Hypertension

Dr. Lucia Mazur-Nicorici MD. PhD

Kieran McGlade Nov 2001 Department of General Practice QUB

 Definition
High risk hypertensive patient means
hypertensive patient with evidence of
atherosclerosis (coronary, cerebral or peripheral)
Or one or more atherosclerotic risk factors
Or with target organ damage
(cardiac, renal, eye or cerebral affection)

Kieran McGlade Nov 2001 Department of General Practice QUB

 Epidemiology
The prevalence of hypertension worldwide is
estimated approximately 1 million individuals
mortality is about 7.1 million decese/an.
According to WHO hypertension is the leading
cause of mortality consequences worldwide.
Although hypertension is more common in
developed countries (37.3%) compared with those
in developing countries (22.9%), hypertensive
largest number in absolute terms the latter is found
in.

Kieran McGlade Nov 2001 Department of General Practice QUB

 ESC Guidelines 2007
Risk stratification
Category Systolic Diastolic
optimal < 120 and < 80
normal 120-129 and/or 80-84
High normal 130-140 and/or 85-89
Stage 1 140-159 and/or 90-99
Stage 2 160-179 and/or 100-109
Stage 3 >180 and/or > 110
ISP >140 and < 90
Kieran McGlade Nov 2001 Department of General Practice QUB
 Aetiology of Hypertension
Primary 90-95% of cases also termed essential of
idiopathic
Secondary about 5% of cases
Renal or renovascular disease
Endocrine disease
Phaeochomocytoma
Cusings syndrome
Conns syndrome
Acromegaly and hypothyroidism
Coarctation of the aorta
Iatrogenic
Hormonal / oral contraceptive
NSAIDs
Kieran McGlade Nov 2001 Department of General Practice QUB
 This left ventricle is very thickened (slightly over 2 cm in
thickness), but the rest of the heart is not greatly enlarged.
This is typical for hypertensive heart disease. The
hypertension creates a greater pressure load on the heart to
induce the hypertrophy.

Kieran McGlade Nov 2001 Department of General Practice QUB

 The left ventricle is markedly thickened in this patient
with severe hypertension that was untreated for many
years. The myocardial fibers have undergone
hypertrophy.

Kieran McGlade Nov 2001 Department of General Practice QUB

 ESC Guidelines 2007:
Risc stratification

Kieran McGlade Nov 2001 Department of General Practice QUB

 Benefits of lowering BP

Average percent reduction

Stroke incidence 35-40%

Myocardial infarction 20-25%

Heart failure 50%

Kieran McGlade Nov 2001 Department of General Practice QUB

 HOT
Hypertension
Optimal
Treatment

Kieran McGlade Nov 2001 Department of General Practice QUB

 H O T Findings
Lowest incidence of major CV events
occurred at a mean achieved DBP of 83
mmHg. This target (compared to mean
achieved of 105 mmHg was associated with
a 30% reduction in main CV events.
In diabetes Diastolic< or = 80mmhg 51 %
lower risk compared to 90 mmHg

Kieran McGlade Nov 2001 Department of General Practice QUB

 Global heart threat from diabetes
A global explosion in the number of cases
of diabetes is threatening to reverse the
reduction in deaths from heart disease in
many western countries, including the
United Kingdom. To coincide with World
Diabetes Day on 14 November, Diabetes
UK is calling for action to be taken to
reduce the 20,000 deaths per year from
coronary heart disease (CHD) among
people with diabetes in the UK.

Kieran McGlade Nov 2001 Department of General Practice QUB

 Hypertension and Diabetes
Hypertension co-exists with type II in about
40% at age 45 rising to 60% at age 75.
70% of type II patients die from cardio-
vascular disease.
At least 60% of patients will require 2 or 3
antihypertensive agents to achieve tight
control.

Kieran McGlade Nov 2001 Department of General Practice QUB

 Stages
Identification of hypertensive patients
Baseline investigations
Initiating therapy
Reviewing patients
Stepping up therapy
Motivation and compliance

Kieran McGlade Nov 2001 Department of General Practice QUB

 Investigation of the New
Hypertensive
History and examination
Exclude secondary Hypertension
Urea and electrolytes
FBP and ESR
ECG
Lipid profile

Chest x-ray no longer routinely indicated

Kieran McGlade Nov 2001 Department of General Practice QUB
 Clinical clues to renal vascular
disease
Hypertension under 50 Yrs of age.
Generalised vascular (esp peripheral)
disease.
Mild moderate renal dysfunction.
Sudden onset pulmonary oedema.

