Hypertension

DrZakaHaq,MBBS,MRCPCardiologyRegistrarQueensHospitalRomfordHypertension1【高血壓英文課件】-Hypertension2HypertensionPrevalence(UK)NICEBetaBlockersChallengesPrimaryCareHypertensionPrevalence(UK)Ch3【高血壓英文課件】-Hypertension4【高血壓英文課件】-Hypertension5Hypertension,Introduction.Diastolicpressureismorecommonlyelevatedinyoungerpeople.Withageing,systolichypertensionbecomesamoresignificantproblem.Theclinicalmanagementofhypertensionisoneofthemostcommon22interventionsinprimarycare,accountingforapproximately￡1billionindrugcostsalonein2006.Hypertensionisoftensymptomless,soscreeningisvital-beforedamageisdone.Manysurveyscontinuetoshowthathypertensionremainsunderdiagnosed,undertreatedandpoorlycontrolledintheUKHypertension,Introduction.Di6Hypertension,IntroductionInmanycountries,50%ofthepopulationolderthan60yearshashypertension.Overall,approximately20%oftheworld’sadultsareestimatedtohavehypertension.UK,1inevery4thpersonhasHypertensionandthisincreasesto1ineverysecondpersonagedover60.Hypertension,IntroductionInm7TypesofhypertensionEssentialhypertension(Primary)90%NounderlyingcauseSecondaryhypertension5%UnderlyingcauseTypesofhypertensionEssential8CausesofSecondaryHypertensionRenaldiseaseApproximately75%arefromintrinsicrenaldisease:glomerulonephritis,polyarteritisnodosa,systemicsclerosis,chronicpyelonephritis,orpolycystickidneys.

Approximately25%areduetoRenovasculardisease-mostfrequentlyatheromatous(e.g.elderlycigarettesmokerswithperipheralvasculardisease)orfibromusculardysplasia(morecommoninyoungerfemales).Endocrinedisease

Cushing’ssyndrome,Conn'ssyndrome,pheochromocytoma,acromegaly,HyperparathyroidismOthersCoarctation,Preeclampsia,

Drugsandtoxins,e.g.alcohol,cocaine,ciclosporin,tacrolimus,erythropoietin,adrenergicmedications,decongestantscontainingephedrineandherbalremediescontainingliquoriceCausesofSecondaryHypertensi9DefinitionsandClassificationsofBPLevels

SBP DBPCategory* (mmHg) (mmHg)Optimal <120 <80Normal <130 <85High-normal 130-139 85-89Grade1hypertension(mild) 140-159 90-99Grade2hypertension(moderate) 160-179 100-109Grade3hypertension(severe) >180 >110ISH >140 <90ReadingtoRemember14090WHO-ISHGuidelinesSubcommitteeJHypertens1999;17:151DefinitionsandClassification10Hypertension:PredisposingfactorsAge>60yearsSex(menandpostmenopausalwomen)FamilyhistoryofcardiovasculardiseaseSmokingHighcholesteroldietCo-existingdisorderssuchasdiabetes,obesityandhyperlipidaemiaHighintakeofalcoholSedentarylifestyleRememberallthesearepredisposingfactorsforHTNbuttheyallincludingHTNareriskfactorsforCardiovasculardisease.Hypertension:Predisposingfac11DiseasesAttributabletoHypertensionHYPERTENSIONGangreneoftheLowerExtremitiesHeartFailureLeftVentricularHypertrophyMyocardialInfarctionHypertensiveEncephalopathyAorticAneurysmBlindnessChronicKidneyFailureStrokePreeclampsia/EclampsiaCerebralHemorrhageCoronaryHeartDiseaseAdaptedfromDustanHPetal.ArchInternMed.1996;156:1926-1935DiseasesAttributabletoHyper12HypertensioninspecialcircumstancesHTNinYoung-CausesHTNandPregnancy-CautionsHTNandDiabetes-ProteinureaHTNandRenalFailure–viceversaHypertensiveEmergencies–urgency,EmergencyHypertensioninspecialcircum13Managementofhypertension:theissuesMeasurementClassificationInvestigationsRiskassessmentNon-pharmacologicalmeasuresTreatmentthresholds-1stline-sequencing-beyondBPTreatmenttargetsConcomitanttherapy

