Hypertension

7/18/2019 Hypertension

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Hypertension

management:

key recommendations

This presentation is adapted with permission from the National Heart Foundation of Australia

(National Blood Pressure and Vascular Disease Advisory Committee). Guide to management of hypertension 2008.

www.heartfoundation.org.au Guide to management of hypertension 2008. Updated December 2010

http://www.heartfoundation.org.au/SiteCollectionDocuments/HypertensionGuidelines2008to2010Update.pdf






Summary of presentation

1 Background





1 Background

2 Key recommendation

areas…





1 Background


areas…


Measurement

of blood

pressure

BP)




1 Background


areas…


Diagnosis

and

classification

Measurement

of blood

pressure

BP)




1 Background


areas…


Diagnosis

and

classification

Assessment

Measurement

of blood

pressure

BP)




1 Background


areas…


Diagnosis

and

classification

Assessment

Absolute

risk

Measurement

of blood

pressure

BP)




1 Background


areas…


Diagnosis

and

classification

Assessment

Absolute

risk

When to

intervene

Measurement

of blood

pressure

BP)




1 Background


areas…


Diagnosis

and

classification

Assessment

Absolute

risk

When to

intervene

Lifestyle

advice

Measurement

of blood

pressure

BP)




1 Background


areas…


Diagnosis

and

classification

Assessment

Absolute

risk

When to

intervene

Drug

treatment

Lifestyle

advice

Measurement

of blood

pressure

BP)




1 Background


areas…

3 Development

process


Diagnosis

and

classification

Assessment

Absolute

risk

When to

intervene

Drug

treatment

Lifestyle

advice

Measurement

of blood

pressure

BP)




1 Background


areas…

3 Development

process

4 Endorsing organisations


Diagnosis

and

classification

Assessment

Absolute

risk

When to

intervene

Drug

treatment

Lifestyle

advice

Measurement

of blood

pressure

BP)



Background

Hypertension is common: The most frequently managed chronic problem in general

practice1

1 in 3 Australians are diagnosed with hypertension2

Hypertension is serious: Major risk factor for stroke and coronary heart disease3

Major contributor to chronic heart failure (CHF), chronic kidneydisease and its progression3


1. Australian Institute of Health and Welfare, Australia’s Health 2008

2. AusDiab 2005, The Australian Diabetes, Obesity and Lifestyle Study, Tracking the Accelerating Epidemic:

Its Causes and Outcomes, Australian Diabetes Institute 2006

3. Levy D, Larson MG, Vasan RS, et al. The progression from hypertension to congestive heart failure.

JAMA 1996; 275: 1557-1562



Background

‘Hypertension’ is an arbitrary term Generally, the lower the BP, the lower the risk Decision to treat is based on ‘absolute risk’ or evidence of

end-organ damage – not levels of blood pressure alone.




ckground

What’s new in the 2008 guide? Revised recommendations based on new evidence Revised treatment targets Revised recommendations for drug treatment of uncomplicated

hypertension

Revised format for quick reference guide.


http://www.heartfoundation.org.au/SiteCollectionDocuments/hypertension-quick-reference-guide.pdf




Key recommendation areas






Measurement

of blood

pressure

BP)





Diagnosis

and

classification

Measurement

of blood

pressure

BP)





Diagnosis

and

classification

Assessment

Measurement

of blood

pressure

BP)





Diagnosis

and

classification

Assessment

Absolute

risk

Measurement

of blood

pressure

BP)





Diagnosis

and

classification

Assessment

Absolute

risk

When to

intervene

Measurement

of blood

pressure

BP)





Diagnosis

and

classification

Assessment

Absolute

risk

When to

intervene

Lifestyle

advice

Measurement

of blood

pressure

BP)





Diagnosis

and

classification

Assessment

Absolute

risk

When to

intervene

Drug

treatment

Lifestyle

advice

Measurement

of blood

pressure

BP)



1. Measurement of BP

Use recommended technique every time Use regularly validated and serviced sphygmomanometer Measure BP on both arms on first measurement Ensure patient is seated and relaxed Measure sitting and standing if orthostatic hypotension

is suspected Use right cuff size Repeat and average two readings




2. Diagnosis and classification

Obtain BP measurement outside clinic if possible Ambulatory monitoring

and/or Self-measurement at home




2. Diagnosis and classification

Diagnosis should be based on multiple BPmeasurements taken on separate occasions

Review at intervals determined by both BP category

and absolute risk

Click to see table






3 Assessment

Why assess all patients with ‘hypertension’? Identify all CVD risk factors Calculate absolute risk (see later) Detect end-organ damage Detect co-morbid conditions

Identify causes of secondary hypertension

If secondary hypertension is suspected, consider specialist

referral.




