Transcript Recent published experience in AML - rHuGM

Practical Management of
Hypertension in Primary Care
Back to Medical School Group
Dr Rob Sapsford
Consultant Cardiologist
Leeds Teaching Hospitals
Objectives
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Prevalence
NICE guidance (CG 127 August 2011)
Investigation
Treatment
Resistant Hypertension
Malignant Hypertension
NICE Clinical Guideline CG 127
The incidence of hypertension is
predicted to increase dramatically
Population with hypertension (%)
30
2000
2025
25% of all adults hypertensive
50% adults 60yrs> hypertensive
28
26
24
Overall
Men
Women
The global incidence of hypertension in the adult population
is predicted to exceed 29% by the year 2025
Kearney PM, et al. 2005
Pulse
pressure
Cardiovascular risk doubles with each
20/10 mmHg increment
8
6
CV Mortality
risk (fold
increase)
4
2
0
115/75
135/85
155/95
175/105
SBP / DBP (mmHg)
Lewington et al Lancet 2002:60;1903-1913
Any BP reduction makes a difference
2 mmHg
decrease in
mean SBP
7% reduction in
risk of IHD
mortality
10% reduction in
risk of CVA
mortality
Meta-analysis of 61 prospective observational studies involving
1 million adults (12.7 million patient years)
Lewington S et al lancet 2002:360;1903-1913
Long-term antihypertensive treatment
reduces CV risk
0
CV event
Stroke
CHD
−10
−20
−30
20–21
21–28
−40
30–39
−50
Relative risk reduction (%)
Risk of CV event with ACEI or CCB relative to placebo
CV: cardiovascular
CHD: coronary heart disease
RAS07000047
Neal B, et al. 2000
Measuring BP
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Standardise BP measurements
Never base treatment on an isolated reading
All adults every 5 Years
High / normal (130–139 / 85–89 mmHg) every 1 year
Measuring BP has improved
Rev Hales –
veterinarian
Carl Ludwig’s kymograph
The modern
sphygnomanometer
Riva-Rocci’s
sphygmomanometer
24 Hour BP Monitoring
24 Hr BP – Diagnosis ?
‘White coat effect’
Discrepancy of 20/10 mmHg >between clinic and average daytime ABPM
or average HBPM at time of diagnosis
BP Problems
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Unequal arm BP’s
Difference in BP between arms
BP difference 20mmHg>
Repeat measurements ? persists
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Action
Document as higher risk for vascular disease
Use highest arm for subsequent monitoring
BP Problems
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Postural Hypotension
Falls / postural dizziness
BP seated / standing 1min>
Systolic BP fall on standing 20mmHg>
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Action
Review medication
Measure future BP standing
Consider referral if symptoms persist
Blood Pressure
Clinic BP
140 > / 90 >
Ambulatory BP Monitor
ABPM
Home BP Monitor
HBPM
Minimum 2x readings / Hr
Average 14 daytime readings
2 readings 1 min> apart
Minimum 2x recordings / day
Average min 4 days – 7 days readings
(disregard day 1 readings)
Hypertensive Stages
Stage 1
Clinic BP
Daytime ABPM
Average HBPM
140> / 90>
135> / 85>
135> / 85>
Stage 2
Clinic BP
Daytime ABPM
Average HBPM
160> / 100>
150> / 95>
150> / 95>
Severe
Clinic BP
180> / 110>
Treatment guidelines
BP measurement
<140 /90 mmHg
140–159 / 90-99
160> /100> mmHg
ABPM <135/<85
ABPM 135-149/85-94
ABPM 150>/95>
Annual
review
Assess
risk
Treat
(any age)
BMJ 2004 328:634-640
Treatment Guidelines
ABPM/HBPM 135-150 / 85-95
Target Organ Damage (TOD)
or
Diabetes mellitus
or
Cardio-vascular disease
or
Renal Disease
or
10 yr Cardio-vascular risk 20%>
No Target Organ Damage (TOD)
and
No Diabetes mellitus
and
No Cardio-vascular disease
and
No Renal Disease
and
10 yr Cardio-vascular risk <20%*
Treat
Lifestyle measures
Annual review
BMJ 2004 328:634-640
Investigations
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Cardio-vascular risk
U/E’s, FBC, TFT’s, TC:HDL, Glucose
QRISK2, Framinghm
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Target Organ Damage
ECG
Urinalysis / Alb:Creat ratio
CVA
Retinopathy
Target Organ Damage
LVH
LVH
Nephropathy
Framingham Cardiovascular Risk
(morbidity and mortality)
Atherosclerotic disease anywhere – high risk
Sex
Age
Systolic BP / Diastolic BP
Smoking history
Total cholesterol : HDL
ECG – evidence of LVH
Calculate
10 year
CV risk
Treat 20% >
CV risk
Average male 45 years 1% per annum risk (10% 10 year risk)
QRISK2 Calculator
Variables included in the first version were
Age
Sex
Smoking status
Systolic BP
Ratio TC:HDL
BMI
Family history of IHD (first degree relatives <60 yrs)
Area measure of deprivation (Townsend score)
Treatment with antihypertensive agent
A more recent version
(QRISK2) has additional
variables
Self assigned ethnicity
Type 2 diabetes
Rheumatoid arthritis
Renal disease
Atrial fibrillation
Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, May M, Brindle P. BMJ 2007;335:136.
