Colin Edwards. Cardiologist Auckland Heart Group Waitemata Health
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1 Colin Edwards Cardiologist Auckland Heart Group Waitemata Health AUG 2012
2 Introduction Case Summary
3 BP MEASUREMENTS measured seated mean of 2 BP recordings per visit at least 2 visits Diet Exercise Weight loss
4 Size of problem: 20-30% of adults in Western societies have hypertension Accounts for 1 in 6 deaths (silent assassin) 95% is essential hypertension
5 Trials 35-40% mean reduction in stroke 20-25% reduction in MI 50% reduction in heart failure BUZZ WORD Patient Buy In Pt with BP 159/95 mmhg (stage 1) on treatment for 10 yrs 12mmHg prevent 1 death for every 11 pts treated
6 GP Referral: 66 yr old rotund Croatian female patient. Difficulty controlling BP BP last year was 140/80mmHg. BP s now are persistently raised 190/100mmHg despite intensification of therapy Known moderate coronary artery disease CV Risks: NIDDM x 5 years longstanding mild hypertension treated dyslipidemia ex-smoker
7 Aspirin EC 100mg/d Cilazapril 5mg/d Metoprolol 95mg/d Amlodipine 5mg/d Lipitor 80mg/d Compliance prefer not to be on medication; occasionally forgets 3 oil, and glucosamine- takes religiously
8 First diagnosed at age 40 years Mother was a bad hypertensive- RIP stroke at 65 yrs Exercise- 2 rounds of golf per week Alcohol- wine every night with evening meal- 1-2 glasses 1 or 2 drinks after golf No liquorice liquor Enjoys salty snacks Uses Voltaren 75mg bad back No HRT No hx of malignant phase ht, renal failure or heart failure
9 Appeared a little anxious BMI-30, waist circumferece 104cm ( normal<88cm) BP-160/95mmHg; PR-90 bpm Fundi- arteriolar narrowing Heart sounds-?s4, S1, S2, no CHF No clinical evidence of PVD ECG- SR, LV voltages Creatinine-63umol/l, K+ 3.8mmol/l Urine micro-albumin-mildly raised Fasting glucose-5.8mmol/l Thyroid functions-normal Renin:aldosterone-normal 24 hr urine metanephrine-normal
10 Moderate Hypertension despite 3 agents LVH Recent loss of BP control- why? Compliance BMI-30, Waist 104cm, doesn t exercise Alcohol NSAID Secondary cause- ATHEROSCLEROTIC RENAL ARTERY STENOSIS - unlikely Stress? STRESS? Nasty altercation with her neighbour she accused him of stealing the fruit off one of her citrus trees. Very upset-she s not sleeping at night.
11 45/48 interpretable measurements >95% 24 hour mean-168/93 mmhg (normal <135/85mmHg) non-dipper - minimal drop (6%) in nocturnal BP measurements
12 Step 1: Solve the stress Make up with your neighbour Take him a bowl of fruit Step2: MEDICATION Aspirin EC 100mg/d Inhibace 5mg/d Metoprolol 95mg/d Amlodipine 5mg/d Lipitor 80mg/d- TC- 4.8mmol/l, HDL- 0.9 mmol/l, LDL- 2.8 mmol/l, TG-2.4 mmol/l What s missing? Need to add a diuretic
13 VOLUME EXPANSION: Vasodilators (ACE and Amlodipine)-lead to fluid retention OR volume expansion due to efferent arteriolar dilatation. vasodilators Efferent capillary dilatation Drop in trans-glomerular pressures Filtrate is altered and more readily reabsorbed by the peri-capillary network Volume expansion Cancels BP lowering of vasodilators
14 ? Inhibace plus ( Cilazapril 5mg + hydrochlorthiazide 12.5mg) Inadequate dose of diuretic Favorite thiazide is Chlorthalidone-12.5mg-25mg/d More potent Longer half life Proven in clinical trials Hypertension 2006
