determinants of cardiovascular risk in hypertensive patients(1)课件

Hypertension,Dr Zaka Haq, MBBS, MRCP Cardiology Registrar Queens Hospital Romford,Hypertension,Prevalence (UK) NICE Beta Blockers,Challenges Primary Care,Hypertension-Overview,Hypertension itself-Introduction Types Classification Risk Factors Sequels Hypertension in special circumstances Management Follow Up Guidelines Referral to Secondary care,Hypertension, Introduction.,Hypertension is one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for stroke (ischemic and haemorrhagic), myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension may result in vascular and renal damage that can culminate in a treatment-resistant state. The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischemic heart disease and a 10% increased risk of mortality from stroke.,Hypertension, Introduction.,Diastolic pressure is more commonly elevated in younger people. With ageing, systolic hypertension becomes a more significant problem. The clinical management of hypertension is one of the most common 22 interventions in primary care, accounting for approximately 1 billion in drug costs alone in 2006. Hypertension is often symptom less, so screening is vital - before damage is done. Many surveys continue to show that hypertension remains under diagnosed, undertreated and poorly controlled in the UK,Hypertension, Introduction,In many countries, 50% of the population older than 60 years has hypertension. Overall, approximately 20% of the worlds adults are estimated to have hypertension. UK, 1 in every 4th person has Hypertension and this increases to 1 in every second person aged over 60.,Types of hypertension,Essential hypertension (Primary) 90% No underlying cause Secondary hypertension 5% Underlying cause,Causes of Secondary Hypertension,Renal disease Approximately 75% are from intrinsic renal disease: glomerulonephritis, polyarteritis nodosa, systemic sclerosis, chronic pyelonephritis, or polycystic kidneys. Approximately 25% are due to Reno vascular disease - most frequently atheromatous (e.g. elderly cigarette smokers with peripheral vascular disease) or fibromuscular dysplasia (more common in younger females). Endocrine disease Cushings syndrome, Conns syndrome, pheochromocytoma, acromegaly, Hyperparathyroidism Others Coarctation, Preeclampsia, Drugs and toxins, e.g. alcohol, cocaine, ciclosporin, tacrolimus, erythropoietin, adrenergic medications, decongestants containing ephedrine and herbal remedies containing liquorice,Definitions and Classifications of BP Levels,SBP DBP Category* (mm Hg) (mm Hg) Optimal 180 110 ISH 140 90 Reading to Remember 140 90 WHO-ISH Guidelines Subcommittee J Hypertens 1999; 17:151,Hypertension: Predisposing factors,Age 60 years Sex (men and postmenopausal women) Family history of cardiovascular disease Smoking High cholesterol diet Co-existing disorders such as diabetes, obesity and hyperlipidaemia High intake of alcohol Sedentary life style Remember all these are predisposing factors for HTN but they all including HTN are risk factors for Cardiovascular disease.,Diseases Attributable to Hypertension,HYPERTENSION,Gangrene of the Lower Extremities,Heart Failure,Left Ventricular Hypertrophy,Myocardial Infarction,Hypertensive Encephalopathy,Aortic Aneurysm,Blindness,Chronic Kidney Failure,Stroke,Preeclampsia/Eclampsia,Cerebral Hemorrhage,Coronary Heart Disease,Adapted from Dustan HP et al. Arch Intern Med. 1996; 156: 1926-1935,Hypertension in special circumstances,HTN in Young-Causes HTN and Pregnancy-Cautions HTN and Diabetes - Proteinurea HTN and Renal Failure vice versa Hypertensive Emergencies urgency, Emergency,Management of hypertension: the issues,Measurement Classification Investigations Risk assessment Non-pharmacological measures Treatment thresholds - 1st line - sequencing - beyond BP Treatment targets Concomitant therapy,Diagnosis and Measurement- 2011,If the first and second blood pressure measurements taken during consultation are 140/90 mmHg or higher, offer 24-hour ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. new 