High Blood Pressure in Context. Dr Yassir Javaid GP Northampton Primary Care CVD lead EMSCN

Transcription

1 High Blood Pressure in Context Dr Yassir Javaid GP Northampton Primary Care CVD lead EMSCN

2 Premature Deaths by Cause in UK, 2012 Men Women Cardiovascular Disease Statistics, 2014 British Heart Foundation

3 Hypertension Prevalence by Age *Based on data from the Hypertension is defined as blood pressure 140/90 mm Hg or as receiving antihypertensive treatment. Fields LE, et al. Hypertension. 2004;44:

4 Risk Factors for Stroke Increases stroke risk by 430% Increases stroke risk by 480% Increases stroke risk by 140% Increases stroke risk by 240%

5 INTERHEART Study Case control study acute MI in 52 countries n risk factors account for > 90% attributable risk of MI Abnormal Lipids Diabetes Abdominal Obesity Adverse diet Lack of regular exercise Smoking Hypertension Psychosocial Excess Alcohol Lancet Sep 11-17;364(9438):937-52

6 Abnormal lipids and current smoking status confer the greatest risk of developing acute myocardial infarction Odds ratios for risk factors most associated with the development of acute myocardial infarction *Lipid profile as measured by apolipoprotein B/apolipoprotein A1 ratio (5 th quintile vs 1st) Adapted from Yusuf S, et al. Lancet. 2004; 364:

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8 Hypertension is a major risk factor Cushman WC. J Clin Hypertens. 2003;5(Suppl):14-22

9 LVH

10 Assessing cardiovascular risk and target organ damage All patients with BP > 140/90 should undergo a formal estimation of cardiovascular risk: Q-RISK2 to assess 10 year risk Discuss treatment options both for: raised BP other modifiable risk factors Assess for target organ damage: Urinalysis: Proteinuria, ACR, haematuria Bloods: U&E, creatinine, egfr, lipids, HbA1c ECG: LVH, AF, ischaemic changes Fundoscopy: Retinopathy

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13 Diagnosis of Hypertension (NICE/BHS Hypertension guidelines 2011) ABPM predicts CV outcomes better than home BP and clinic BP monitoring Home BP correlates much better with ABPM than clinic BP readings Offer ambulatory ABPM to any patient with clinic BP > 140/90 at least 14 day time readings Offer home BP if ABPM declined readings twice daily for at least 4 days (preferably 7 days) Lower cut offs 135/85 (stage 1) and 150/95 (stage 2) White coat hypertension is not a benign condition & importance of loss of nocturnal dipping (10-20% drop in BP)

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15 Cost Effectiveness of ABPM Data are QALY (95% CI) or costs (95% CI). CBPM=clinic blood-pressure monitoring. HBPM=home blood-pressure monitoring. ABPM=ambulatory blood-pressure monitoring. CE=cost effective at a threshold. QALYs=quality-adjusted life years. Lovibond et al Lancet 2011

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18 Similar BP lowering amlodipine vs atenolol

19 Anti-hypertensive drug therapy CCBs first line for patients < 55 or black patients (significantly fewer cases of new onset DM) Beta-blockers not for routine use (except women of child bearing age) Thiazide-type diuretics: Thiazide-like preferred over classic thiazide (more contemporary studies and used lower doses) ie indapamide and chlorthalidone preferred over bendroflumethiazide and hydrochlorothiazide If patient already on bfz and well controlled with no undesirable effects continue 4 th line: add spirononlactone 25mg (if K + 4.5) or inc dose thiazide-like diuretic if ineffective or not tolerated alpha or beta blocker Adapted from BHS/NICE guidance for Hypertension 2011

20 Special Cases Diabetes >50% Diabetics have high BP (metabolic syndrome) >70% will need 3 or more drugs UKPDS: BP control > Glycaemic control 1st line - ACE-I (renal protection): max tolerated dose if microalbuminuria Women of child bearing age: CCB Stable Angina 1 st line BB 2 nd line CCB Heart Failure 1 st line ACE-I, BB +/- MRA

21 Cardiovascular Risk Assessment: 10yr vs Lifetime risk

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28 SPRINT TRIAL Systolic Blood Pressure Interventional Trial Intensive (< 120mmHg) vs Standard (<140mmHg) BP Control Multicentre Study in USA 9361 patients: > 50 yrs SBP mmHg CV risk: CKD (egfr 20-60ml/min) 10 yr Framingham risk > 15% > 75 yrs Diabetics and prior stroke patients excluded

29 (Avg 2 drugs) (Avg 3 drugs)

30 Primary Outcome: Composite of: - Myocardial infarction - Acute coronary syndrome, - Stroke, - Heart failure, or - Death from CVD

31 Primary Outcome According to Subgroups

32 Serious Adverse Events

33 Key Points Increasing prevalence: vast majority of cases are > 45 yrs old; 78% of > 75 yr olds Most patients remain either undiagnosed or undertreated Improved outcomes with treatment: 50% reduction in heart failure 40% reduction in stroke Diagnosis: ABPM (or HBPM) if elevated clinic readings > 140/90 Lower ABPM cut off (Average daytime: > 135/85) Monitoring: Clinic BP (or HBPM/ABPM if white coat hypertension)

34 Key Points BP targets: 140/90 (or 150/90 in those > 80 years) Optimise drug treatment + lifestyle before adding additional Rx Appropriate assessment CVD risk and intervene to reduce total CVD risk Majority will require combination treatment Monotherapy highly likely to be inadequate therapy Drug treatment should be tailored to the individual taking into account cardiovascular risk, co-morbidity, adverse effects of medication and patient preference (Compliance issues = asymptomatic disease)