Kieran McGlade Nov 2001 Department of General Practice QUB

 Tailored Approach
Assessment of overall cardiovascular risk
Recognition of co-morbidities
Lipid profile
Renal function
Existing contra- indications

Kieran McGlade Nov 2001 Department of General Practice QUB

Kieran McGlade Nov 2001 Department of General Practice QUB
 Coronary Risk Calculator

Launch risk calculator program

Kieran McGlade Nov 2001 Department of General Practice QUB

Compelling and possible indications and contrindications for
the major classes of antihypertensive drugs

INDICATIONS CONTRAINDICATIONS

CLASSS OF DRUG COMPELLING POSSIBLE POSSIBLE COMPELLING

a-blockers Prostatism Dyslipidaemia Postural Hypotension Unrinary incontinence

Angiotensin converting enzyme (ACE) inhibitors Heart failure Chronic renal disease * Renal impairment * Pregnancy
Left ventricular dysfunction Type II diabetic nephropathy Peripheral vascular disease Renovascular disease

Angiotensin II receptor antagonists Cough induced by ACE inhibitor Heart failure Peripheral vascular disease Pregnancy
Intolerance of other antihypertensive drugs Renovascular disease
Myocardial infarction Heart failure
b-blockers
Angina
Heart failure

Dyslipidaemia Asthma or COPD

Peripheral vascular disease Heart block

Calcium antagonists (dihydropyridine) Isolated systolic hypertension (ISH) in elderly patients Angina _ _
Elderly patients

Calcium antagonists (rate limiting) Angina Myocardial infarction Combination with b-blockade Heart block
Heart failure
Thiazides Elderly patients including ISH _ Dyslipidaemia Gout

* ACE inhibitors may be beneficial in chronic renal failure but should be used with caution. Close supervision and specialist advice are needed when there is established and

significant renal impairment

Caution with ACE inhibitors and angiotensin II receptor antagonists in peripheral vascular disease because of association with renovascular disease.

If ACE inhibitor indicated

f b-blockers may worsen heart failure, but in specialist hands may be used to treat heart failure

Kieran McGlade Nov 2001 Department of General Practice QUB

British Hypertension Society Guidelines 2000
 Therapeutic targets
Measured in clinic Mean daytime ABPM
or home measurement

Blood Pressure No diabetes Diabetes No diabetes Diabetes

Optimal <140/85 <140/80 <130/80 <130/75
Audit Standard <150/90 <140/85 <140/85 <140/80

The audit standard reflects the minimum recommended levels of BP control. Despite best practice, it may not be
achievable in some treated hypertensive patients.
NB: Both systolic and diastolic targets should be reached

British Hypertension Society Guidelines

Kieran McGlade Nov 2001 Department of General Practice QUB
 Logical Combinations

b- ACE a-
Diuretic CCB
blocker inhibitor blocker
Diuretic - -

b-blocker - * -

CCB - * -

ACE inhibitor - -

a-blocker -
* Verapamil + beta-blocker = absolute contra-indication

Kieran McGlade Nov 2001 Department of General Practice QUB

 ACE Inhibitor Side Effects
Cough (15% of patients. Is reversible)
Taste disturbance (reversible)
Angiodema
First-dose hypotension
Hyperkalaemia ( esp. in patients with type
II diabetes and renal dysfunction)

Kieran McGlade Nov 2001 Department of General Practice QUB

 Follow-up
For patients with BP stabilised by management,
follow up should normally be three monthly (interval
should not exceed 6 months), at which the following
should be assessed by a trained nurse:

* Measurement of BP and weight

* Reinforcement of non-pharmacological advice
* General health and drug side-effects
* Test urine for proteinuria (annually)

Kieran McGlade Nov 2001 Department of General Practice QUB

 Drug Treatment of Essential
Hypertension in Older People
Hypertension is very common, occuring in over
50% of older people, and is a major risk factor
for stroke and ischaemic heart disease.
Drug treatment of hypertension in older people
saves lives and prevents unnecessary morbidity.
Treating isolated systolic hypertension also
saves lives.