2011 When using ABPM to confirm a diagnosis of hypertension, ensure that: Blood pressure is measured for a total of 24 hours. At least two measurements per hour are taken during the day (08:00 to 22:00). At least one measurement per hour is taken during the night (22:00 to 08:00). Use the average daytime blood pressure measurement, new 2011,Diagnosis and Measurement- 2011,When using home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension, ensure that: For each blood pressure measurement, two consecutive measurements are taken, at least 1 minute apart and with the person seated. Blood pressure measurements are taken twice daily, ideally in the morning and evening. Blood pressure measurement continues for at least 4 days, ideally for 7 days. Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of HTN-2011,Potential indications for the use of ambulatory blood pressure monitoring,Unusual variability Possible white coat hypertension Informing equivocal treatment decisions Evaluation of nocturnal hypertension Evaluation of drug-resistant hypertension Determining the efficacy of drug treatment over 24 hours Diagnoses and treatment of hypertension in pregnancy Evaluation of symptomatic hypotension,Why Home or ABPM?,2004 Guideline recommended that BP should not be diagnosed and treated based on one clinic BP measurement Majority will need repeated clinic visits to confirm or refute the diagnosis Inaccurate clinic measurements may weaken the relationship between BP and CVD risk People who do not have sustained BP may be wrongly diagnosed and commenced on treatment with risk of side effects and unnecessary diagnosis and anxiety and cost.,Equipment,Training Servicing,Investigations,Urine Biochemistry Blood Glucose Lipid Profile Electrocardiogram, CXR USG-KUB, Urinary catecholamine, TSH, CXR, ECHO, urinary free cortisol, Specialist investigations,Life Style Modifications.,Maintain normal weight for adults (BMI 20-25 kg/m2) Reduce salt intake to 30 min per day Consume at least five portions/day of fresh fruit and vegetables Reduce the intake of total and saturated fat STOP SMOKING,Next,Initiating and monitoring antihypertensive drug treatment, including blood pressure targets,Drug therapy for hypertension,Class of drug Example Initiating dose Usual maintenance dose Diuretics Hydrochlorothiazide 12.5 mg o.d. 12.5-25 mg o.d. -blockers Atenolol 25-50 mg o.d. 50-100 mg o.d. Calcium Amlodipine 2.5-5 mg o.d. 5-10 mg o.d. channel blockers -blockers Doxazosin 1 mg o.d. 1-8 mg o.d. ACE- inhibitors Lisinopril 2.5-5 mg o.d. 5-20 mg o.d. Angiotensin II Losartan 25-50 mg o.d. 50-100 mg o.d. receptor blockers -Centrally Acting Methyledopa Hydralazine,Antihypertensive therapy: Side-effects and Contraindications,Class of drugs Main side-effects Contraindications/ Special Precautions Diuretics Electrolyte imbalance, Hypersensitivity, Anuria (e.g. Hydrochloro- total and LDL cholesterol thiazide) levels, HDL cholesterol levels, glucose levels, uric acid levels b-blockers Impotence, Bradycardia, Hypersensitivity, (e.g. Atenolol) Fatigue Bradycardia, Conduction disturbances, Diabetes, Asthma, Severe cardiac failure,Class of drug Main side-effects Contraindications/ Special Precautions Calcium channel blockers Pedal edema, Headache Non-dihydropyridine (e.g. Amlodipine, CCBs (e.g diltiazem) Diltiazem) Hypersensitivity, Bradycardia, Conduction disturbances, Congestive heart failure, Left ventricular dysfunction. Dihydropyridine CCBs Hypersensitivity a-blockers Postural hypotension Hypersensitivity (e.g. Doxazosin) ACE-inhibitors Cough, Hypertension, Hypersensitivity, Pregnancy, (e.g. Lisinopril) Angioneurotic edema Bilateral renal artery stenosis Angiotensin -II receptor Headache, Dizziness Hypersensitivity, Pregnancy, blockers (e.g. Losartan) Bilateral renal artery stenosis,Antihypertensive therapy: Side-effects and Contraindications (Contd.),Factors affecting choice of antihypertensive drug,The cardiovascular risk profile of the patient Coexisting disorders Target organ damage Interactions with other drugs used for concomitant conditions Tolerability