Overview. NOT A REPETION OF LOCAL GUIDELINE Dr Diviash Thakrar

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1 Overview 1. Why hypertension is important? 2. What are basic principles in treatment? 3. Different ways of measuring 4. Hypercholesterolemia NOT A REPETION OF LOCAL GUIDELINE

2 CVD risk factors? Non modifiable Modifiable

3 Prevalence of disease 2007/8 England Scotland And Wales

5 Stroke CAD CHF LVH Hypertension Renal disease Peripheral vascular disease Morbidity Disability National High Blood Pressure Education Program Working Group. Arch Intern Med. 1993;153:

6 BP 20/10 x2 risk of death from CHD in age group BP 20/10 x0.5 risk of CHD in age group Normal BP at 55, 90 % lifetime chance of developing hypertension Small changes big Effect

7 Average Percent Reduction Stroke incidence 35 40% Myocardial infarction 20 25% Heart failure 50%

9 The Real Reason General Practitioner Hospital Consultant?

10 4-Year Progression To Hypertension: The Framingham Heart Study Participants age 36 and older 37 Patients (%) Optimal Normal High-Normal (<120/80 mm (130/85 mm Hg) Hg) Vasan, et al. Lancet 2001;358: ( /85 89 mm Hg)

11 16 Cumulative Incidence (%) of Major CV Events High-normal BP ( /85-89 mm Hg) Normal BP ( /80-84 mm Hg) Optimal BP (<120/80 mm Hg) Time (y) * Defined as death due to CV disease; recognized myocardial infarction (MI), stroke, or congestive heart failure (CHF). Adapted from Vasan RS. N Engl J Med. 2001;345:

12 Overview 1. Why hypertension is important? 2. What are basic principles in treatment? 3. Different ways of measuring 4. Hypercholesterolemia NOT A REPETION OF LOCAL GUIDELINE

13 THRESHOLDS FOR INTERVENTION Initial blood pressure (mmhg) >180/ <130/85 * ** *** 160/ <140/90 Target organ damage or cardiovascular complications or diabetes or 10 year CVD risk 20% No target organ damage and no cardiovascular complications and no diabetes and 10 year CVD risk <20% Treat Treat Treat Observe, reassess CVD risk yearly Reassess yearly Reassess in 5 years * Unless malignant phase of hypertensive emergency confirm over 1 2 weeks then treat ** If cardiovascular complications, target organ damage or diabetes is present, confirm over 3 4 weeks then treat; if absent re-measure weekly and treat if blood pressure persists at these levels over 4 12 *** If cardiovascular complications, target organ damage, or diabetes is present, confirm over 12 weeks then treat: if absent re-measure monthly and treat if these levels are maintained and if estimated 10 year CVD risk is 20% Assessed with CVD risk Dr chart Diviash Thakrar

14 Threshold For Intervention Blood Pres (mm Hg) >160/100 Treat /90-99 Assess risk factors <140/90 No intervention Risk factor assessment Target organ damage Cardiovascular complications 10 year CVD risk >20% If established heart / stroke related damage treat BP to target

15 Churchill, Roosevelt, Stalin in Yalta 1944

16 Modification Weight reduction Adopt DASH eating plan Dietary sodium reduction Physical activity Moderation of alcohol consumption Approximate SBP reduction (range) 5 20 mmhg/10 kg weight loss 8 14 mmhg 2 8 mmhg 4 9 mmhg 2 4 mmhg

18 Case 1 AB 50 years old Asian male referred up due to labile BP ( /83 109) Atenolol 100mg OD Indapamide 1.5mg OD BP 136/89 (right arm) BP 143/89(left arm ) Comments Age use of ACEi Asian use of ACEi Dose of atenolol Combination of diuretic and B Blockers BP both arms

19 Case 2 29 year old Polish lady recently diagnosed hypertension picked up at pill check Started on BZ 2.5mg od COCP stopped BP 130/82 right arm BP 125/76 left arm Comments Bendraflumethazide not 1 st line Hypertension consider alternative contraception Do not use ACEi/ARB Full work up including MRI angiogram of the renal system

20 Case 3 JH 57 year old gentleman not been in 18/12 for BP or blood check Ischemic heart disease PVD Aspirin 75 mg,amlodpine 5mg, Perindropril 2mg OD, Doxasosin Previous BP 144/80 18/12 ago Na 144, K 4.3 C 97 U 3.6 Seen by nurse BP 180/103 Dr informed increase Perindropril to 4mg bloods and review in 1/12 Na 138 K 4.4 C 188 U 7.9 Urgent renal team opinion stop ACEi Bilateral renal artery stenosis post op BP 133/84 restarted ACEi

21 List of additional drugs used α- blockers ( doazosin) Spirinolactone Moxonidine Clonidine Β-Blockers Rasilez

22 Overview 1. Why hypertension is important? 2. What are basic principles in treatment? 3. Different ways of measuring 4. Hypercholesterolemia NOT A REPETION OF LOCAL GUIDELINE

23 Ways of assessing blood pressure (For medical staff and patients!) Office BP Ambulatory monitors Home readings Take 3 readings 5minsapart and average of 2 nd & 3 rd 24 monitor Possible self monitoring how to interpret? Free standing waiting room monitors How to use?