Kieran McGlade Nov 2001 Department of General Practice QUB

 Drug Treatment of Essential
Hypertension in Older People
There is strong evidence to support the use of diuretics as
first-line agents.
Antihypertensive treatments are most cost-effective when
targeted at older patients.
There is evidence of under detection and under treatment
of hypertension.
Factors influencing patient adherence with treatment are
not well understood and require further research.

Kieran McGlade Nov 2001 Department of General Practice QUB

RECOMMENDATIONS (for the treatment of the elderly)

Through the wider use of antihypertensive therapies more older

people would be able to maintain a healthy and active lifestyle.
Through the wider use of antihypertensive therapies more older
people would be able to maintain a healthy and active lifestyle.
For first-line agents there is strong evidence to support the use of
diuretics and some evidence for the use of beta-blockers.
Systems to ensure that older people with hypertension are
diagnosed, treated and followed up need to be developed.
A system of audit should be cultivated to assure adequate treatment.
High quality research on patient adherence with antihypertensive
medications is needed.
NHS Centre for reviews and dissemination 1999

Kieran McGlade Nov 2001 Department of General Practice QUB

 Practical Points
15 20% of adult western population.
Isolated systolic hypertension just as dangerous.
Primary cause identified in only 5%.
Investigate Urine, FBP, ESR, ECG, U&E, Lipids.
Target < 140/85.
Refer patients needing more than 3 drugs to control their
hypertension.

Kieran McGlade Nov 2001 Department of General Practice QUB

 Este important ca efectul antihipertensiv
al preparatelor utilizate s acopere 24 de
ore. Alegerea preparatelor cu administrare
unic zilnic favorizeaz creterea
complianei la tratament.
Au fost demonstrate i efecte favorabile
ale anumitor medicamente antihipertensive
asupra riscului cardiovascular global, la
pacienii cu valoare TA relative controlate
sau pentru reduceri mici n valoare
absolut ale valorilor TA de pornire .
Kieran McGlade Nov 2001 Department of General Practice QUB
 Antihipertensive cu efect dovedit de reducere a riscului
cardio-vascular independent de reducerea valorilor TA

Medicament Populaia studiat Rezultat Acronim trial

Ramipril Pacieni peste 55 de ani cu risc Reducerea cu 22% a incidenei HOPE la
cardiovascular nalt (istoric de boal evenimentelor cardiovasculare puterea 62
cardiac ischemic, accident vascular
cerebral, boal arterial periferic sau
diabetul zaharat plus cel puin unul dintre
ceilali factori de risc convenionali)
Felodipin Pacieni hipertensivi cu vrste ntre 50-79 Reducere a incidenei eveni-mentelor FEVER la
de ani i risc cardiovascular moderat cardiovasculare cu 28% puterea63
Perindopril Pacieni cu boal coronarian cronic Reducere cu 20% a riscului relativ de EUROPA la
stabil evenimente cardiovasculare puterea64
Nifedipina Pacieni hipertensivi cu angin pectoral Reducere cu 13% a riscului combinat ACTION la
retard stabil de mortalitate de orice cauz, infarct puterea65,66
miocardic, angin pectoral refractar,
accident vascular cerebral i
revasculizare periferic
Amlodipine Pacieni cu boal cardiac ischemic Reducere cu 31% a riscului relative de CAMELOT la
documentat i TA diastolic sub evenimente adverse cardiovasculare puterea 67
100mmHg (reducere absolut a riscului de 6,5%)
Candesartan Pacieni vrstnici (peste 70 de ani) cu HTA Reducere cu 28% a riscului de accident SCOPE la
uoar vascular cerebral non-fatal puterea 68