Managementofhypertension:th14DiagnosisandMeasurement-2011Ifthefirstandsecondbloodpressuremeasurementstakenduringconsultationare140/90mmHgorhigher,offer24-hourambulatorybloodpressuremonitoring(ABPM)toconfirmthediagnosisofhypertension.[new

2011]WhenusingABPMtoconfirmadiagnosisofhypertension,ensurethat:Bloodpressureismeasuredforatotalof24hours.Atleasttwomeasurementsperhouraretakenduringtheday(08:00to22:00).Atleastonemeasurementperhouristakenduringthenight(22:00to08:00).Usetheaveragedaytimebloodpressuremeasurement,[new2011]DiagnosisandMeasurement-20115DiagnosisandMeasurement-2011Whenusinghomebloodpressuremonitoring(HBPM)toconfirmadiagnosisofhypertension,ensurethat:Foreachbloodpressuremeasurement,twoconsecutivemeasurementsaretaken,atleast1minuteapartandwiththepersonseated.Bloodpressuremeasurementsaretakentwicedaily,ideallyinthemorningandevening.Bloodpressuremeasurementcontinuesforatleast4days,ideallyfor7days.DiscardthemeasurementstakenonthefirstdayandusetheaveragevalueofalltheremainingmeasurementstoconfirmadiagnosisofHTN-2011DiagnosisandMeasurement-20116Potentialindicationsfortheuseofambulatorybloodpressuremonitoring

UnusualvariabilityPossiblewhitecoathypertensionInformingequivocaltreatmentdecisionsEvaluationofnocturnalhypertensionEvaluationofdrug-resistanthypertensionDeterminingtheefficacyofdrugtreatmentover24hoursDiagnosesandtreatmentofhypertensioninpregnancyEvaluationofsymptomatichypotension

Potentialindicationsforthe17WhyHomeorABPM?2004GuidelinerecommendedthatBPshouldnotbediagnosedandtreatedbasedononeclinicBPmeasurementMajoritywillneedrepeatedclinicvisitstoconfirmorrefutethediagnosisInaccurateclinicmeasurementsmayweakentherelationshipbetweenBPandCVDriskPeoplewhodonothavesustainedBPmaybewronglydiagnosedandcommencedontreatmentwithriskofsideeffectsandunnecessarydiagnosisandanxietyandcost.WhyHomeorABPM?18EquipmentTraining

ServicingEquipmentTraining19InvestigationsUrineBiochemistryBloodGlucoseLipidProfileElectrocardiogram,CXRUSG-KUB,Urinarycatecholamine,TSH,CXR,ECHO,urinaryfreecortisol,SpecialistinvestigationsInvestigationsUrine20LifeStyleModifications.Maintainnormalweightforadults(BMI20-25kg/m2)Reducesaltintaketo<100mmol/day(<6gNaClor<2.4gNa+/day)Limitalcoholconsumptionto<3units/dayformenand<2units/dayforwomenEngageinregularaerobicphysicalexercise(briskwalkingratherthanweightlifting)for>30minperdayConsumeatleastfiveportions/dayoffreshfruitandvegetablesReducetheintakeoftotalandsaturatedfat

STOPSMOKINGLifeStyleModifications.21NextInitiatingandmonitoringantihypertensivedrugtreatment,including

bloodpressuretargetsNextInitiatingandmonitoring22DrugtherapyforhypertensionClassofdrug

Example Initiatingdose Usual

maintenancedoseDiuretics Hydrochlorothiazide 12.5mgo.d. 12.5-25mgo.d.

