Determinants-of-cardiovascular-risk-in-hypertensiv.ppt

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1、HypertensionDrZakaHaq,MBBS,MRCPCardiologyRegistrarQueensHospitalRomfordHypertensionnPrevalence(UK)nNICEnBeta BlockersnChallengesnPrimaryCareHypertension-OverviewnHypertensionitself-IntroductionnTypesnClassificationnRiskFactorsnSequelsnHypertensioninspecialcircumstancesnManagementnFollowUpnGuidelines

2、nReferraltoSecondarycareHypertension,Introduction.nDiastolicpressureismorecommonlyelevatedinyoungerpeople.Withageing,systolichypertensionbecomesamoresignificantproblem.nTheclinicalmanagementofhypertensionisoneofthemostcommon22interventionsinprimarycare,accountingforapproximately1billionindrugcostsal

3、onein2006.nHypertensionisoftensymptomless,soscreeningisvital-beforedamageisdone.Manysurveyscontinuetoshowthathypertensionremainsunderdiagnosed,undertreatedandpoorlycontrolledintheUKHypertension,IntroductionnInmanycountries,50%ofthepopulationolderthan60yearshashypertension.Overall,approximately20%oft

4、heworldsadultsareestimatedtohavehypertension.nUK,1inevery4thpersonhasHypertensionandthisincreasesto1ineverysecondpersonagedover60.Types of hypertensionnEssential hypertension(Primary)u90%uNounderlyingcausenSecondary hypertensionu5%uUnderlyingcauseDefinitions and Classifications of BP LevelsSBPDBPCat

5、egory*(mmHg)(mmHg)Optimal12080Normal130180110ISH14060yearsnSex(menandpostmenopausalwomen)nFamilyhistoryofcardiovasculardiseasenSmokingnHighcholesteroldietnCo-existingdisorderssuchasdiabetes,obesityandhyperlipidaemianHighintakeofalcoholnSedentarylifestylenRemember all these are predisposing factors f

6、or HTN but they all including HTN are risk factors for Cardiovascular disease.Hypertension in special circumstancesnHTNinYoung-CausesnHTNandPregnancy-CautionsnHTNandDiabetes-ProteinureanHTNandRenalFailureviceversanHypertensiveEmergenciesurgency,EmergencyDiagnosis and Measurement-2011nIfthefirstandse

7、condbloodpressuremeasurementstakenduringconsultationare140/90mmHgorhigher,offer24-hourambulatorybloodpressuremonitoring(ABPM)toconfirmthediagnosisofhypertension.new 2011 nWhenusingABPMtoconfirmadiagnosisofhypertension,ensurethat:nBloodpressureismeasuredforatotalof24hours.nAtleasttwomeasurementsperho

8、uraretakenduringtheday(08:00to22:00).nAtleastonemeasurementperhouristakenduringthenight(22:00to08:00).nUsetheaveragedaytimebloodpressuremeasurement,new 2011 Diagnosis and Measurement-2011nWhenusinghomebloodpressuremonitoring(HBPM)toconfirmadiagnosisofhypertension,ensurethat:nForeachbloodpressuremeas

9、urement,twoconsecutivemeasurementsaretaken,atleast1minuteapartandwiththepersonseated.nBloodpressuremeasurementsaretakentwicedaily,ideallyinthemorningandevening.nBloodpressuremeasurementcontinuesforatleast4days,ideallyfor7days.nDiscardthemeasurementstakenonthefirstdayandusetheaveragevalueofalltherema

10、iningmeasurementstoconfirmadiagnosisofHTN-2011Why Home or ABPM?n2004GuidelinerecommendedthatBPshouldnotbediagnosedandtreatedbasedononeclinicBPmeasurementnMajoritywillneedrepeatedclinicvisitstoconfirmorrefutethediagnosisnInaccurateclinicmeasurementsmayweakentherelationshipbetweenBPandCVDrisknPeoplewh

11、odonothavesustainedBPmaybewronglydiagnosedandcommencedontreatmentwithriskofsideeffectsandunnecessarydiagnosisandanxietyandcost.EquipmentTrainingServicingInvestigationsnUrinenBiochemistrynBloodGlucosenLipidProfilenElectrocardiogram,CXRnUSG-KUB,Urinarycatecholamine,TSH,CXR,ECHO,urinaryfreecortisol,nSp