of the drug Cost of the drug,Choosing the right antihypertensive,Condition Preferred drugs Other drugs Drugs to be that can be used avoided Asthma Calcium channel a-blockers/Angiotensin -II b-blockers blockers receptor blockers/Diuretics/ ACE-inhibitors Diabetes a-blockers/ACE Calcium channel blockers Diuretics/ mellitus inhibitors/ b-blockers Angiotensin -II receptor blockers High cholesterol a-blockers ACE inhibitors/ Angiotensin -II b-blockers/ levels receptor blockers/ Calcium Diuretics channel blockers Elderly patients Calcium channel -blockers/ACE- (above 60 years) blockers/Diuretics inhibitors/Angiotensin -II receptor blockers/- blockers BPH a-blockers b-blockers/ ACE inhibitors/ Angiotensin -II receptor blockers/ Diuretics/ Calcium channel blockers,Limitations on use of antihypertensives in patients with coexisting disorders,Coexisting Diuretic b-blocker ACE All CCB a1-blocker Disorder inhibitor antagonist Diabetes Caution/x Caution/x Dyslipidaemia x x CHD Heart failure 3/Caution Caution Asthma/COPD x /Caution Peripheral Caution Caution Caution vascular disease Renal artery x x stenosis,WHICH PATIENTS NEED TREATMENT,Concentrate Bp Reading Target Organ Damage 10 Year CVD Risk Diabetes Young Hypertensives,Initiating Treatment,Offer people older than 80 years the same antihypertensive drug treatment as people aged 5580 years, taking into account any comorbidities 2011 Offer Stage 1 Hypertensives treatment if they have target organ damage or 86 established cardiovascular disease or renal disease or diabetes or a 10-year cardiovascular risk equivalent to 20% or greater. new 2011,Initiating Treatment,Hypertension is not controlled with monotherapy in at least 50% of patients; in these patients combination therapy is required Offer antihypertensive drug treatment to people with stage 2 hypertension. new 2011 For people younger than 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular (CV) disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10-year CV risk assessments can underestimate the lifetime risk of CV events in these people -new 2011,Choosing drugs for patients newly diagnosed with hypertension: NICE/BHS,Antihypertensive Drug Treatment - 2011,Treatment Recommendations General Concepts,Offer people with isolated systolic hypertension (systolic BP 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure. 2004 Offer people older than 80 years the same antihypertensive treatment as people aged 5580 years, taking into account any co morbidities. new 2011 Offer step 1 antihypertensive treatment with an ACE inhibitor or a low-cost ARB to people aged under 55 years. If an ACE inhibitor is used and not tolerated, offer an ARB. new 2011 Do not combine an ACE inhibitor with an ARB to treat hypertension. new 2011,Step 1 Treatment Recommendations,Offer step 1 antihypertensive treatment with a CCB to people aged 55 years and older and to black people of African and Caribbean descent of any age. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure, or a high risk of heart failure, offer a thiazide -like diuretic . new 2011 If a diuretic is required, choose a thiazide -like diuretic, such as chlortalidone (12.5 mg25.0mg once daily) or indapamide (2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. new 2011,Step 2 Treatment Recommendations,If step 2 antihypertensive treatment is required, offer a CCB in combination with either an ACE Inhibitor or a low-cost ARB. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic new 2011,Step 3 Treatment Recommendations,If treatment with three drugs is required, the combination of ACE inhibitor or angiotensin II receptor blocker, calcium-channel blocker and thiazide-like diuretic should be used. 2006,Step 4 Treatment Recommendations Resistant Hypertension,For treatment of resistant hypertension at step 4, consider further diuretic therapy with low-dose spironolactone (25 mg once daily) if blood potassium levels are lower than 4.5 mmol/l and eGFR is higher than 60 ml/min/1.73m2. If blood potassium levels are higher than 4.5 mmol/l, consider therapy with a higher-dose