3. Assessment

A thorough evaluation of all patients includes: Taking a full medical history Performing a physical examination, with

particular attention to CVD system Undertaking initial investigations

Urine dip stick –for proteinuria and microalbuminuria Blood analysis ECG

Undertaking further investigations as indicated Calculating absolute cardiovascular risk

See full guide for further details






4. Absolute cardiovascular risk AR)

Why assess AR in all patients? To determine optimal management plan To identify other modifiable risk factors that require management To communicate degree of urgency for reducing BP to patients





What is AR? Probability (as a %) of someone

experiencing a CVD event

(heart attack or stroke) Current risk calculators underestimate

cardiovascular risk in Aboriginal,Torres Strait Islander, Maori, and

Pacific Islander peoples


http://www.heartfoundation.org.au/SiteCollectionDocuments/guidelines-Absolute-risk.pdf




Who is at ‘high’ (>15%) AR?







Group

Patients aged

75 years and older

For almost allindividuals aged

≥75 years,the absolute risk of

a cardiovascular event>15 %

in the next 5 years






Group

Patients aged

75 years and older




in the next 5 years

Group B

Patients with existing

cardiovascular diseaseAssume risk of

cardiovascular event>15%

in the next 5 yearsif either of the following

is present: symptomaticcardiovascular disease

or left ventricularhypertrophy






Group

Patients aged

75 years and older




in the next 5 years

Group B

Patients with existing

cardiovascular diseaseAssume risk of

cardiovascular event>15%

in the next 5 yearsif either of the following

is present: symptomaticcardiovascular disease

or left ventricularhypertrophy

Group C

Patients with

associated clinicalconditionsand/or

end-organ disease

(including diabetes,coronary heart disease,

chronic kidney disease – see guide)

Assume >15 %in the next 5 years




Australian cardiovascular risk chart (See full guide for information on how to use the chart)






5. When to intervene






Management

of hypertension

aims to:

Reduce BP

Reduce absolutecardiovascular risk

Minimise end-organdamage





Management

of hypertension

aims to:

Reduce BP



Decision to

intervene should

be based on:

A thoroughassessment(Section 3)

Absolutecardiovascular risk

Evidence ofend-organ damage





Management

of hypertension

aims to:

Reduce BP



Decision to

intervene should

be based on:

A thoroughassessment(Section 3)

Absolutecardiovascular risk

Evidence ofend-organ damage

Lifestyle risk

reduction is

indicated for all

patients

Especially thosewith high – normal

BP or

hypertension



6. Lifestyle advice

Indicated for all patients with hypertension,regardless of drug therapy: 30 minutes moderate activity on most days

of the week Smoking cessation

Healthy weight: waist <94 cm for men and<80 cm for women, BMI <25 kg/m2

Dietary salt restriction: ≤4 g/day Limited alcohol: ≤two standard drinks per day for

men or ≤one standard drink per day for women.

(See the full guide for more information

on lifestyle modification)






7. When to initiate drug treatment


Are any of the following present?

• Grade 3 hypertension (SBP ≥180 mmHg and/or DBP ≥110 mmHg)

• Isolated systolic hypertension with widened pulse pressure

• (SBP ≥160 mmHg and DBP 70 mmHg)

• Associated conditions or target-organ damage (See table 3 in the full guide)





Start drug treatment immediately

(See figure 3 in the full guide:

Initiating drug treatment)

• Lifestyle modification

• Manage associated conditions

• Confirmed hypertension grades 1–2

(SBP 140–179 mmHg or DBP 90–109 mmHg)

• All other adults

Assess 5-year absolute cardiovascular risk (See figure 1

in the full guide)






YES NO










• Confirmed hypertension grades 1–2

(SBP 140–179 mmHg or DBP 90–109 mmHg)

• All other adults

Assess 5-year absolute cardiovascular risk (See figure 1

in the full guide)


• Monitor BP

Reassess 5-year absolute

cardiovascular risk in 3–6 mths


• Monitor BP








YES

Moderate

(10–15%)

SEE NEXT SLIDE SEE NEXT SLIDE

High

(>15%)

Low

(<10%)

NO











• Monitor BP




• Monitor BP



Moderate

(10–15%)

Low

(<10%)






• Monitor BP



LOW <10%

SBP 140–150 mmHg

DBP <90 mmHg

Continue monitoring


• Monitor BP



Moderate

(10–15%)

Low

(<10%)