12、ecialistinvestigationsLife Style Modifications.nMaintainnormalweightforadults(BMI20-25kg/m2)nReducesaltintaketo100mmol/day(6gNaClor2.4gNa+/day)nLimitalcoholconsumptionto3units/dayformenand30minperdaynConsumeatleastfiveportions/dayoffreshfruitandvegetablesnReducetheintakeoftotalandsaturatedfatnSTOPSM

13、OKINGNextInitiatingandmonitoringantihypertensivedrugtreatment,including bloodpressuretargetsAntihypertensivetherapy:Side-effectsandContraindicationsClassofdrugsMainside-effectsContraindications/SpecialPrecautionsDiureticsElectrolyteimbalance,Hypersensitivity,Anuria(e.g.Hydrochloro-totalandLDLcholest

14、erolthiazide)levels,HDLcholesterollevels,glucoselevels,uricacidlevelsb-blockersImpotence,Bradycardia,Hypersensitivity,(e.g.Atenolol)FatigueBradycardia,Conductiondisturbances,Diabetes,Asthma,SeverecardiacfailureClassofdrugMainside-effectsContraindications/SpecialPrecautionsCalciumchannelblockersPedal

15、edema,HeadacheNon-dihydropyridine(e.g.Amlodipine,CCBs(e.gdiltiazem)Diltiazem)Hypersensitivity,Bradycardia,Conductiondisturbances,Congestiveheartfailure,Leftventriculardysfunction.DihydropyridineCCBsHypersensitivitya-blockersPosturalhypotensionHypersensitivity(e.g.Doxazosin)ACE-inhibitorsCough,Hypert

16、ension,Hypersensitivity,Pregnancy,(e.g.Lisinopril)AngioneuroticedemaBilateralrenalarterystenosisAngiotensin-IIreceptorHeadache,DizzinessHypersensitivity,Pregnancy,blockers(e.g.Losartan)BilateralrenalarterystenosisAntihypertensivetherapy:Side-effectsandContraindications(Contd.)Factorsaffectingchoiceo

17、fantihypertensivedrugnThecardiovascularriskprothepatientnCoexistingdisordersnTargetorgandamagenInteractionswithotherdrugsusedforconcomitantconditionsnTolerabilityofthedrugnCostofthedrugLimitationsonuseofantihypertensivesinpatientswithcoexistingdisordersCoexistingDiureticb b-blockerACEAllCCBa a1 1-bl

18、ockerDisorderinhibitorantagonistDiabetesCaution/xCaution/xDyslipidaemiaxxCHDHeartfailure3/CautionCautionAsthma/COPDx/CautionPeripheralCautionCautionCautionvasculardiseaseRenalarteryxxstenosisWHICH PATIENTS NEED TREATMENTnConcentratenBpReadingnTargetOrganDamagen10YearCVDRisknDiabetesnYoungHypertensiv

19、esInitiating TreatmentnOfferpeopleolderthan80yearsthesameantihypertensivedrugtreatmentaspeopleaged5580years,takingintoaccountanycomorbidities2011nOfferStage1Hypertensivestreatmentiftheyhaventargetorgandamageor 86nestablishedcardiovasculardiseaseor nrenaldiseaseorndiabetesor na10-yearcardiovascularri

20、skequivalentto20%orgreater.new 2011 Initiating TreatmentnHypertensionisnotcontrolledwithmonotherapyinatleast50%ofpatients;inthesepatientscombinationtherapyisrequirednOfferantihypertensivedrugtreatmenttopeoplewithstage2hypertension.new2011nForpeopleyoungerthan40yearswithstage1hypertensionandnoevidenc

21、eoftargetorgandamage,cardiovascular(CV)disease,renaldiseaseordiabetes,considerseekingspecialistevaluationofsecondarycausesofhypertensionandamoredetailedassessmentofpotentialtargetorgandamage.Thisisbecause10-yearCVriskassessmentscanunderestimatethelifetimeriskofCVeventsinthesepeople-new 2011 nChoosin

22、gdrugsforpatientsnewlydiagnosedwithhypertension:NICE/BHSAntihypertensive Drug Treatment-2011Treatment Recommendations General ConceptsnOfferpeoplewithisolatedsystolichypertension(systolicBP160mmHgormore)thesametreatmentaspeoplewithbothraisedsystolicanddiastolicbloodpressure.2004nOfferpeopleolderthan

