welcome to our free weekly webinar! · 2021. 1. 19. · welcome to our free weekly webinar! ways to...
TRANSCRIPT
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Primary Care Series
Hypertension
Presented by:
Mr Innes Eaton
Paramedic Practitioner
18th January 2021
Please make yourself comfortable – this webinar will begin at 1900 GMT
Welcome to our free weekly webinar!
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Ways to Interact
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Primary Care Series | Episode 1 | Hypertension
1. Grab your smart phone
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4. Answer the question
07535 382223
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In the Zoom chat:
STC Admin
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Session Plan
www.stctrainingsolutions.co.uk | 01895 730020 | [email protected]
Primary Care Series | Episode 1 | Hypertension
• Regulation of blood pressure
• The pathophysiology of hypertension
• Diagnosis of hypertension
• Red flags
• NICE guidelines
• Pharmacodynamics of common medications
• Referral into secondary care
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Overview
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Primary Care Series | Episode 1 | Hypertension
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What is Blood Pressure?
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Primary Care Series | Episode 1 | Hypertension
BP
Cardiac Output (Systolic)
Stroke Volume
Preload (EDV)
Blood Volume Venomotor Tone
Afterload (SVR) Contractility
Heart Rate
Systemic Vascular Resistance (Diastolic)
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CNS Control
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Primary Care Series | Episode 1 | Hypertension
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RAAS Control
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Primary Care Series | Episode 1 | Hypertension
Renin
Angiotensinogen
Angiotensin I Angiotensin II
Angiotensin Converting Enzyme
(ACE)
Renin
1. Juxtaglomerular Cells
2. Sympathetic NS
3. Macula Densa Cells
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RAAS Control
www.stctrainingsolutions.co.uk | 01895 730020 | [email protected]
Primary Care Series | Episode 1 | Hypertension
Angiotensin II
Antidiuretic
Hormone
(ADH)
Aldosterone
Angiotensin II: ↑Na+ Reabsorption PCT Aldosterone:↑Na+ Reabsorption DCT/CD
ADH:↑H2O Reabsorption CD
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Primary vs Secondary
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Primary Care Series | Episode 1 | Hypertension
• Primary/essential hypertension: no identifiable secondary cause
• Glomerulonephritis or coarctation of the aorta in the young
• Renal artery stenosis (bruit, rapid ↑creatinine with ACEi/ARB)
• Renal disease (↑creatinine, ↑urine ACR)
• Primary aldosteronism (↑ARR, hypokalaemia)
• Pheochromocytoma (headaches, diaphoresis, labile BP)
• Cushing’s Syndrome (raised urinary cortisol)
• Thyroid dysfunction (TFTs)
• Obstructive sleep apnoea
• Iatrogenic/drug induced (POP/COCP/NSAIDs, steroids, illicit drugs)
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Diagnosing Hypertension
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Primary Care Series | Episode 1 | Hypertension
• Check bilateral BP – use the higher reading• Consider differentials and/or referral if gross difference
• If BP consistently ≥140/90mmHg in clinic• Offer ABPM/HBPM for 7-14 days
• During this time, Ix target organ damage and calculate QRISK3
• Consider secondary causes
• If clinic BP ≥180/120mmHg• Ix target organ damage ASAP and repeat clinic BP within 7 days
• Start antihypertensives immediately if target organ damage identified
• If retinal haemorrhage or papilloedema then refer same day (AECU)
• If symptomatic (confusion, CP, HF, AKI) then refer same day (AECU)
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Ix Target Organ Damage
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Primary Care Series | Episode 1 | Hypertension
• ECG – LVH +/- strain
• Renal & electrolytes, urine ACR – CKD
• Hba1c and lipid profile – associated risk factors
• Fundoscopy – retinopathy, papilloedema
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Stages of Hypertension
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Primary Care Series | Episode 1 | Hypertension
• Stage 1• Clinic BP 140/90 – 159/99mmHg
• Stage 2• Clinic BP 160/100 – 179/119mmHg
• Stage 3• Clinic BP ≥180/120mmHg
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Indications for Antihypertensives
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Primary Care Series | Episode 1 | Hypertension
• Any age• Persistent stage 2 hypertension• Caution: frailly and/or multimorbidity (postural hypotension)
• Adults under 80• Persistent stage 1 hypertension with 1 or more of the following:
• Target organ damage• Established cardiovascular disease (CVA/TIA/MI/angina/PAD etc)• Renal disease• DM• QRISK3 ≥10%
• Adults under 40• Additionally consider secondary causes +/- specialist opinion
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Treatment Aims
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Primary Care Series | Episode 1 | Hypertension
• Age
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Non-Pharmacological Options
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Primary Care Series | Episode 1 | Hypertension
• Exercise
• Salt restriction
• Weight loss
• Smoking cessation
• Alcohol reduction
• Relaxation techniques
• High potassium diet
• Lipid management (diet)
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Step 1
Primary Care Series | Episode 1 | Hypertension
T2DM?