• Monitor BP



LOW <10%

MODERATE 10–15%

SBP <140 mmHg

DBP <90 mmHg

Continue monitoring

SBP 140–150 mmHg

DBP <90 mmHg

Continue monitoring


• Monitor BP



Moderate

(10–15%)

Low

(<10%)






• Monitor BP




(See figure 3 in full guide:




LOW <10%

MODERATE 10–15%

SBP <140 mmHg

DBP <90 mmHg

Continue monitoring

SBP ≥140 mmHg

DBP ≥90 mmHg

SBP 140–150 mmHg

DBP <90 mmHg

Continue monitoring

SBP ≥150 mmHg

DBP ≥90 mmHg


• Monitor BP



Moderate

(10–15%)

Low

(<10%)



7. Drug treatments

The benefit from drug treatments is mainly due to BPlowering (not mechanism of action)

In uncomplicated hypertension, these are equally effective

as first-line treatment (see figure 3 in full guide): ACE inhibitor (or angiotensin II receptor antagonist) Calcium channel blocker Low-dose thiazide diuretics

(for people aged 65 years and older)




7. Drug treatments

* ACE inhibitors and angiotensin II

receptor antagonists have been

shown to be equally efficacious in

prevention of cardiovascular end

points, and in lowering BP.

† Thiazide diuretics are not

recommended for younger patients

due to risk of diabetes associated

with long-term use.

See table 7 in full guide for

information regarding choice of

antihypertensive agent in patients

with comorbid and associated

conditions.

See page 25 in full guide for

information on combination therapy.


FIRST CHOICE

ACE inhibitor (or angiotensin ll receptor antagonist)*

or



7. Drug treatments









with long-term use.





conditions.




FIRST CHOICE


or

Calcium channel blocker

or



7. Drug treatments









with long-term use.





conditions.




FIRST CHOICE


or


or

Low-dose thiazide diuretic (consider for people aged ≥65 years only)†

or



7. Drug treatments









with long-term use.





conditions.




FIRST CHOICE

If target BP not reached


or


or


or

ACE inhibitor (or angiotensin ll receptor antagonist)* + calcium channel blocker

or



7. Drug treatments









with long-term use.





conditions.




FIRST CHOICE



or


or


or


or

ACE inhibitor (or angiotensin ll receptor antagonist)* + low-dose thiazide diuretic

or



7. Drug treatments









with long-term use.





conditions.




FIRST CHOICE




or


or


or


or


or

ACE inhibitor (or angiotensin ll receptor antagonist)*+ calcium channel blocker + low-dose thiazide diuretic



7. Drug treatments









with long-term use.





conditions.




FIRST CHOICE




Consider seeking specialist advice


or


or


or


or


or

ACE inhibitor (or angiotensin ll receptor antagonist)*+ calcium channel blocker + low-dose thiazide diuretic



7. Drug treatments

Treat to recommended target level


Patient group Target mmHg)

People with proteinuria >1 g/day

(with or without diabetes)<125 / 75



7. Drug treatments



* Specific lower BP targets have not

been established for other high-risk

groups (e.g. those with peripheral

arterial disease, those with familial

hypercholesterolaemia or those at

high risk of cardiovascular disease)

due to the current lack of evidence

from clinical trials. Targets will be set

when evidence becomes available.


People with associated condition/s or

end-organ damage:*

• Coronary heart disease

• Diabetes

• Chronic kidney disease

• Proteinuria (>300 mg/day)

• Stroke / TIA



<130 / 80



7. Drug treatments



* Specific lower BP targets have not

been established for other high-risk

groups (e.g. those with peripheral

arterial disease, those with familial

hypercholesterolaemia or those at

high risk of cardiovascular disease)

due to the current lack of evidence

from clinical trials. Targets will be set

when evidence becomes available.


People with associated condition/s or

end-organ damage:*


• Diabetes



• Stroke / TIA

People with none of the following:


• Diabetes



• Stroke / TIA



<140 / 90

or lower

if tolerated

<130 / 80



7 Drug treatments

How to achieve target BP: Start with lowest dose of first drug If drug not tolerated, change to a different class If target BP not reached, add second low-dose drug

(different class) If target BP still not achieved and both drugs well tolerated,

increase doses Trial each dose regimen for at least 6 weeks

If necessary, use drugs from different classes in

combination to achieve target BP. See full guide for details of combination therapy About 50–75% of patients will not achieve BP targets with

monotherapy







7. Drug treatments

If BP remains elevated despite maximal doses of at leasttwo appropriate agents, reassess for: Non-adherence Undiagnosed secondary hypertension Hypertensive effects of other drugs