-blockers Atenolol 25-50mgo.d. 50-100mgo.d.Calcium Amlodipine 2.5-5mgo.d. 5-10mgo.d.channel blockers

-blockers Doxazosin 1mgo.d. 1-8mgo.d.ACE-inhibitors Lisinopril 2.5-5mgo.d. 5-20mgo.d.AngiotensinII Losartan 25-50mgo.d. 50-100mgo.d.receptorblockers -CentrallyActing Methyledopa HydralazineDrugtherapyforhypertensionC23Antihypertensivetherapy:

Side-effectsandContraindicationsClassofdrugs Mainside-effects Contraindications/

SpecialPrecautionsDiuretics Electrolyteimbalance, Hypersensitivity,Anuria

(e.g.Hydrochloro- -totalandLDLcholesterol

thiazide) levels,ˉHDLcholesterol levels,-glucoselevels,

-uricacidlevelsb-blockers Impotence,Bradycardia, Hypersensitivity,

(e.g.Atenolol) Fatigue Bradycardia,Conduction

disturbances,Diabetes,

Asthma,Severecardiac

failureAntihypertensivetherapy:

Side24Classofdrug Mainside-effects Contraindications/Special PrecautionsCalciumchannelblockers Pedaledema,Headache Non-dihydropyridine

(e.g.Amlodipine, CCBs(e.gdiltiazem)–

Diltiazem) Hypersensitivity,

Bradycardia,Conduction

disturbances,Congestiveheart

failure,Leftventricular

dysfunction. DihydropyridineCCBs– Hypersensitivitya-blockers Posturalhypotension Hypersensitivity

(e.g.Doxazosin)ACE-inhibitors Cough,Hypertension, Hypersensitivity,Pregnancy,

(e.g.Lisinopril) Angioneuroticedema BilateralrenalarterystenosisAngiotensin-IIreceptor Headache,Dizziness Hypersensitivity,Pregnancy,

blockers(e.g.Losartan) Bilateralrenalarterystenosis

Antihypertensivetherapy:Side-effectsandContraindications(Contd.)Classofdrug Mainside-effect25FactorsaffectingchoiceofantihypertensivedrugThecardiovascularriskprofileofthepatientCoexistingdisordersTargetorgandamageInteractionswithotherdrugsusedforconcomitantconditionsTolerabilityofthedrugCostofthedrugFactorsaffectingchoiceofan26ChoosingtherightantihypertensiveCondition Preferreddrugs Otherdrugs Drugstobe

thatcanbeused avoided

Asthma Calciumchannel a-blockers/Angiotensin-II b-blockers

blockers receptorblockers/Diuretics/

ACE-inhibitorsDiabetes

a-blockers/ACE Calciumchannelblockers Diuretics/

mellitus inhibitors/ b-blockers

Angiotensin-II

receptorblockersHighcholesterol

a-blockers ACEinhibitors/Angiotensin-II b-blockers/

levels receptorblockers/Calcium Diuretics

channelblockersElderlypatients Calciumchannel

-blockers/ACE- (above60years) blockers/Diuretics inhibitors/Angiotensin-II receptorblockers/

-blockersBPH

a-blockers b-blockers/ACEinhibitors/ Angiotensin-IIreceptor blockers/Diuretics/ CalciumchannelblockersChoosingtherightantihyperte27Limitationsonuseofantihypertensivesinpatients

withcoexistingdisordersCoexisting Diuretic b-blocker ACE All CCB a1-blocker

Disorder inhibitor antagonistDiabetes Caution/x Caution/x

Dyslipidaemia x x

CHD

Heartfailure

3/Caution

Caution

Asthma/COPD

x

/Caution

Peripheral

Caution Caution Caution

vascular

diseaseRenalartery

x x

stenosisLimitationsonuseofantihype28

29

30WHICHPATIENTSNEEDTREATMENTConcentrateBpReadingTargetOrganDamage10YearCVDRiskDiabetesYoungHypertensivesWHICHPATIENTSNEEDTREATMENTC31InitiatingTreatmentOfferpeopleolderthan80yearsthesameantihypertensivedrugtreatmentaspeopleaged55–80years,takingintoaccountanycomorbidities2011OfferStage1Hypertensive'streatmentiftheyhave

targetorgandamageor86establishedcardiovasculardiseaseorrenaldiseaseordiabetesora10-yearcardiovascularriskequivalentto20%orgreater.[new2011]InitiatingTreatmentOfferpeop32InitiatingTreatmentHypertensionisnotcontrolledwithmonotherapyinatleast50%ofpatients;inthesepatientscombinationtherapyisrequiredOfferantihypertensivedrugtreatmenttopeoplewithstage2hypertension.[new2011]Forpeopleyoungerthan40yearswithstage1hypertensionandnoevidenceoftargetorgandamage,cardiovascular(CV)disease,renaldiseaseordiabetes,considerseekingspecialistevaluationofsecondarycausesofhypertensionandamoredetailedassessmentofpotentialtargetorgandamage.Thisisbecause10-yearCVriskassessmentscanunderestimatethelifetimeriskofCVeventsinthesepeople-new2011