23、80yearsthesameantihypertensivetreatmentaspeopleaged5580years,takingintoaccountanycomorbidities.new2011nOfferstep1antihypertensivetreatmentwithanACEinhibitororalow-costARBtopeopleagedunder55years.IfanACEinhibitorisusedandnottolerated,offeranARB.new2011nDonotcombineanACEinhibitorwithanARBtotreathypert

24、ension.new2011Step1TreatmentRecommendationsnOfferstep1antihypertensivetreatmentwithaCCBtopeopleaged55yearsandolderandtoblackpeopleofAfricanandCaribbeandescentofanyage.IfaCCBisnotsuitable,forexamplebecauseofoedemaorintolerance,orifthereisevidenceofheartfailure,orahighriskofheartfailure,offerathiazide

25、-likediuretic.new2011nIfadiureticisrequired,chooseathiazide-likediuretic,suchaschlortalidone(12.5mg25.0mgoncedaily)orindapamide(2.5mgoncedaily)inpreferencetoaconventionalthiazidediureticsuchasbendroflumethiazideorhydrochlorothiazide.new2011Step 2 Treatment RecommendationsnIfstep2antihypertensivetrea

26、tmentisrequired,offeraCCBincombinationwitheitheranACEInhibitororalow-costARB.IfaCCBisnotsuitable,forexamplebecauseofoedemaorintolerance,orifthereisevidenceofheartfailureorahighriskofheartfailure,offerathiazide-likediureticnew2011Step 3 Treatment RecommendationsnIftreatmentwiththreedrugsisrequired,th

27、ecombinationofACEinhibitororangiotensinIIreceptorblocker,calcium-channelblockerandthiazide-likediureticshouldbeused.2006Step4TreatmentRecommendationsResistantHypertensionnFortreatmentofresistanthypertensionatstep4,considerfurtherdiuretictherapywithlow-dosespironolactone(25mgoncedaily)ifbloodpotassiu

28、mlevelsarelowerthan4.5mmol/landeGFRishigherthan60ml/min/1.73m2.Ifbloodpotassiumlevelsarehigherthan4.5mmol/l,considertherapywithahigher-dosethiazide-likediuretictreatment.new2011nWhenusingfurtherdiuretictherapyforresistanthypertensionatstep4,monitorbloodsodiumandpotassiumandrenalfunctionwithin1montha

29、ndrepeatasrequiredthereafter.new2011Step4TreatmentRecommendationsResistantHypertensionnIffurtherdiuretictherapyforresistanthypertensionatstep4isnottolerated,contraindicatedorineffective,consideranalpha-orbeta-blocker.new2011nIfbloodpressureremainsuncontrolledwiththeoptimalormaximumtolerateddosesoffo

30、urdrugs,seekexpertadviceifithasnotyetbeenobtained.new2011BP Targets in Various GuidelinesGuidelines Uncomp.HTN DM C RFUSA(JNCVII2003)140/90mmHg130/80mmHg130/80mmHgEurope(ESH2007)140/90mmHg130/80mmHg130/80mmHgChina(CSH2005)140/90mmHg130/80mmHg130/80mmHgRussia140/90mmHg130/80mmHg130/80mmHgKorea(KSH200

31、4)140/90mmHg130/80mmHg130/80mmHgWHOISHSBP140mmHg130/80mmHg130/80mmHgBHSIV2004 140/85mmHg130/80mmHg=140/90orhypertensionnMorethanofthose60ormoreHypertension in NICE(DRAFT)nStrongemphasisondiagnosisandmeasuringbloodpressurenEnsuringtrainingforthosetakingbloodpressuremeasurementsnValidation,maintenance

32、andcalibrationofdevicesandcorrectcuffsizenStandardprocedureformeasurementresting5-10minnCheckpulserhythmforAFnCheckforposturaldropnIffirstandsecondreadingsarebothhigherthan140/90toarrangeanABPMnIfbloodpressure180/110starttreatmentSuggested indications for specialistreferralnUrgent treatment needednA

33、cceleratedhypertension(severehypertensionandngradeIII-IVretinopathy)nParticularlyseverehypertension(220/120mmHg)nImpendingcomplications(forexample,transientnischemicattack,leftventricularfailure)nPossible underlying causenAnyclueinhistoryorexaminationofasecondaryncause,suchashypokalaemiawithincrease