24 Ambulatory BP Practical Pointers Use correct arm Correct cuff size Frequency day 30 mins, night 1 hourly Minimum 85 % Day>14 Night >7. Correct for sleep & wake time Normal day not day of rest Side effects petechia / discomfort especially disturbed sleep

25 Indications for Ambulatory BP Unusual variability White coat hypertension? Equivocal treatment decisions Evaluation of nocturnal hypertension Evaluation of drug resistant hypertension Determining efficacy of treatment over 24 hours Evaluation of symptomatic hypertension

26 Normal Sleeping Pattern Sys<17% Dia <13% American Family Physician. Vol 67. No 11. June

27 White Coat Hypertension

28 Case 4 TD 54 year old unemployed gentleman Referred from hospital was being treated for hypertension several years Significant LVH on the echocardiogram 24 monitor from confirms average corrected reading 167/94 with no nocturnal dip In clinic BP 140/76 ( both arms ) Lisinopril 20mg OD(A) Amlodopine 10mg OD(C) Bz 2.5md OD (D) Doxaziosin 4mg ODincreased to 8mg Said BP always appears to be fine at GPs & does not like monitors

29 Possible reversed white coat hypertension 24 hour average 157/91 Day time average 160/93 ; nocte 149/86 corrected average 170/98. Poor nocturnal drop

30 Ideally next step was home monitoring Ensure patient has approved device Appropriate cuff size and used properly Take morning and evening readings Only once each time Over 7 days BHS guidance Ignore day 1 Add last 12 reading Obtain average Add 10/5

31 What does it all mean? White Coat Hypertension? Reversed White coat Hypertension?

32 Progression of Risk TOD, morbidity / mortality/lvh BMJ reference

33 Suggested Target BP Clinic BP (mmhg) No diabetes Diabetes Optimal treated BP <140/85 <130/80 Audit standard <150/90 <140/80 Adapted from Journal of Human Hypertension(2004) 18,

34 Suggested Target BP Office setting Ambulatory BP Optimal treated BP <140/85 Overall <130/80 Day <135/85 Night <129/70 Audit standard <150/90 >50% readings over threshold Adapted from Journal of Human Hypertension(2004) 18, / NICE June 2006/ Hospital Physician 47 March 2003

35 Hillingdon Referral Guidelines Malignant hypertension refer immediately to a & E Referral Guidelines 1. Refractory BP > 150 / 90 despite 3 agents 2. Problems controlling BP due to drug side effects 3. Screening for suspected secondary hypertension 4. For ambulatory BP monitor 5. Patients under 35 suspected / confirmed hypertension

36 Hospital Referrals Referral to renal team. Microscopic haematuria with proteinuria (PCR>45). Microscopic haematuria with abnormal renal function. Microscopic haematuria in absence of proteinuria in patients over 50 years should be directed to urology first to rule out renal tract cancer. Abnormal renal function especially if egfr < 30ml/min. Suspected renal disease. Nephritic syndrome, Reno vascular disease, Polycystic disease.. Isolated persistent proteinuria > 1g/24 hours (i.e.pcr>100). Referral to cardiology. Associated secondary cardiac disease.

37 Other Associated Drugs Aspirin thins blood Cholesterol drugs lowers risk

38 Aspirin All secondary prevention Primary prevention:75mg in controlled hypertensive patients aged over 50 and end organ damage or diabetes, or CVD risk>=20%

39 Cholesterol targets All secondary prevention Primary prevention:statin therapy indicated when 10 year CVD risk is >=20% Targets Cholesterol <4,LDL<2 Audit criteria <5,<3

41 Statins My Rules 1. Chol/LDL <5/3 or 30% reduction 2. LFTs before 3. LFTs 3/12 after starting and then annual 4. Trial of diet 6/52 prior 5. Take simvastain at night 6. Which statin? 1. Stop if LFTs >3 times abnormal 2. Joint / muscle pains arrange CK 3. Simvastatin/Atorvastat in 4. Tg> 2.5 consider Fibrate

43 Steps taken Diet and lifestyle advice Simvastatin 40mg Sim 20 40mg Pravastin 20 40mg Atorvastain 20 40mg +/ ezetemible Simvatatin 80mg Other drugs fibrates / nicotinic acid Rousavatsin

44 Cholesterol/HDL ratio determines risk High HDL general population Cholesterol 6 HDL 1.6 Cholesterol/ HDL ratio: 6/1.6 =3.75 < 5 ratio is good Low HDL Asian population Cholesterol 5.0 HDL 0.8 Cholesterol/HDL ratio: 5/0.8 = 6.25 > 5 ratio is bad How to increase HDL 1 exercise 2 alcohol 3 Certain drugs

45 Thank you

Blood Pressure Acre Surgery Diviash Thakrar

Blood Pressure Acre Surgery Diviash Thakrar Why Are We Doing This? 1. Improve education for patients within the practice 2. Allow us use this for general health promotion Raise money for charity 3. Raise