Hypertension

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Hypertension

• Introduction and care pathways

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Hypertension adds to the overall risk of CV
disease Jackson R, et al. Lancet 2005 365
434-441
5-year CVD risk ()
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Care Pathway
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Diagnosing hypertensionNICE Guideline CG034 2006

• Accurate measurement of BP needs meticulous
  clinical technique using properly validated and
  regularly calibrated devices
• Several BP measurements are required before
  hypertension is diagnosed
• Ask patients with initial BP gt140/90mmHg to
  return for at least two further visits, normally
  a month apart
• Measure BP twice on each visit under the best
  possible conditions
• Refer patients with signs/symptoms of malignant
  hypertension immediately (BPgt180/110mmHg)
• Ambulatory/home monitoring is not currently
  recommended but may be useful on occasions (e.g.
  for establishing white-coat hypertension)

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Device Bulletin DB2006(03) July 2006

• Ensure that only clinically validated equipment
  is purchased
• Check mercury devices at least annually and
  aneroid devices at least twice a year
• Ensure large and regular cuffs are available
• Undercuffing overestimates BP, overcuffing
  underestimates BP
• Dont discount hypertension because of suspected
  anxiety
• Consider ABPM if gt10mmHg discrepancy (systolic)
• Measure BP in both arms initially and use arm
  with higher values for subsequent readings
• Consider referral if gt20mmHg (systolic) or
  gt10mmHg (diastolic) difference between arms

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Device Bulletin DB2006(03) July 2006

• Ensure arm is supported, with cuff at the level
  of the heart
• Measure BP at the same time of day if practically
  possible
• Remember average daytime ABPM are approx 10/5mmHg
  less than surgery measurements
• Remember the white coat effect
• Remember BP variability is large
• It can vary from the mean by a standard deviation
  of 12/8mmHg in the same patient on different days
• Measurement of BP by any method is less reliable
  in the presence of arrhythmias such as atrial
  fibrillation

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Hypertension guidelines thresholds NICE and
JBS-2NICE Guidelines 2002, 2004 and 2006 JBS-2
2005
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Hypertension guidelines targets NICE and
BHS-IVNICE Guidelines 2002, 2004 and 2006 JBS-2
2005
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The HOT study Hansson L, et al. Lancet 1998
351 1755-1762
Major CV events
All MIs
The principal results of the HOT Study
demonstrate the benefits of lowering blood
pressure in patients with hypertension to 140mmHg
systolic and 85mmHg diastolic, or lower. Efforts
to lower blood pressure further, down to 120mmHg
systolic and 70mmHg diastolic, appear to give
little further benefit, but do not cause any
significant additional risk.
All stroke
CV mortality
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Diet and lifestyle
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Effect for lifestyle interventions
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The three steps to hypertension heaven

• Does the patient really need to use drug therapy?
• check the sphyg and your technique
• do several readings on different occasions
• review all potential drug causes and try non-drug
  therapies first (unless the BP is really high)
• attend to other risk factors e.g. smoking,
  lipids, etc.
• If you do need to treat, getting the pressure
  down is more important than worrying too much
  about which drugs to use
• thiazides are still first choice for most people,
  CCBs and Ace-Is are first choice for some people,
  ß-blockers should not routinely be used
  first-line, doxazosin is first choice for almost
  no-one
• choose agent(s) according to the individual (e.g.
  ACEI in heart failure)
• think about switching drug classes if you dont
  get a response
• Treat the patient, not the blood pressure
• compliance is important a drug that is not
  taken will not work
• remember the U-shaped curves in HOT the
  potential benefits to be gained from decreasing
  BP ever further must be weighed against the
  acceptability to the patient of aggressive
  therapy with multiple drugs