InitiatingTreatment33【高血壓英文課件】-Hypertension34【高血壓英文課件】-Hypertension35

36Choosingdrugsforpatientsnewlydiagnosedwithhypertension:NICE/BHS

Choosingdrugsforpatientsne37AntihypertensiveDrugTreatment-2011AntihypertensiveDrugTreatmen38TreatmentRecommendations–GeneralConceptsOfferpeoplewithisolatedsystolichypertension(systolicBP160mmHgormore)thesametreatmentaspeoplewithbothraisedsystolicanddiastolicbloodpressure.[2004]Offerpeopleolderthan80yearsthesameantihypertensivetreatmentaspeopleaged55–80years,takingintoaccountanycomorbidities.[new2011]Offerstep1antihypertensivetreatmentwithanACEinhibitororalow-costARBtopeopleagedunder55years.IfanACEinhibitorisusedandnottolerated,offeranARB.[new2011]DonotcombineanACEinhibitorwithanARBtotreathypertension.[new2011]TreatmentRecommendations–Ge39Step1TreatmentRecommendations

Offerstep1antihypertensivetreatmentwithaCCBtopeopleaged55yearsandolderandtoblackpeopleofAfricanandCaribbeandescentofanyage.IfaCCBisnotsuitable,forexamplebecauseofoedemaorintolerance,orifthereisevidenceofheartfailure,orahighriskofheartfailure,offerathiazide-likediuretic.[new2011]Ifadiureticisrequired,chooseathiazide-likediuretic,suchaschlortalidone(12.5mg–25.0mgoncedaily)orindapamide(2.5mgoncedaily)inpreferencetoaconventionalthiazidediureticsuchasbendroflumethiazideorhydrochlorothiazide.[new2011]Step1TreatmentRecommendatio40Step2TreatmentRecommendationsIfstep2antihypertensivetreatmentisrequired,offeraCCBincombinationwitheitheranACEInhibitororalow-costARB.IfaCCBisnotsuitable,forexamplebecauseofoedemaorintolerance,orifthereisevidenceofheartfailureorahighriskofheartfailure,offerathiazide-likediuretic[new2011]Step2TreatmentRecommendatio41Step3TreatmentRecommendationsIftreatmentwiththreedrugsisrequired,thecombinationofACEinhibitororangiotensinIIreceptorblocker,calcium-channelblockerandthiazide-likediureticshouldbeused.[2006]Step3TreatmentRecommendatio42Step4TreatmentRecommendations

ResistantHypertension

Fortreatmentofresistanthypertensionatstep4,considerfurtherdiuretictherapywithlow-dosespironolactone(25mgoncedaily)ifbloodpotassiumlevelsarelowerthan4.5mmol/landeGFRishigherthan60ml/min/1.73m2.Ifbloodpotassiumlevelsarehigherthan4.5mmol/l,considertherapywithahigher-dosethiazide-likediuretictreatment.[new2011]Whenusingfurtherdiuretictherapyforresistanthypertensionatstep4,monitorbloodsodiumandpotassiumandrenalfunctionwithin1monthandrepeatasrequiredthereafter.[new2011]Step4TreatmentRecommendatio43Step4TreatmentRecommendations

ResistantHypertensionIffurtherdiuretictherapyforresistanthypertensionatstep4isnottolerated,contraindicatedorineffective,consideranalpha-orbeta-blocker.[new2011]Ifbloodpressureremainsuncontrolledwiththeoptimalormaximumtolerateddosesoffourdrugs,seekexpertadviceifithasnotyetbeenobtained.new2011]Step4TreatmentRecommendatio44BPTargetsinVariousGuidelines

