hypertension what to do when you don’t know what to do! fiona stewart auckland heart group...
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HypertensionWhat to do when you don’t know what to do!
Fiona StewartAuckland Heart GroupAuckland City Hospital
2nd Sept 2011
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Essential Hypertension BP < 140/85
Hypertension withDiabetes BP < 130/80Renal disease BP < 130/80Proteinuria > 1g/d BP < 125/75
Age > 80 BP < 150/
HypertensionNZ Heart Foundation Recommendations
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Correct cuff size Sitting x2 at 2 minute intervals Standing
BUT in patients with borderline BPs Single recordings are unreliable Multiple clinic recordings correlate poorly with ABU Home BP monitoring is not much better
ConsiderRepeat visitNurse check (“white coat hypertension”)Home BP monitoringAmbulatory 24hr BP monitoring
Blood Pressure Measurement
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Home BP Measurements
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Ambulatory Blood Pressure Monitoring
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History◦ Other illnesses (cardiovascular disease,
diabetes, renal disease, gout)◦ Family history
Lifestyle assessment◦ Smoking, alcohol (max 1-2/d) salt intake,
liquorice ingestion, weight, exercise, stress Basic tests
◦ FBC, U + E, urate, creat, eGFR, gluc, lipids, MSU◦ ECG
Blood Pressure Review
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Indication◦ Abnormal screening tests◦ Young ◦ BP severe or hard to control
Renin, aldosterone, cortisol 24h U metanephrines Renal scan and doppler study Echocardiogram – LVH, ascending aorta
Blood Pressure ReviewAdditional Tests
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Linear increase in risk from BP 115/75
↑20mmHg SBP or ↑10mmHg DBP doubles mortality from cardiovascular disease
BP 120-139/80-89 “prehypertension”
Prehypertension
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Weight Salt intake (including soya sauce) Liquorice ingestion Alcohol Stress Exercise Contributing drugs (NSAIDs)
Prehypertension Management
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Systolic BP better predictor of adverse cardiovascular events especially in elderly
Persistent BP > 140/85 → treat
Over 80 years – aim for SBP<150◦ Always check standing BP
Hypertension - Treatment
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Chlorthalidone 12.5 – 25mg Amlodipine Lisinopril Doxazosin
Which Antihypertensive is Best?ALLHAT Trial
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Doxazosin or Chlorthalidone?ALLHAT Trial
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ALLHAT TrialDoxazosin and Chlorthalidone
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ALLHAT TrialBP Control
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Target BP < 140/90 67% achieved target 2/3 were taking 2+ agents 1/4 were taking 3+ agents
Expect to need multiple medications to control BP
ALLHAT Trial
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ALLHAT TrialFatal Cardiac Event and Nonfatal MI
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ACEI + Amlodipine ACEI + Hydrochlorothiazide
ACCOMPLISH Trial
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ACCOMPLISH Trial
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ACCOMPLISH Trial Cardiovascular Events
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21% Reduction in CV death, MI, CVA over 3 years
NNT to prevent one major event = 77
37% were taking > 3 agents
ACCOMPLISH Trial
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Assess comorbidity. Multiple drugs are usually necessary
First Line◦ Thiazides◦ ACEI/ARB◦ CCB
Second Line- Beta blockers
Third Line◦ Spironolactone◦ Alpha blockers◦ Clonidine
Fourth Line◦ Ardian radiofrequency ablation of renal artery
Statin
HypertensionTreatment Choice
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Patients aged > 80 SBP >160mmHg, DBP < 110mmHg Indapamide 1.5mg + Perindopril 2-4mg
vs placebo Target BP 150/80
Treatment of Hypertension in the Very Elderly > 80
HYVET trial
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Blood pressure separation
