnant)

Case 2

• ?Na retention – steroids, low K

• Amiloride 20 mg (not to become pregnant)

• HBPM 150-165/90

• Clinic BP 177-182/101-108, HR 104-110• Clinic BP 177-182/101-108, HR 104-110

• Renin 80.4, Aldo 242, N urine mets

• Not keen to increase amiloride (headaches)

• Add spironolactone 25 mg od

Case 2

• spironolactone 25 mg od – improved ankle swelling

• BP 198-176/117-105

• ABPM – Day 191-103, HR 129, Night 187/94 HR 111

• ABPM – Day 191-103, HR 129, Night 187/94 HR 111

• Add bisoprolol

• CMR – aPWV 8.1 m/s,

• LVH, Wall motion AbN’s - diffuse fibrosis

• But Takayasu’s accel coronary atheroclerosis

Case 2

• Angiography: Baseline i.a. ISDN

• Central Aortic BP 184/91 166/83

• Brachial BP 165/95 146/90

• Did not tolerate ISMN mr 30 mg od

• Tolerates GTN patch, folic acid

Case 2

• Bisoprolol now up to 10 mg bd

• Clinic BP 212-195/102-95 HR 110

• What next?• What next?

• Admission for observed tablet taking?

• MRI brainstem

Case 2

• Bisoprolol now up to 10 mg bd

• Clinic BP 212-195/102-95 HR 110

• What next?

• Admission for observed tablet taking?• Admission for observed tablet taking?

• MRI brainstem

• Clonidine 25 mcg tds, increase by 25 mcg

• Clonidine

• 25: 176/101

• 50: 182/101

• 75: 157/78• 75: 157/78

• 100: Clinic BP 140/74, HR 64

• But half-asleep

• 1 espresso every morning

Case 2

• Admission with UTI, cellulitis

Clonidine (100 microg)

Systolic BP

0

5

10

BP

(m

m H

g)

-1 0 1 2 3 4 5 6

-10

-5

0

24

ControlBeetroot Juice

‡‡

†††

‡‡‡

‡ ‡

‡‡

Time (h)

∆∆ ∆∆B

P (

mm

Hg)

Webb A. et al., Hypertension 2008;51:1-7

Case 2

• Clonidine 100, 100, 200

• Clinic BP 132/70

• Ramipril,

• Carvedilol 25 mg od (gluc intoler)• Carvedilol 25 mg od (gluc intoler)

• Spiro 25

• Stopped: BFZ, nifedipine, amiloride, dox, GTN patches, furosemide

Case 3

• 42 y.o. Woman

• Severe resistant hypertension, migraine,

• Obese BMI 38.7

• Candesartan 32, propranolol 80, furosemide• Candesartan 32, propranolol 80, furosemide

20, doxazosin 4 mg bd,

• BP211-183/130-120

Case 3

• Raised normetdrenaline 4.09 nmol/L (<3.3)

• Daytime somnolescence: ESS 10/24

• Sleep studies – OSA

• Commenced CPAP• Commenced CPAP

• BP improved 150/95

• Pseudophaeochromocytoma

FDR, 63 yrs,married politician

• C/O: Terrific headache

51 yrs- 136/7854 yrs- 162/9854 yrs- 162/9859 yrs- 188/10562 yrs- 226/118 short of breath at rest

and LV strain

Clinical course• 12- 4-1945• Sudden loss of conciousness• 300/190- died• No autopsy but difficult to embalm-heavy smoker• ?renovascular hypertension• NEJM 1995, 332:1038-1039.

Roosevelt’s blood pressure (Breunn) Messerli NEJM

1945

Yalta Conference

Case: Young hypertensive

• Age 35

• Asymptomatic,

• Grade 1

• Further Assessments – PWV: 8.4 m/s• Further Assessments – PWV: 8.4 m/s

• Reference range: normotensive: 5.2-8.0 m/s

1.3 240412 Hypertension event-presentation-FINAL · PDF file5/1/2012 · GPwSI Cardiology (MD, PGD Cardiology) Hypertension ... Cardiology , 67:723–7. 2. BP measurement: how...

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