When to refer ?
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Stage 1 hypertension in young (<40 yrs) :even if low
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Target organ damage (LVH / albuminria / proteinuria) : but
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Accelerated Hypertension (BP usually 180/110 > with
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Supected phaeochromocytoma (labile BP, headache,
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Secondary cause supected on signs or symptoms
estimated 10 yr risk (under-estimation of lifetime risk)
no evidence of hypertension
papilloedema / retinal changes) – urgent admission
palpitations, sweating) – urgent admission
(RAS – bruit, young female, PVD, Renal dysfunction)
Treatment
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Lifestyle advice
Diet / exercise
Alcohol reduction
Caffeine reduction
Reduce dietary Sodium
Smoking cessation
NICE / BHS guidelines
Older(>55) or
black any age
Age (<55)
Step 1
A
C
Key :
A = ACE-I / ARB
A+C
Step 2
B = Beta-blocker
C = Calcium antagonist
Step 3
Step 4
A
+
C
+
D
D = Diuretic (chlortalidone /
indapamide)
Spironolactone
if K<4.5
Resistant25mg
Hypertension
Higher dose thiazide
if K /higher
A+C+D+further
diuretic
alpha or BB
NICE CG 127
Treatment - ? Beta-blockers
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If co-morbidity benefiting from use
(angina / systolic heart failure)
Younger patient (<55yrs) intolerance or
contra-indication to ACE/ARB
Women of child bearing potential
Evidence increased sympathetic drive
Avoid BB with thiazide like diuretic
Optimal BP Targets
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Patients <80yrs
Patients 80yrs >
Clinic BP
ABPM / HBPM
<140 / <90
mmHg
<135 / <85
mmHg
<150 / <90
mmHg
<145 / <85
mmHg
NICE CG 127 2011
Resistant Hypertension
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Failure to achieve goal BP despite optimal doses of 3
or more agents from different classes (ideally one a
diuretic)
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Prevalence around 10%
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True resistance: secondary causes, OSA, Volume
overload, Drug induced, obesity, alcohol excess
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Apparent resistance – non compliance, cuff related
artefacts, white coat resistance (25-37% reclassified)
Heart 2012;98:254-261
Malignant Hypertension
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Sudden / rapid hypertension with diastolic 130mmHg>
1% hypertensives (particularly african-americans)
Associated CTD, CKD, pregnancy toxaemia, RAS
Symptoms – retinal / cerebral / renal / cardiac
Signs – retinal / +/- oedema
Treatment – IV / oral (aim diastolic <110 within 24 hrs)
Aspirin in Hypertensives
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Recommended : Primary prevention
75mg / day if Patient
aged >50 yrs
BP controlled <150 / 90
target organ damage
And
Diabetic
one of
10 CV risk >20%
BMJ 2004 328:634-640
Statin Trials: ASCOT - LLA
Percentage with CHD event
10
9
8
7
WOSCOPS-P
WOSCOPS-S
6
5
AFCAPS-S
AFCAPS-P
4
Primary prevention
Pravastatin
3
ASCOT-P
2
1
Lovastatin
Atorvastatin
ASCOT-S
0
2.3 (90)
2.8 (110)
3.4 (130)
3.9 (150) 4.4 (170)
4.9 (190) 5.4 (210)
LDL-C, mmol/L (mg/dL)
S = statin treated; P = placebo treated
ASCOT 10 yr CV risk 9%
Modified from Kastelein JJP. Atherosclerosis. 1999; 143(suppl 1): S17-S21
Conclusion
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Treatment of BP dependent on level and
assessment of baseline CV risk
Individualise treatment accepting several
agents will be required
Compliance important
Treat all CV risk factors – statins usually
indicated
NICE Guidelines: Primary Prevention
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Statins are recommended as part of
management strategy for primary
prevention of CVD for adults who
have a 20% 10-year risk of
developing CVD
Statins for the prevention of cardiovascular events. NICE Technology Appraisal 94. January 2006
24 Hour Ambulatory BP
Ambulatory BP measurement
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Unusual variation
Possible white coat hypertension
Equivocal treatment decisions
Evaluation nocturnal hypertension
Evaluation of drug resistant hypertension
Evaluation 24 hour treatment control
Diagnosis and treatment of pregnancy hypertension
Evaluation of symptomatic hypotension
BP thresholds 10 / 5 mmHg lower than clinic BP’s