70
80
90
100
110
120
130
140
150
160
170
180
0 1 2 3 4 5
Follow-up (years)
Blo
od
Pre
ssu
re (
mm
Hg
)
Placebo
Indapamide SR +/-perindoprilIMedian follow-up 1.8
years
15 mmHg
6 mmHg
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All stroke(30% reduction)
PlaceboIndapamideSR ±perindopril
Indapamide
SR
±perindopril
Placebo
P=0.055
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Total Mortality(21% reduction)
Placebo
Indapamide
SR
±perindopril
P=0.019
PlaceboIndapamideSR ±perindopril
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Fatal Stroke(39% reduction)
Indapamide
SR
±perindopril
Placebo
P=0.046
PlaceboIndapamideSR ±perindopril
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Heart Failure(64% reduction)
P<0.0001
Placebo
IndapamideSR
±perindopril
PlaceboIndapamideSR ±perindopril
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0 20.50.20.1
HR 95% CI
0.70 (0.49, 1.01)
0.61 (0.38, 0.99)
0.79 (0.65, 0.95)
0.81 (0.62, 1.06)
0.77 (0.60, 1.01)
0.71 (0.42, 1.19)
0.36 (0.22, 0.58)
0.66 (0.53, 0.82)
All Stroke
Stroke Death
All cause mortality
NCV/Unknown death
CV Death
Cardiac Death
Heart Failure
CV events
ITT – Summary
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Starting Antihypertensive Treatment
Change only one medication at a time Arrange follow up BP measurements (L+S) Check electrolytes with diuretics Escalate early to a second agent Feedback results to the patient
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Confirm hypertension with 24hr monitor Check for secondary causes
◦ Renal scan ? Renal artery stenosis◦ Cortisol, renin, aldosterone, metanephrines
Lifestyle adjustments – stress, salt Compliance Optimal medication dose and frequency
BP Remains Elevated
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Thiazides◦ Chlorthalidone more effective than HCZ
ACEI◦ Cilazapril and lisinopril – daily dose◦ Enalapril and quinapril – bd dose
Angiotensin II Blockers◦ Titrate dose to 32mg candesartan, 100mg
losartan CCBs
◦ Amlodipine and felodipine 10mg
Optimising Medication
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Measurement◦ Sitting◦ DBP 4th Korotkoff sound
DBP <90mmHg from conception to 20/40 is strongly correlated with lower rates of pre-eclampsia
ACEI and ARB are contraindicated from 6 weeks gestation. ACEI are safe with breast feeding.
Metoprolol, oxprenolol and labetalol are associated with a better fetal outcome than other beta-blockers
Methydopa has a long record of safety in pregnancy
CCBs are well tolerated in pregnancy
Chronic Hypertension and Pregnancy
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HypertrophyArrhythmiaOxygen Consumption
VasoconstrictionAtherosclerosis
InsulinResistance
The kidney as origin of sympathetic drive carried centrally via renal afferent sympathetic nerves generating central
sympathetic drive
Renal AfferentNerves
↑ Renin Release RAAS activation↑ Sodium Retention↓ Renal Blood Flow
Sleep Disturbances
Renal EfferentNerves
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Radiofrequency energy can ablate the renal sympathetic nerves
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• First-in-man, non-randomized
• 45 patients with resistant HTN (SBP ≥160 mmHg on ≥3 anti-HTN drugs, including a diuretic)
Expanded cohort of patients (n=153)
• 24-month follow-up
Lancet. 2009;373:1275
35
Symplicity HTN-1
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Significant, Sustained BP Reduction
BP change(mmHg)
1 M(n=138)
3 M(n=135)
6 M(n=86)
12 M(n=64)
18 M(n=36)
24 M(n=18)
-50
-40
-30
-20
-10
0
10
-20 -24 -25 -23 -26 -32-10 -11 -11 -11 -14 -14
Systolic Diastolic
36
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Primary Endpoint: 6-Month Office BP
∆ from Baseline
to 6 Months (mmHg)
33/11 mmHg difference between RDN and Control
(p<0.0001)
• 84% of RDN patients had ≥ 10 mmHg reduction in SBP• 10% of RDN patients had no reduction in SBP
37
Systolic
Diastolic
Systolic Diastolic
Symplicity HTN-2 Investigators. Lancet. 2010;376:1903.
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Changes in Glucose Toleranceat 3 Months after Renal Denervation
Mahfoud et al. European Society of Cardiology. 2010.