Treatment resistance due to sleep apnoea Undisclosed use of alcohol or recreational drugs Unrecognised high salt intake ‘White coat’ hypertension Technical factors affecting measurement Volume overload, especially with chronic kidney disease (CKD)




7. Drug treatments

Most effective combination:


PLUS

ACE inhibitor

or Angiotensin ll

receptor antagonist

Calcium channel

blocker

Particular role in the

presence of d iabetes or lipid

abnormalities



7. Drug treatments

Other effective combinations include:


PLUS

ACE inhibitor

or Angiotensin ll

receptor antagonist

Thiazide diuretic

Particular role in the presence

of heart failure or post stroke



7. Drug treatments



PLUS

PLUS

ACE inhibitor

or Angiotensin ll

receptor antagonist

ACE inhibitor

or Angiotensin ll

receptor antagonist

Thiazide diuretic



Recommended post-

myocardial infarction or in

people with heart failure

Beta-blocker



7. Drug treatments



PLUS

PLUS

PLUS

ACE inhibitor

or Angiotensin ll

receptor antagonist

ACE inhibitor

or Angiotensin ll

receptor antagonist

Beta-blocker

Thiazide diuretic



Recommended post-




of coronary heart disease

Beta-blocker

Dihydropyridine calcium

channel blocker



7. Drug treatments



PLUS

PLUS

PLUS

PLUS

ACE inhibitor

or Angiotensin ll

receptor antagonist

ACE inhibitor

or Angiotensin ll

receptor antagonist

Beta-blocker

Thiazide diuretic

Thiazide diuretic



Recommended post-





Beta-blocker


channel blocker

Calcium channel

blocker



7. Drug treatments



PLUS

PLUS

PLUS

PLUS

PLUS

ACE inhibitor

or Angiotensin ll

receptor antagonist

ACE inhibitor

or Angiotensin ll

receptor antagonist

Beta-blocker

Thiazide diuretic

Thiazide diuretic

Thiazide diuretic



Recommended post-



Not recommended in people

with glucose intolerance

metabolic syndrome or

established diabetes



Beta-blocker


channel blocker

Calcium channel

blocker

Beta-blocker



7. Drug treatments

Avoid the following combinations:


PLUS

Due to risk of hyperkalaemia

ACE inhibitor

or Angiotensin ll

receptor antagonist

Potassium-sparing

diuretic



7. Drug treatments



PLUS

PLUS


Due to risk of heart block

ACE inhibitor

or Angiotensin ll

receptor antagonist

Verapamil Beta-blocker

Potassium-sparing

diuretic



7. Drug treatments



PLUS

PLUS


Due to risk of heart block

ACE inhibitor

or Angiotensin ll

receptor antagonist

Verapamil Beta blocker

PLUS

In a large trial comb ination therapy

did not reduce cardiovascular death

or morbidity in patients with vascular

disease or diabetes but increased

the risk of hypotensive symptoms

syncope and renal dysfunction

ACE inhibitor

Angiotensin ll

receptor antagonist

Potassium sparing

diuretic



7 Drug treatments

Once a combination regimen is established as long-term

therapy, a fixed combination preparation may be more

convenient

Co-morbidities may either favour or limit the use of

particular drug classes See table 7 in full guide for further details

Strategies to maximise adherence to treatment

recommendations should be used See table 8 in full guide for further details








Hypertension quick reference

guide 2008

Designed as a practical tool for

use in general practice

The quick reference guide is

a summarised version of the

full guide including key

recommendations and

treatment tables and

algorithms







Guide development process

Developed by the National Blood Pressure and Vascular

Disease Advisory Committee of the Heart Foundation Literature review conducted by experts on the Committee to

identify new evidence since 2004 Recommendations were derived from the evidence and/or

consensus of the Committee Draft guide sent to endorsing organisations and key

stakeholders for comment (including a small

group of Victorian GPs in a focus group)




Take home messages

1 Management is determined by assessment of

‘absolute risk’ and evidence of end-organ damage

2 Treat to ‘target’ blood pressure

3 Lifestyle modification is indicated for all

4 New recommendations for uncomplicated hypertension: Begin drug monotherapy with any of:

ACE inhibitor (or angiotensin II receptor antagonist) Calcium channel blockers Thiazide diuretics (consider for people aged 65 years or older only)






ow to get copies of the guide

The full guide, the quick reference guide and related

resources can be accessed online at

www.heartfoundation.org.au/information-for-

professionals/Clinical-Information/Pages/hypertension.aspx

Alternatively contact the Heart Foundation’s HealthInformation Service on 1300 36 27 87 or

[email protected]