15 Study began 1994 x 8yrs pts Aim:? Best drug to start Rx. Results: SBP -greatest with chlorthalidone Less CHF with chlorthalidone JNC VII- start with diuretic
16 Aim: Optimal combination Rx for ht Compared the effects of two combinations AML/ACE or HCTZ/ACE on major fatal and nonfatal cardiovascular events. HCTZ 12.5mg/d men and women 55 years or older who had SBP >160 mm Hg. 60% diabetic RESULTS: 20% in morbidity and mortality in AML/ACE group.? HCTZ not good Rx for diabetics
17 Do use B-Blockers coronary artery disease, left ventricular impairment. Carvedilol- α blocking properties Labetalol
18 HYVET- benefits and risks of reducing BP (SBP>160mmHg) in very elderly hypertensives. (aged 80 or more). BP lowering benefits could be offset by harm due to hypotension-related syncope patients, international trial 11 different countries Followed for 2 years Elderly pts are prone to postural hypotension Monitor/measure BP s in the standing position RESULT: Treatment of hypertension Stroke 30% Mortality 21% Heart failure 64%
19 Aspirin EC 100mg/d Inhibace 5mg/d Metoprolol 95mg/d Amlodipine 10mg/d Lipitor 80mg/d Chlorthalidone 12.5mg/d Home Monitoring: Average 12 reading over 3 weeks -153/92 mmhg Home Monitoring: Encourage purchasing of unit Engages the patient-improves compliance 2 morning and 2 evening readings per week, at rest, sitting. Keep a diary to bring to clinic- NEED AT LEAST 12 MEASUREMENTS Normal <135/85mmHg
20 FANTASTIC Aspirin EC 100mg/d Inhibace 5mg/d Metoprolol 95mg/d Amlodipine 10mg/d Lipitor 80mg/d Chlorthalidone 12.5mg/d BP 153/92mmHg ACHIEVED TARGET Chlorthalidone 25mg/d 3 weeks later- average of 12 home BP measures-bp145/86mmhg What Next? Spironolactone 12.5mg/d 3 weeks later average of 12 home BP measures- BP 128/78mmHg
21
22 Aspirin EC 100mg/d Inhibace 5mg/d Metoprolol 95mg/d Amlodipine 10mg/d Lipitor 80mg/d Add Chlorthalidone 12.5mg/d- SBP 153/92mmHg Chlorthalidone 25mg/d Acute gout Colchicine 0.6mg bd Reduced Chlorthalidone 12.5 mg/d Added Spironolactone 25mg/d Patient very skeptical -? compliance Come back in 3 weeks with home monitoring To start some allopurinol once joint had settled To check K+ in 10d ACE and Spironolactone combination
23 20h00- Phone call from lab K+ 5.7mmol/l Phoned pt please stop Spironolactone Toe is still very sore-can t sleep. BP tonight was 190/110mmHg Saw her urgently Prednisone 20mg/d, and stopped all diuretics. Start Doxazosin 1mg/d
24 Happily referred her Referred her John Ormiston at Mercy Angiography
25 Reduce BP to <140/90mmHg and in diabetics <130/80mmHg Lifestyle changes are critical to achieving BP control Most important step in prescribing anti-hypertensive therapy is achieving patient buy in
26 Need a good diuretic e.g. Chlorthalidone 25mg/d egfr <40mls/min Frusemide bd Maximise doses of ACE/ARB, calcium blockers If obese- spironolactone 12.5mg-25mg/d check K+ if combine with ACE/ARB Promote home BP monitoring-engages the pt and improves compliance Benefit in treating hypertension in the very elderly (HYVET) BP Target are lower- SBP-150mmHg Postural hypotension- monitor Rx in the standing position
27 If SBP>160mmHg Lisinopril 10mg/d Chlorthalidone 12.5mg/d Still poor control REFER
Colin Edwards. Cardiologist Auckland Heart Group Waitemata Health
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