Management Flashcards
2018 NZ Hypertension Guidelines
‒ Ideal BP 130/80
‒ ↓ salt, liquorice, weight, ↑ exercise
‒ BP >160/90 Treat
‒ 5y CVD risk > 15%, BP > 130/80 Treat
‒ 5y CVD risk 5 – 15%, BP > 140/90 Discuss
‒ Target BP < 130/80
Mangement plan based on CV risks
Predict 5 yr CV risk Plan
< 5 Life style
5-15 Shared decesion
>15 Treat with meds
BP > 160/100 Treat with meds
CVD Risk Assessment for people with type 2 diabetes
in New Zealand
Benefit of treatment
‒ Systolic BP better predictor of adverse cardiovascular events especially in elderly
‒ Linear increase in risk from BP 115/75
‒↑20mmHg SBP or ↑10mmHg DBP doubles mortality from cardiovascular disease
‒ Benefit of treatment is seen at all age group
It is essential that HTN is accurately diagnosed in primary careerse effects.
Rx of HTN often involves lifelong exposure to multiple medicines and their potential adverse effects
It is recommended that at least 2 BP measurements be taken, at least two minutes apart.
measurements should be taken from both arms.
If the difference between the arms is more than 20 mmHg, the measurements should be repeated.
If this difference persists then subsequent measurements should be taken from the arm with the highest reading.
Consistent differences in BP measurements of > 10 mmHg between arms is associated with increased CVR
Ambulatory or home testing of BP should be considered whenever substantial differences persist between clinic BP measurements to exclude the possibility of “white-coat” HTN (where the pt’s BPe is raised due to the anxiety of having it measured in the clinic).
Life-style modification is always important
There are only a limited number of people that can be effectively managed with monotherapy
Start with non-drug therapy if:
- systolic >140 mmHg
- and diastolic BP >90 mmHg
Weight reduction (if necessary); for every 1kg loss, SBP gose 1 mmHg down, ie for 10kg = 10 mmHg
Reduced alcohol intake to 1–2 SDs/d (max.)
Reduced sodium intake (avoid excess salt)
Increased exercise
Reduction of particular stress
Smoking cessation
Consider drug factors (e.g. NSAIDs, steroids)
Ensure adequate potassium and calcium intake
Excessive salt intake
Plays a significant role in HTN as well as contributing to resistant HTN.
Daily salt intake for most people ranges from 9 – 12 g per day.
Reducing salt intake to 5 g/day can achieve a reduction in SBP of 4 – 5 mmHg.
The benefits of salt reduction are greatest for people at increased CVR, e.g. older people and people with diabetes or CKD.
Decreasing the amount of processed food in the diet is the best way to achieve this as approximately 80% of dietary salt is “hidden” in processed food.
The NZ Heart Foundation, https://www.heartfoundation.org.nz/
- “A guide to heart healthy eating”
- “The Pacific heartbeat programme”
- “Know your numbers” tool allows pts to calculate their 5-yr CVR.
Intensification of treatment
The main benefits of antihypertensive Rx are due to the BP lowering properties of medicines.
Most people who are being treated for HTN will require multiple medicines and increased doses to achieve Rx targets.
Therefore the decision of when to initiate Rx is more important than which medicine is chosen.
Choice of medicine is also influenced by the presence of co-morbidities and other clinical findings
Goals of treatment (adults)
People with: Target BP (mm Hg)
proteinuria >1 g/day (with or without DM) <125/75
coronary heart disease <130/80
diabetes
chronic kidney disease
proteinuria (>300 mg/day)
stroke or TIA
others <140/90
If the clinic blood pressure is ≥140/90 mmHg a clinical evaluation should be conducted in order to:
- Confirm a diagnosis of hypertension
- Assess the pt’s cardiovascular risk
- Determine if any end organ damage has occurred
- Detect any causes of secondary hypertension
In pts with severe HTN (SBP ≥180 mmHg or DBP ≥110 mmHg) initiation of Rx should be considered immediately, before the diagnosis of HTN is confirmed, e.g. with ambulatory monitoring
When to initiate antihypertensive medicines
BP ≥160/100 mmHg, i.e. Stage 2 (moderate) or severe HTN
Any pts with HTN who have any of the following factors:
- Evidence of target organ damage
- CVD
- Renal disease
- Diabetes
- Five-year CVR ≥15%
Pts aged under 40 yrs with a CVR < 15% with stage one HTN (140 – 160 / 90 – 100 mmHg), who do not have any other criteria for the treatment of HTN, may still require management of BP.
- Consider referring them for more extensive evaluation for end organ damage, e.g. echocardiogram, and specialist assessment for secondary causes of hypertension.
Pts with isolated SBP, e.g. > 160 mmHg, should be offered the same Rx as people with elevated systolic and DBP.
- The importance of isolated diastolic HTN is considered to be less than isolated systolic HTN
- If BP 170/70, should be treated. Egnore the DBP.
Pts with isolated diastolic HTN without significant co-morbidities should be treated according to their overall CVR.
Pts with an intermediate BP level, i.e. between 120 – 139/80 – 89 mmHg, should be encouraged to implement lifestyle measures to control or reduce their BP and prevent being diagnosed with HTN.
Determine whether medications are indicated
If office BP ≥ 160 mmHg systolic or ≥ 100 mmHg diastolic (≥ 150/95 on ambulatory or home monitoring) after lifestyle modifications, treat regardless of CVD risk.
If 5‑year CVD risk is high (≥ 15%) and persistent office BP ≥ 130/80 (≥ 125/75 on ambulatory or home monitoring), treat with lifestyle changes and strongly recommend drug treatment.
If 5‑year CVD risk is moderate (5% to 15%) and persistent office BP of ≥ 140/90 (≥ 135/85 on ambulatory or home monitoring), advise lifestyle changes and discuss the risks and benefits of drug treatment.
Be aware that the current New Zealand CVD guidelines are more conservative (i.e., recommend Rx only at higher CVD risk levels) than European/NICE guidelines.
For each 10 mmHg reduction in SBP, there is an approximate 20% relative risk reduction in CVD events over 5 yrs.
Where calculators are available, calculate the absolute risk reduction for individual pts to facilitate shared decision-making.
Individual blood pressure targets
BP targets should be individualised according to:
- pt’s age
- the presence of co-morbidities.
For uncomplicated HTN:
- A target of < 140/90 mmHg for people aged
- > 80 years a target of < 150/90 mmHg
If out-of-clinic monitoring of BP is used:
- target of < 135/85 mmHg in people < 80 years
- or < 145/85 mmHg for > 80 years
Pts with CKD, diabetes or CVD aim for a target of < 130/80
- Lower targets should be approached with caution
- SBP of < 120 mmHg is associated with serious adverse effects in people with II DM
Alwys check sitting and standing BP in people with DM and elderlies
Drug treatment
Monotherapy
Start with a single agent at low dose
(depends on the individual and risk factors), e.g.
- diuretic (preferred in elderly)
- or β-blocker (cardioselective)
Can use:
- an ACE inhibitor
- angiotensin II receptor blocker (ARB)
- or a calcium channel blocker (CCB) as first line.
Common combinations of the therapeutic drug classes used for first-line therapy of hypertension.
are effective combinations are:
- A + D
- B + C
- B + D
Example start with perindopril 5 mg (o)/d increasing to max 10 mg/d.
If inadequate, add:
- Indapamide 1.25 mg (o) d or
- hydrochlorothiazide 12.5 mg (o)/d
Monitor electrolytes, esp. s. potassium.