thiazide-like diuretic treatment. new 2011 When using further diuretic therapy for resistant hypertension at step 4, monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter. new 2011,Step 4 Treatment Recommendations Resistant Hypertension,If further diuretic therapy for resistant hypertension at step 4 is not tolerated, contraindicated or ineffective, consider an alpha- or beta-blocker. new 2011 If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained. new 2011,BP Targets in Various Guidelines Guidelines Uncomp.HTN DM C RF USA (JNC VII 2003) 140/90 mmHg 130/80 mmHg 130/80 mmHg Europe (ESH 2007) 140/90 mmHg 130/80 mmHg 130/80 mmHg China (CSH 2005) 140/90 mmHg 130/80 mmHg 130/80 mmHg Russia 140/90 mmHg 130/80 mmHg 130/80 mmHg Korea (KSH 2004) 140/90 mmHg 130/80 mmHg 130/80 mmHg WHOISH SBP 140 mmHg 130/80 mmHg 130/80 mmHg BHS IV 2004 140/85 mmHg 130/80 mmHg 130/80 mmHg,Hypertension in DRAFT NICE,Big changes with impact on Primary Care Hypertension as a disease Primary not Essential hypertension At least of adult UK population have a BP = 140/90 or hypertension More than of those 60 or more,Hypertension in NICE ( DRAFT),Strong emphasis on diagnosis and measuring blood pressure Ensuring training for those taking blood pressure measurements Validation, maintenance and calibration of devices and correct cuff size Standard procedure for measurement resting 5-10 min Check pulse rhythm for AF Check for postural drop If first and second readings are both higher than 140/90 to arrange an ABPM If blood pressure 180/110 start treatment,Suggested indications for specialist referral,Urgent treatment needed Accelerated hypertension (severe hypertension and grade III-IV retinopathy) Particularly severe hypertension ( 220/120 mm Hg) Impending complications (for example, transient ischemic attack, left ventricular failure) Possible underlying cause Any clue in history or examination of a secondary cause, such as hypokalaemia with increased or high normal plasma sodium (Conns syndrome) Elevated serum creatinine Suspected phaeochromocytome with labile BP or postural hypotension, headache, palpitations, pallor,Suggested indications for specialist referral, Proteinuria or haematuria Sudden onset or worsening of hypertension Resistant to multidrug regimen ( 3 drugs) Young age (any hypertension 20 years; needing treatment 30 years) Therapeutic problems Multiple drug intolerance Multiple drug contraindications Persistent non-adherence or non-compliance Special situations Unusual blood pressure variability Possible white coat hypertension Hypertension in pregnancy,Groups that will not be covered 420,People with diabetes. Children and young people (younger than 18 years). Pregnant women. Secondary causes of hypertension (for example, Conns adenoma, phaeochromocytoma and renovascular hypertension). People with accelerated hypertension (that is, severe acute hypertension 426 associated grade III retinopathy and encephalopathy). People with acute hypertension or high blood pressure in emergency care,Drugs in special conditions,Condition Pregnancy Coronary heart disease Congestive heart failure,Preferred Drugs Nifedipine, labetalol, hydralazine, beta-blockers, methyldopa, prazosin Beta-blockers, ACE inhibitors, Calcium channel blockers ACE inhibitors, beta-blockers,1999 WHO-ISH guidelines,HTN and Pregnancy,Chronic hypertension (2-4%) Hypertension first identified in early pregnancy Hypertension that persists postpartum Gestational hypertension (2-4%) Non- proteinuric hypertension Pre- eclampsia 3% primigravida at term and 0.5% pre-term,HTN and Pregnancy,During pregnancy, BP target; 130/80 - 150/100mmHg If BP 150/100; start labetolol/methyldopa/nifedipine SR Avoid ACE-I and ARBs during pregnancy Consider secondary hypertension in women with severe hypertension especially in early pregnancy and postpartum Consider prophylactic low-dose aspirin from 12 weeks Both systolic and diastolic hypertension important Early onset pre-eclampsia, a serious threat to mother and foetus Long-term follow up is essential for future womans health,CKD and Diabetes,I