UNCONTROLLED HYPERTENSION

Case history

Edmond 75 years presented with ‘shocking” blood pressure recordings of 184/102 in the morning. His afternoon and night readings were in the ‘acceptable target ranges”He has atrial fibrilliation and is on warfarin 5 mg daily. In addition he is on prazosin 5 mg, atenolol 50 mg , coversyl 10 mg and valsaltan

Questions

What is the prevalence rate of under achieving target blood pressures?

List 5 cause of failure to achieve target blood pressures? How can we reach blood pressure targets?

What is the choice of antihypertensives in angina, post myocardial infarct, post stroke, heart failure, diabetes with proteinuria or microalbuminuria,gout, chronic kidney disease, atrial fibrilliation ?

What are the potentially harmful antihypertensives in asthma/COPD, bradycardia 2nd or 3rd atrioventricular failure,depresion,gout,heart failure, bilatral renal artery stenosis + diabetes with proteinuria or microalbuminuria?

List 3 effective antihypertensive combination therapies + 3 combinations to avoid.

Blood pressure treatment targets

Patient group Target ( mm Hg)

Proteinuria > 1 gm / day ( with or without diabetes)

<125/75

Associated conditions of end organ damage: (coronary heart disease, stroke, diabetes, chronic kidney disease, proteinuria >300 mg / day)

<130/80

None of the above <140/90 or lower if tolerated

Prevalence of underachieving

Trials Prevalence of underachieving target blood pressures

AusDiab study( The Australian Diabetes, Obesity + Lifestyle)

40%

ALLHAT(The Antihypertensive + Lipid Lowering Treatment to Prevent Heart Attack Trial)

66%

CONVINCE( Controlled Onset Verapamil Investigation of Cardiovascular Endpoints)

70%

Reaching blood pressure targets

(1) Lifestyle factors not implemented(2) Adherence medication poor: costs, side effects(3) Substances increasing BP: NSAIDs,

prednisolone, alcohol, caffeine, salt intake(4) Systems issues: social or economic barriers,

recall or reminder systems(5) Secondary hypertension:(6) Therapeutic inertia: need to increase a

current agent or add another agent(7) Measurement issues: white coat effect,

inappropriate cuff size

Choice of Antihypertensives

Condition Potentially beneficial

Angina ACEI,Beta blockers(except oxprenolol,pindolol),CCBs

Post myocardial infarct ACEI, Beta blockers(except oxprenolol, pindolol),Eplerone

Post stroke ACEI,A2RA,low dose thiazide-like diuretics

Heart failure ACEI,A2RA,Thiazide diuretics,Beta blockers(bisoprolol,carvedilol,metoprolol controlled release) spironolactone

Type 1 or 2 Diabetes with proteinuria or microalbuminuria

ACEI,A2RA

Gout Losartan

Chronic kidney disease ACEI,A2RA

Atrial fibrilliation ACEI,A2RA

Potentially harmful Antihypertensives

Condition Caution Contraindicated

Asthma/COPD Cardioselective BB use in mild/moderate asthma/COPD only

BB(except cardioselective agents)

Bradycardia,2nd/3rd AV block

BB,verapamil,diltiazem

Depression BB, clonidine,methyldopa, minoxidine

Gout Thiazide diuretics

Heart failure CCBs(verapamil,dilthiazem)

Alpha blockes in AS,BB in uncontoled HF

Bilateral RAS( Unilateral solitary kidney)

ACEI,A2RA

Type 1 /2 diabetes with proteinuria or microalbuminuria

BB,Thiazide diuretics

Effective combination therapies

First drug Additional drug Recommendation

ACEI or A2RA CCB Diabetes or lipid abnormalities

ACEI or A2RA Thiazide diuretic Heart failure or post stroke

ACEI or A2RA BB Post MI or heart failure

BB Dihydrpyridine CCB Coronary heart disease

Thiazide Diuretics CCB,BB( not recommended in glucose intolerance, metabolic syndrome or established diabetes

Combinations to avoid

First drug Additional drug Recommendation

ACEI or A2RA Potassium sparing diuretics

Risk of hyperkalaemia

Verapamil Beta blocker Risk of heart block

ACEI A2RA Large trial did not reduce cardiovascular death or morbidity in vascular disease or diabetes but increased risk of hypotensive symptoms, syncope + renal dysfunction