BPAC BPJ 2013 54

primary care handbook 2012/2013

Individual assessment

• CVRA underestimate risk in younger adults when blood pressure only significant risk factor

• short-rem risk assessment influenced by age

• presence of end organ damage = important factor when making treatment decisions in patients when traditional risk scores do no indicate high overall CVRA

Definition

• every 2mmHg increase in sBP:

  • risk of death from IHD and stroke increase by 7% and 10%

• intermediate BP = 120-139/80-89

• stage 1: clinic ≥ 140/90 or average daytime ambulatory BP ≥ 135/85

• stage 2: clinic ≥ 160/100 or average ambulatory ≥ 150/95

• Severe: clinic sB{P ≥ 180 or dBP ≥ 110

• Isolated systolic: sBP ≥ 160 and dBP \<90

• Isolated diastolic: dBP ≥ 90 and sBP \<140

• take two different arms

• use higher of arms

• conssitent differences of >10mmHg = increase cardiovascular risk

• if hypertension

  • confirm diagnosis

  • assess CVRA

  • determine any end organ damage

    • dipstick urine

    • ACR

    • eGFR, HbA1c, lipis, urate, electrolyteis

    • Opthalmoscopy

      • copper/silver wiring

      • AV nipping

      • retinal haemorrhages

    • ECG

  • detect causes of secondary hypertension

    • EtOH

    • recent caffeine

    • OSA

    • Medicines

      • OCP

      • steroids/oestrogen

      • NSAIDs

      • decongestants

    • Drug missue

      • amphetamine

      • cocaine

    • Renal parenchymal disease

      • GN

      • polycystic kidney disease

    • Renal artery stenosis

    • Primary hyperaldosterism (Conn’s syndrome)

      • significantly raised BP

      • hypokalaemia

      • FHx

    • Cushing’s syndrome

    • Phaeochromocytoma

    • coarctation of aorta

• if severe hypertension = start prior to confirmation

Management

• taget BP \<140/90 appropriate for most people under 80

• if DM/CKD/cardiovascular disease target \<130/80

• \<120 associated with increase serious afdverse effects in T2 DM

• >80yo - target \<150/90

Lifestyle

• weight

• exercise

• etoh

• smoking

• diet

  • Salt

    • \<5g/day = improvement 4-5mmHg sBP

    • aim 1600mg sodium (4g of salt)

Pharmacological

• indications

• Patients with BP ≥ 160/100

• Any patients with evidence of any:

  1. target organ damage

  2. cardiovascualr disease

  3. renal disease

  4. diabetes

  5. five year CVRA ≥ 20% - see new cvra

• Adding combination early often results in increase numer of patients responding more quickly compared to monotherapy

• also synergies

Step 1:

• \<55yo

  • ACEi/ARB

  • (not together)

    • Cilazapril 500mcg -1mg od (max 5mg/day)

    • Quinapril 10mg od (max 40mg in divided doses)

    • Enalapril 5mg od (maintenece 20mg, max40mg/day)

    • Lisinopril 5mg OD (max 8mg)

  • ARB

    • Candesartan 8mg od (max 32mg/day)

    • Losartan 50mg OD (increase to 100mg od after weeks)

• ≥ 55yo

  • CCB

    • provide greater benefit

    • Felodipine 5mg od mane (2.5 elderly 5-10mg od)

    • Amlodipine 5mg od (max 10mg/day)

    • Diltiazem CD - 120-180mg OD - max 240-360mg/day

Step 2:

• Add ACEi or CCB (depending on what started)

  • ACCOMPLISH:

    • ACEi (benazepril) + CCB (amlodipine)>> ACEi + thiazide (hydrochlortiazide)

Step 3:

• Add thazide

  • indapamide 2.5mg mane

  • chlorthalidone 12.5-25mg od

  • strongest evidence compared to bendrofluazide

  • may help reduce peipheral oedema associated with CCB?

  • increase incidence of new-onset DM

    • especially when combined with Beta-blocker

Betablockers

• not recommended inital treatment

• don’t reduce risk of stroke

• generally pporly tolerated

resistant hypertension

• if ACEi + CCB + diuretic

• max adherence, lifestyle

• secondary causes considered

Antihypertensive in very elderly

• HYVET

• if over 80 life expectancy = 8-10yrs

• treatment substantially reduce risk of death

• if lower bp to 150/80

  • stroke reduced by 30%

  • heart failure mortality decrease 64%

  • all cause 21%

• don’t withold on basis of age alone

• consider orthostatic BP

After MI

• beta blockers reduce total mortality, cardiovascular mortality and morbidity

• all people with betablocker

• consider ACEi

  • especially if any significant left ventricular impairment

• aspirin adn statin

After stroke or TIA

Acute blood pressure lowering therapy

• don’t treat unless extremely high

  • >220/120 ischaemic

  • >180/100 haemorrhagic

    • reduce cautiously

      • 10-20% max and monitored for signs of neurological detioration

• continue usual medicines as long as no symptomatic hypotension

Secondary prevention

• long term anticoagulation

• OAC - if AF or cardioembolic stroke and no CI

• antihypertensive

  • regardless of BP

  • unless CI by symptomatic hypotension

  • ACEi = direct evidecne

Lifestyle

• every person

  • smoking cessation

  • improving diet

  • increasing regular exercise

Aged >75yo

• risk increase with age

• greater potential to benefit

• isolated raised systolic hypertnsion

  • increase risk of ischaemic stroke

    • should be managed aggressively

• generally tolerate as well as younger people

• postural hyptension common

  • alpha blockers used with great caution