Hypertension Management in Primary Care

1. Hypertension Management in Primary Care

2. The scope of the problem • The size of the problem is massive, The Blood Pressure Association estimates that there are 16,000,000 people with hypertension in the UK ( 2007) • The US Joint National Committee describes pre-hypertension making the numbers even bigger! • This demands a population based approach. • But we treat individuals, not populations • Need to manage hypertension in context of overall cardiovascular risk

3. Considerations in hypertension management • The diagnosis • The effect of diagnosis • The treatment • The effects of treatment

4. Diagnosis - lessons • Always consider blood pressure in context • Ignore raised blood pressure levels at the patients peril – not yours, so always follow them up. • Remember secondary hypertension • Not stressed in the guidelines • Found in 1 – 5% of patients with hypertension • Rare things are common!

5. Assessment of the patient

6. Evidence of causation • Drugs ( NSAIDs, oral contraceptives steroids ) • Renal disease ( Family history, abdominal masses, proteinuria haematuria ) • Reno vascular disease and coarctation ( pulses, bruits ) • Endocrine disease ( Cushing's, Conn's phaeochromocytoma )

7. Other sources of cardiovascular risk • Established cardiovascular disease • Diabetes • CKD • Family history • Smoking • Lipids

8. Evidence of target organ damage • Established cardiovascular disease • ECG evidence of LVH or strain • Hypertensive retinopathy • Raised creatinine • proteinuria

9. Target organ damage

10. Target organ damage after treatment

11. Contributing factors • Weight • Alcohol • Salt • Inactivity • Environmental stress

12. Effects of exercise on Blood Pressure • Acute Vs long term effects • Aerobic Vs isometric • Hypertensive response marker of vascular disease – does this apply in the elderly? • Regular aerobic exercise reduces systolic BP by 4 – 9 mm Hg. • Systolic BP falls by 5 – 10 mm Hg per 10 kg lost. • Lifestyle interventions as effective as pharmacological treatments, but underused.

13. Putting it all together • Offer treatment for: • BP > 160/100 mmHg; • BP > 140/90 mmHg and 10-year risk of CVD > 20% or existing target organ damage. • Consider other treatments for raised cardiovascular risk including lipid lowering and antiplatelet therapies.

14. So what’s the gain?

15. But what’s the downside?

16. But what’s the downside? • Change in perception of health status and well being • Increase in reported depression • 80% increase in all cause time lost from work • We make well people into ill patients • So its not treating x patients for 5 years to prevent 1 stroke…..its adversely changing the lives of x patients for 5 years to prevent 1 stroke

17. How to mitigate these effects • Take time to listen and explore patients values • Communicate risk sensitively • Frightening patients does not work • Be prepared to negotiate • How would you feel? • Is the label hypertension helpful?

18. Treatment: What to Consider • The evidence • The cost • NICE • The current vogue • Anyway most patients will need polypharmacy • The patient

19. What’s the evidence? • Numerous unequivocal placebo controlled trials • Treatment associated with significant reductions in cardiovascular morbidity and mortality • Benefit seen in all ages, all races and both genders • 30 – 40% reduction in stroke • 20% reduction in coronary events • Large reduction in heart failure

20. What’s the evidence? • Trials comparing different treatments difficult to interpret as different trial arms may have different blood pressure reductions which may explain differing outcomes • Calcium antagonists provide slightly better stroke reductions than beta blockers and thiazides • ACE inhibitors provide more protection against coronary events and heart failure than calcium antagonists

21. What’s the evidence? • Calcium antagonists provide less protection against heart failure than ACE inhibitors, ARB, diuretics and beta blockers • Overall these differences are trivial and it is the magnitude of blood pressure reduction that is the only significant factor

22. Treatment • It’s all about lowering the blood pressure • That’s all about changing lifestyle and taking the tablets • That’s all about concordance • That’s all about the doctor, the patient and a shared understanding

23. Concordance • <10% of patients treated to target • Concordance probably means different things to patients and doctors • Concerns re side effects • Complex medication regimens • Value judgements around medication • Doctor patient relationship and confidence

24. Concordance – how can we help • Simple medication regimen • Communicate well – that means listening • Behavioural strategies e.g. Self monitoring, BP diaries • Social support • Monitor concordance • Choose drugs well

25. Medication Choice • A (B) C D fine, all other things being equal • They rarely are • Consider compelling indications and compelling contraindications • Consider other relevant patient factors and prescribe smart

26. Examples • A 70 yr old man. Varicose veins swollen ankles. Prostatic symptoms. • C or D? • A 60 yr old woman with frequent migraine and detrusor instability • C or D? • 40 yr old woman always bloated with swollen ankles • A or B?

27. Summary • Don't ignore isolated raised blood pressure readings • Don’t forget secondary hypertension • Assess and address the total cardiovascular risk • Remember the psychological and social effects of diagnosis • Prescribe smart and individually – dump the cook book!