Guidelines

Uncomp.HTNDMCRF

USA(JNCVII[2003])<140/90mmHg <130/80mmHg<130/80mmHg

Europe(ESH2007) <140/90mmHg <130/80mmHg<130/80mmHg

China(CSH2005) <140/90mmHg <130/80mmHg<130/80mmHg

Russia<140/90mmHg <130/80mmHg<130/80mmHg

Korea(KSH2004) <140/90mmHg <130/80mmHg<130/80mmHg

WHOISH SBP<140mmHg <130/80mmHg<130/80mmHg

BHSIV2004 <140/85mmHg <130/80mmHg<130/80mmHg BPTargetsinVariousGuidelin45HypertensioninDRAFTNICEBigchangeswithimpactonPrimaryCareHypertensionasadiseasePrimarynotEssentialhypertensionAtleast?ofadultUKpopulationhaveaBP>=140/90orhypertensionMorethan?ofthose60ormoreHypertensioninDRAFTNICE46HypertensioninNICE(DRAFT)

StrongemphasisondiagnosisandmeasuringbloodpressureEnsuringtrainingforthosetakingbloodpressuremeasurementsValidation,maintenanceandcalibrationofdevicesandcorrectcuffsizeStandardprocedureformeasurementresting5-10minCheckpulserhythmforAFCheckforposturaldropIffirstandsecondreadingsarebothhigherthan140/90toarrangeanABPMIfbloodpressure>180/110starttreatment

HypertensioninNICE(DRAFT)47Suggestedindicationsforspecialist

referralUrgenttreatmentneeded?Acceleratedhypertension(severehypertensionandgradeIII-IVretinopathy)?Particularlyseverehypertension(>220/120mmHg)?Impendingcomplications(forexample,transientischemicattack,leftventricularfailure)Possibleunderlyingcause?Anyclueinhistoryorexaminationofasecondarycause,suchashypokalaemiawithincreasedorhighnormalplasmasodium(Conn’ssyndrome)?Elevatedserumcreatinine?SuspectedphaeochromocytomewithlabileBPorposturalhypotension,headache,palpitations,pallor

Suggestedindicationsforspec48Suggestedindicationsforspecialist

referral?Proteinuriaorhaematuria?Suddenonsetorworseningofhypertension?Resistanttomultidrugregimen(≥3drugs)?Youngage(anyhypertension<20years;needingtreatment<30years)Therapeuticproblems?Multipledrugintolerance?Multipledrugcontraindications?Persistentnon-adherenceornon-complianceSpecialsituations?Unusualbloodpressurevariability?Possiblewhitecoathypertension?HypertensioninpregnancySuggestedindicationsforspec49Groupsthatwillnotbecovered420Peoplewithdiabetes.Childrenandyoungpeople(youngerthan18years).Pregnantwomen.Secondarycausesofhypertension(forexample,Conn'sadenoma,phaeochromocytomaandrenovascularhypertension).Peoplewithacceleratedhypertension(thatis,severeacutehypertension426associatedgradeIIIretinopathyandencephalopathy).PeoplewithacutehypertensionorhighbloodpressureinemergencycareGroupsthatwillnotbecovere50DrugsinspecialconditionsConditionPregnancy

Coronaryheartdisease CongestiveheartfailurePreferredDrugsNifedipine,labetalol,hydralazine,beta-blockers,methyldopa,prazosin Beta-blockers,ACEinhibitors,CalciumchannelblockersACEinhibitors,

beta-blockers1999WHO-ISHguidelinesDrugsinspecialconditionsCon51HTNandPregnancy?Chronichypertension(2-4%)?Hypertensionfirstidentifiedinearlypregnancy?Hypertensionthatpersistspostpartum?Gestationalhypertension(2-4%)Non-proteinurichypertension?Pre-eclampsia3%primigravidaattermand0.5%pre-termHTNandPregnancy52HTNandPregnancy?Duringpregnancy,BPtarget;130/80-150/100mmHg?IfBP≥150/100;startlabetolol/methyldopa/nifedipineSR?AvoidACE-IandARBsduringpregnancy?Considersecondaryhypertensioninwomenwithseverehypertensionespeciallyinearlypregnancyandpostpartum?Considerprophylacticlow-doseaspirinfrom12weeks?Bothsystolicanddiastolichypertensionimportant?Earlyonsetpre-eclampsia,aseriousthreattomotherandfoetus?Long-termfollowupisessentialforfuturewo