34、dorhighnnormalplasmasodium(Connssyndrome)nElevatedserumcreatininenSuspectedphaeochromocytomewithlabileBPorposturalhypotension,headache,palpitations,pallor Suggested indications for specialistreferralnProteinuriaorhaematurianSuddenonsetorworseningofhypertensionnResistanttomultidrugregimen(3drugs)nYou

35、ngage(anyhypertension20years;needingntreatment30years)nTherapeutic problemsnMultipledrugintolerancenMultipledrugcontraindicationsnPersistentnon-adherenceornon-compliancenSpecial situationsnUnusualbloodpressurevariabilitynPossiblewhitecoathypertensionnHypertensioninpregnancyGroups that will not be co

36、vered 420nPeoplewithdiabetes.nChildrenandyoungpeople(youngerthan18years).nPregnantwomen.nSecondarycausesofhypertension(forexample,Connsadenoma,phaeochromocytomaandrenovascularhypertension).nPeoplewithacceleratedhypertension(thatis,severeacutehypertension426associatedgradeIIIretinopathyandencephalopa

37、thy).nPeoplewithacutehypertensionorhighbloodpressureinemergencycareDrugsinspecialconditionsConditionnPregnancynCoronaryheartdiseasenCongestiveheartfailurePreferredDrugsnNifedipine,labetalol,hydralazine,beta-blockers,methyldopa,prazosinnBeta-blockers,ACEinhibitors,CalciumchannelblockersnACEinhibitors

38、,beta-blockers1999 WHO-ISH guidelinesHTN and PregnancynChronichypertension(2-4%)nHypertensionfirstidentifiedinearlypregnancynHypertensionthatpersistspostpartumnGestationalhypertension(2-4%)Non-proteinurichypertensionnPre-eclampsia3%primigravidaattermand0.5%pre-termHTN and PregnancynDuringpregnancy,B

39、Ptarget;130/80-150/100mmHgnIfBP150/100;startlabetolol/methyldopa/nifedipineSRnAvoidACE-IandARBsduringpregnancynConsidersecondaryhypertensioninwomenwithseverehypertensionespeciallyinearlypregnancyandpostpartumnConsiderprophylacticlow-doseaspirinfrom12weeksnBothsystolicanddiastolichypertensionimportan

40、tnEarlyonsetpre-eclampsia,aseriousthreattomotherandfoetusnLong-termfollowupisessentialforfuturewomanshealthCKD and DiabetesuIn people with CKD aim for:systolicbloodpressurebelow140mmHg(targetrange120139mmHg)diastolicbloodpressurebelow90mmHguIn people with CKD and diabetes-orwhenACR70mg/mmol,aimfor:s

41、ystolicbloodpressurebelow130mmHg(targetrange120129mmHg)diastolicbloodpressurebelow80mmHgPlace Of Beta blockersnBeta-blockersarenotapreferredinitialtherapyforhypertension.However,beta-blockersmaybeconsideredinyoungerpeople,particularly:nthosewithanintoleranceorcontraindicationtoACEinhibitorsandangiot

42、ensin-IIreceptorantagonistsornwomenofchild-bearingpotentialornpeoplewithevidenceofincreasedsympatheticdrive.nInthesecircumstances,iftherapyisinitiatedwithabeta-blockerandaseconddrugisrequired,addacalcium-channelblockerratherthanathiazide-typediuretictoreducethepersonsriskofdevelopingdiabetes.Otherme

43、dicationsforhypertensivepatientsPrimaryprevention(1)Aspirin:use75mgdailyifpatientisaged50yearswithbloodpressurecontrolledto150/90mmHgandeither;targetorgandamage,diabetesmellitus,or10yearriskofcardiovasculardiseaseof20%(measuredbyusingthenewJointBritishSocietiescardiovasculardiseaseriskchart)(2)Stati

44、n:usesufficientdosestoreachtargetsifpatientisageduptoatleast80years,witha10yearriskofcardiovasculardiseaseof20%(measuredbyusingthenewJointBritishSocietiescardiovasculardiseaseriskchart)andwithtotalcholesterolconcentration3.5mmol/l(3)Vitaminsnobenefitshown,donotprescribeSecondaryprevention(includingpatientswithtype2diabetes)(1)Aspirin:useforallpatientsunlesscontraindicated(2)Statin:usesufficientdosestoreachtargetsifpatientisageduptoatleast80yearswithatotalcholesterolconcentration3.5mmol/l(3)Vitaminsnobenefitshown,donotprescribeOthermedicationsforhypertensivepatients