1.3 240412 hypertension event-presentation-final · pdf file5/1/2012 · gpwsi...
TRANSCRIPT
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
From the old to the new
paradigm, understanding the rationale
• 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 :
From the old to the new
paradigm, understanding the rationale
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
ABPM: gives you “a lot more”!
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
ABPM: gives you “a lot more”!
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
ABPM: gives you “a lot more”!
� 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
ABPM: gives you “a lot more”!
� 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
ABPM: gives you “a lot more”!
» Postprandial hypertension
» Daytime hypotension / nocturnal hypertension
» Drug induced hypotension
» Autonomic failure
ABPM: gives you “a lot more”!
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
• 40 YO woman, white British
Step 4
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
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 1
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
• 40 YO woman, white British
• 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
� What do you do next?
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
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
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 1
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
– 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
� What do you do next?
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
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
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 1
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
� 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
Resistant hypertension
A + C + D + consider further diuretic3, 4
or alpha- or
beta-blocker5
Consider seeking expert advice
Step 3
angiotensin II receptor blocker
(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
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
Resistant hypertension
A + C + D + consider further diuretic3, 4
or alpha- or
beta-blocker5
Consider seeking expert advice
Step 3
angiotensin II receptor blocker
(ARB)1
C – Calcium-channel blocker
(CCB)
D – Thiazide-like diuretic
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
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
Resistant hypertension
A + C + D + consider further diuretic3, 4
or alpha- or
beta-blocker5
Consider seeking expert advice
Step 3
angiotensin II receptor blocker
(ARB)1
C – Calcium-channel blocker
(CCB)
D – Thiazide-like diuretic
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
PlaceboIndapamideSR ±perindopril
Heart Failure(64% reduction)
P<0.0001
IndapamideSR
±perindopril
PlaceboIndapamideSR ±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