Kieran McGlade Nov 2001 Department of General Practice QUB

 Principalele clase de antihipertensive: reprezentani, doze, numr de
administrri zilnice, trialuri n care au fost evaluat eficacitatea acestora n
reducerea evenimentelor cardiovasculare.
Clasa Substana activ Doza zilnic Numr de Acromin trial
(mg) administrri
zilnice
Diuretice tiazidice Clortalidona 12,5-25 1 SHEP la puterea 56
Hidroclorotiazid 12,5-50 1 ALLHAT la puterea
Indapamida 1,25-2,5 1 25
Torasemid 2,5-10 1 HYVET la puterea
Bumetanid 0,5-2 2 57
Antagoniti ai receptorilor de Spironolacton 25-50 1
aldosteron Eplerenon 50-100 1
Diuretice care economisesc potasiu Triamteren 50-100 1-2
Amilorid 5-10 1-2
Beta-blocante Atenolol 25-100 1 MRC 1985 la
Betaxolol 5-20 1 puterea 68 MRCOA
Bisoprolol 2,5-10 1 1992 la puterea 69,
Metoprolol 50-100 1-2 INVEST la puterea
Nadolol 40-320 1 49 HAPPY la
Labetalol 200-800 2 puterea 70
Carvedilol 12,5-50 2 AASK 2002 la
Nebivolol 2,5-5 1 puterea 43, HAPPY
Propranolol 40-180 1-2 la puterea 70
Timolol 20-40 2 VA COOP 1982 la
puerea 71,72, MRC
1985 la puterea 68
Kieran McGlade Nov 2001 Department of General Practice QUB
Clasa Substana activ Doza zilnic Numr de Acromin trial
(mg) administrri
zilnice
Inhibitori ai enzimei de conversie a Benazepril 10-40 1
angiotensinei Captopril 25-100 2 CAPPP la puterea
Enalapril 5-40 1-2 73
Fosinopril 10-40 1 ABCD la puterea 74
Lisinopril 10-40 1 FACET la puterea
Perindopril 4-8 1 75
Quinapril 10-80 1 ALLHAT la puterea
Ramipril 2,5-20 1 25
Trandolapril 1-4 1 PROGRESS la
puterea 45
HOPE la puterea 62
Antagoniti ai receptorilor Candesartan 8-32 1 SCOPE la puterea
deangiotensin Eprosartan 400-800 1-2 47
Irebsartan 150-300 1 MOSES la puterea
Losartan 25-100 1-2 76
Olmesartan 20-40 1 IDNT la puterea 58
Telmisartan 20-80 1 RENALL la puterea
Valsartan 80-320 1-2 59, LIFE la puterea
77,78
ONTRAGET la
puterea 79
VALUE la puterea
80
Blocante ale canalelor de calciu Diltiazem 120-360 1-2 NORDIL la puterea
non-dihidropiridinice Verapamil 120-480 1-2 81
CONVINCE la
Kieran McGlade Nov 2001 Department of General Practice QUB puterea 82
Clasa Substana activ Doza zilnic Numr de Acromin trial
(mg) administrri
zilnice
Blocante ale canalelor de calciu Amlodipin 5-10 1 ALLHAT la puterea
dihidropiridinice Felodipin 2,5-20 1 25, VALUE la puterea
Isradipin 2,5-10 2 80
Nicardipin 60-120 2 ASCOT-BPLA la
Nifedipin 30-60 1 puterea 83,
Lacidipin 2-6 1 CAMELOT la puterea
Nitrendipin 1 1-2 67
Lercanidipin 0-40 1 HOT la puterea 84,
5-20 FEVER la puterea 63
ACTION la puterea
65,66 INSIGHT la
puterea 85
SHELL la puterea 86
Syst-Eur la puterea 87
Alfa 1-blocante Doxazosin 1-16 1
Prazosin 1-20 2
Terazosin 2-20 1
Alfa 2-agonti cu aciune central Metildopa 250-1000 2
Clonidin 0,1-0,8 2
Gaunabenz 0,1-0,25 1
Rezerpin 0,5-2 1
Guanfacin 0,2-0,4 1-2
Moxodipin 0,14-0,3 1-2
Rilmedipin
Vasodilatoare directe Hidralazin 25-100 2
Kieran McGlade Nov 2001 Minoxidil 2,5-80 1-2
Department of General Practice QUB
 Save your heart

Kieran McGlade Nov 2001 Department of General Practice QUB