Yes
Are they black African/Afro-Caribbean ?
Yes
ARB
No
ACEi
No
Are they black African/Afro-Caribbean?
Yes
CCB
No
How old?
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Step 2
Primary Care Series | Episode 1 | Hypertension
What are they on now?
ACEi or ARB
Add CCB
Or TLD
CCB
Are they black African/Afro-Caribbean?
Yes
Add ARB
Or TLD
No
Add ACEi
Or TLD
TLD
Are they black African/Afro-Caribbean?
Yes
Add ARB
No
Add ACEi
• If ACEi is not tolerated – change to ARB
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Step 3
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Primary Care Series | Episode 1 | Hypertension
• Triple therapy• ACEi
• Or ARB if not tolerated, or if black African/Afro-Carribean
• Plus CCB
• Plus TLD
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Step 4
Primary Care Series | Episode 1 | Hypertension
Measure K+
≤4.5mmol
Add spironolactone
(K+ sparing diuretic)
>4.5mmol
Add α blocker
Or β blocker
• Check for postural hypotension before starting
4th line therapy
• Careful monitoring of electrolytes and renal
function
• Refer to cardiology if hypertension remains
uncontrolled
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ACE Inhibitors (ACEi)
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Primary Care Series | Episode 1 | Hypertension
Common ACE inhibitors include:
• Captopril
• Cilazapril
• Enalapril
• Fosinopril
• Imidapril
• Lisinopril
• Moexipril
• Perindopril
• Quinapril
• Ramipril
• Trandolapril
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ACEi
www.stctrainingsolutions.co.uk | 01895 730020 | [email protected]
Primary Care Series | Episode 1 | Hypertension
Renin
Angiotensinogen
Angiotensin I Angiotensin II
Angiotensin Converting Enzyme
(ACE)
Renin
1. Juxtaglomerular Cells
2. Sympathetic NS
3. Macula Densa Cells
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ACEi
www.stctrainingsolutions.co.uk | 01895 730020 | [email protected]
Primary Care Series | Episode 1 | Hypertension
Angiotensin II
Antidiuretic
Hormone
(ADH)
Aldosterone
Angiotensin II: ↑Na+ Reabsorption PCT Aldosterone:↑Na+ Reabsorption DCT/CD
ADH:↑H2O Reabsorption CD
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Angiotensin Receptor Blockers (ARB)
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Primary Care Series | Episode 1 | Hypertension
Common ARBs include:
• Candesartan
• Eprosartan
• Irbesartan
• Losartan
• Olmesartan
• Telmisartan
• Valsartan
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ARBs
www.stctrainingsolutions.co.uk | 01895 730020 | [email protected]
Primary Care Series | Episode 1 | Hypertension
Angiotensin II
Antidiuretic
Hormone
(ADH)
Aldosterone
Angiotensin II: ↑Na+ Reabsorption PCT Aldosterone:↑Na+ Reabsorption DCT/CD
ADH:↑H2O Reabsorption CD
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Calcium Channel Blockers (CCB)
www.stctrainingsolutions.co.uk | 01895 730020 | [email protected]
Primary Care Series | Episode 1 | Hypertension
Common CCBs include:
• Amlodipine
• Diltiazem (non-DHP)
• Felodipine
• Lacidipine
• Nifedipine
• Nimodipine
• Verapamil (non-DHP)
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CCBs
www.stctrainingsolutions.co.uk | 01895 730020 | [email protected]
Primary Care Series | Episode 1 | Hypertension
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Alpha Blockers
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Primary Care Series | Episode 1 | Hypertension
Common alpha blockers include:
• Alfuzosin
• Doxazosin
• Indoramin
• Prazosin
• Tamsulosin
• Terazosin
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Beta Blockers
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Primary Care Series | Episode 1 | Hypertension
Common beta blockers include:
• Atenolol
• Betaxolol
• Bisoprolol
• Celiprolol
• Co-tenidone
• Esmolol
• Metoprolol
• Propanolol
• Nebivolol
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Alpha & Beta Blockers
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Primary Care Series | Episode 1 | Hypertension
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Case Study
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Primary Care Series | Episode 1 | Hypertension
• 60 y/o female presents with clinic BP of 165/99
• Not known DM, white British
• Average HBPM over 1/52 is 162/95
• ECG = NSR, U&Es/GFR normal range, Hba1c 39, TC 5.2
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Next Session
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Primary Care Series | Episode 1 | Hypertension
Primary Care Series | Episode 2 | Heart Failure
Monday 25th January 2021
19:00 GMT
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Any Questions?
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Primary Care Series | Episode 1 | Hypertension