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.
Hypertension Treatment Choice
- Assess comorbidity.
- Multiple drugs are usually necessary.
- Monitor until control achieved
- Early introduction of 2nd agent
- Nocte dosing
First Line
- ‒ Thiazides
- ‒ ACEI/ARB (not cilazapril)
- ‒ CCB
Second Line - Beta blockers (bisoprolol, carvedilol)
Third Line ‒ Spironolactone ‒ Alpha blockers
Recommended starting medication
- ACE inhibitor or ARB esp. if ≥ 55 years or
- Calcium channel blocker (CCB) or low-dose thiazide diuretic (if aged ≥65 years)
- If target not reached:
- ACE1 or ARB + CCB (best evidence) or
- ACE1 or ARB + thiazide
- If target not reached: use combination (best evidence)
* ACE1/ARB + CCB + thiazide - If still not reached, use spironolactone or seek specialist advice
Need at least 4–6 wks to test effect.
If partly effective, increase dose to maximum or add on.
If ineffective, substitute a different class.
Combination (for partly effective monotherapy)
Diuretic + β-blocker or ACE inhibitor/ARB
β-blocker + dihydropyridine Ca antagonist
ACE inhibitor/ARB + Ca antagonist
prazosin + others
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.
Treatment guidance for primary prevention in pts with HTN
Step one treatment for primary prevention in pts with uncomplicated HTN is an ACE inhibitor or calcium channel blocker
Step two treatment, combine an ACE inhibitor or ARB with a calcium channel blocker.
Step three treatment, add a thiazide diuretic e.g. indapamide.
Females of reproductive age should generally not be prescribed an ACE or ARB. Beta-blockers, e.g. metoprolol, or calcium channel blockers, e.g. felodipine, are recommended.
If the pt has diabetes or there is evidence of end organ damage, e.g. LVH, proteinuria, an ACE inhibitor should be prescribed first-line.
Consider a beta-blocker in combination early when:
- Ischaemic heart disease or heart failure is present – to reduce mortality
- Atrial fibrillation is present – for rate control
If PVD is present an ACE inhibitor should be considered to slow disease progression, or a calcium channel blocker to vasodilate the peripheral arteries
HTN is mostly managed in primary care
If hypertensive emergency, seek urgent general medicine advice as admission or urgent assessment may be required.
If hypertensive urgency, treat with oral antihypertensive medication and review daily.
Consider initiating a combination of 2 complementary medications (ACEi or ARB and dihydropyridine CCB) at adequate (non-minimum) doses.
Avoid diuretics, as pts with hypertensive urgency are often hypokalaemic.
Follow up daily to assess BP and clinical features of hypertensive emergency, and to review medications.
Consider slowly increasing interval between follow-ups after BP is
If suspected or confirmed secondary HTN, manage according to suspected cause.
If renal disease is suspected (e.g., signs of RA stenosis, palpable kidneys, suspected urinary obstruction, raised creatinine, family history of kidney disease), investigate and request non-acute nephrology assessment as indicated.
If endocrine disease is suspected, consider non-acute endocrinology assessment.
Develop and maintain a comprehensive management plan:
Advise the pt on lifestyle interventions.
Begin antihypertensive Rx:
- Check indications for antihypertensive drug Rx based on absolute CVR.
- Adjust dose to meet appropriate individualised blood pressure targets.
Consider special groups:
- Hypertension in the elderly
- Isolated systolic hypertension
- Hypertension with proteinuria
- Resistant hypertension
If the patient is pregnant or postpartum, see Hypertension in Pregnancy or Postpartum.
Once blood pressure is satisfactory, review every 6 months.
Request non-acute general medicine assessment if:
- resistant HTN ( > 140/90 despite good adherence to maximally tolerated triple anti‑hypertensive Rx).
- age
- suspicion of secondary cause.
- uncertain whether drug treatment should be initiated.
Request written general medicine advice if referral criteria is not met, but clinical concern remains.
Hypertension in the elderly
Clinical trials in the elderly consistently show benefit from antihypertensive therapy, including in patients aged > 80 years.
Provide close follow-up to identify treatment-related adverse effects, including:
- hypotension
- Postural hypotension ( esp Thiazide)
- syncope
- electrolyte abnormalities
- acute kidney injury
In frail elderly pts, use clinical judgement and consider risks of Rx e.g., orthostatic hypotension, falls, polypharmacy, and interactions.
Isolated systolic hypertension
Pts with isolated systolic HTN, e.g. > 160 mmHg, should be offered the same Rx as people with elevated systolic and DBP
Predominantly a problem in older pts.
Use first-line diuretics or calcium channel blockers.
Pts with isolated diastolic HTN without significant co-morbidities should be treated according to their overall cardiovascular risk. The importance of isolated diastolic HTN is considered to be less than isolated systolic HTN
Hypertension with proteinuria
HTN is a driver for progressive renal failure in CRD.
Use ACE inhibitor or ARB and titrate to the maximum tolerated dose.
Consider a lower SBP target of 25 (males) or > 35 (females).
Monitor eGFR in these groups.
Resistant hypertension
Defined as failure to achieve target despite appropriate lifestyle measures and 3 drugs from different classes, including a diuretic, at adequate doses.
Exclude:
- non-adherence
- white-coat HTN
- use of incorrectly sized BP cuffs.
Use a multi-modal approach:
Check ambulatory or home BPs.
Review lifestyle interventions for unaddressed factors.
Ensure a secondary cause has not been missed, particularly underlying renal disease.
If resistant HTN confirmed, request non-acute general medicine assessment and consider a trial of spironolactone 12.5 to 25 mg daily, with appropriate monitoring of electrolytes and creatinine.
Spironolactone is twice as effective in this setting compared with beta blockers or long-acting alpha-blockers, with approximately 8 versus 4 mmHg reductions respectively.
Watch for hyperkalaemia.
If not reaching Rx targets despite Rx with 3 concurrent medications at adequate doses (or unacceptable side‑effects), request non-acute general medicine assessment.
Invasive treatments (e.g., renal denervation) cannot be recommended outside of specialist centres.
Important Hints
It is hard to have BP controlled especially with one agent only; usually need 2 or more agents
Start with Thiazides first, then ACI, then ARB, then B-blockers
Give combination of small doses of antihypertensive Rx:
- better synergetic effect than increasing the dose of a single agent
If any side effects of a single agent, move out of the same class
If coughs to ACU, move to Ca++ channel blockers
Amlodipine has the least side ankle oedema S/E among the other Ca++ channel blockers
Bisoprolol and Carvedilol are far better than Atenolol and Metoprolol
Doxazosin increases the risk of Ht failure unless you have other reasons and used the other agents first
Do not give Ca++ channel blockers to pregnant ladies
HTN in elderly is characterised with low rennin activity and therefore CCB and thiazide should be used first
Losartan if good for Gout
Hypertension with Diabetes
Target BP < 130/80
Agents of Choice:ACEI or ARBs (high dose)
Bendrofluazide 2.5mg/ Chlorthalidone 25mg – minimal effect on blood sugar
Thiazide + Beta blocker = ↑ diabetes
Hypertension update: beyond cilazapril-plus lecture
