High Blood Pressure in Context
Dr Yassir Javaid
GP Northampton
Primary Care CVD lead EMSCN
Premature Deaths by Cause in UK, 2012
Men
Women
Cardiovascular Disease Statistics, 2014 British Heart Foundation
Hypertension Prevalence by Age
*Based on data from the 1999 2000.
Hypertension is defined as blood pressure  140/90 mm Hg or as receiving antihypertensive treatment.
Fields LE, et al. Hypertension. 2004;44:398-404.
Risk Factors for Stroke
Increases stroke
risk by 430%
Increases stroke
risk by 140%
Increases stroke
risk by 240%
Increases stroke
risk by 480%
INTERHEART Study
• Case control study acute MI in 52 countries n ≈ 30000
• 9 risk factors account for > 90% attributable risk of MI
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Abnormal Lipids
Diabetes
Abdominal Obesity
Adverse diet
Lack of regular exercise
Smoking
Hypertension
Psychosocial
Excess Alcohol
Lancet. 2004 Sep 11-17;364(9438):937-52
Abnormal lipids and current smoking status confer
the greatest risk of developing acute myocardial
infarction
Odds ratios for risk factors most associated with
the development of acute myocardial infarction
*Lipid profile as measured by apolipoprotein B/apolipoprotein A1 ratio (5th quintile vs 1st)
Adapted from Yusuf S, et al. Lancet. 2004; 364: 937–952.
Hypertension is a major risk factor
Cushman WC. J Clin Hypertens. 2003;5(Suppl):14-22
LVH
Assessing cardiovascular risk and target organ
damage
 All patients with BP > 140/90 should undergo a formal
estimation of cardiovascular risk:
 Q-RISK2 to assess 10 year risk
 Discuss treatment options both for:
 raised BP
 other modifiable risk factors
 Assess for target organ damage:
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Urinalysis:
Bloods:
ECG:
Fundoscopy:
Proteinuria, ACR, haematuria
U&E, creatinine, eGFR, lipids, HbA1c
LVH, AF, ischaemic changes
Retinopathy
Diagnosis of Hypertension
(NICE/BHS Hypertension guidelines 2011)
• ABPM predicts CV outcomes better than home BP and clinic BP monitoring
• Home BP correlates much better with ABPM than clinic BP readings
• Offer ambulatory ABPM to any patient with clinic BP > 140/90
• at least 14 day time readings
• Offer home BP if ABPM declined
• readings twice daily for at least 4 days (preferably 7 days)
• Lower cut offs 135/85 (stage 1) and 150/95 (stage 2)
• White coat hypertension is not a benign condition & importance of loss of
nocturnal dipping (10-20% drop in BP)
Cost Effectiveness of ABPM
Data are QALY (95% CI) or costs (95% CI). CBPM=clinic blood-pressure monitoring. HBPM=home blood-pressure monitoring.
ABPM=ambulatory blood-pressure monitoring. CE=cost effective at a £20 000 threshold. QALYs=quality-adjusted life years.
Lovibond et al Lancet 2011
Similar BP lowering
amlodipine vs atenolol
Anti-hypertensive drug therapy
• CCBs first line for patients < 55 or black patients (significantly fewer cases
of new onset DM)
• Beta-blockers not for routine use (except women of child bearing age)
• Thiazide-type diuretics:
• Thiazide-like preferred over classic thiazide (more contemporary studies and
used lower doses)
• ie indapamide and chlorthalidone preferred over bendroflumethiazide and
hydrochlorothiazide
• If patient already on bfz and well controlled with no undesirable effects
continue
• 4th line: add spirononlactone 25mg (if K+ ≤ 4.5) or inc dose thiazide-like
diuretic – if ineffective or not tolerated alpha or beta blocker
Adapted from BHS/NICE guidance for Hypertension 2011
Special Cases
• Diabetes
• >50% Diabetics have high BP (metabolic syndrome)
• >70% will need 3 or more drugs
• UKPDS: BP control > Glycaemic control
• 1st line - ACE-I (renal protection): max tolerated dose if microalbuminuria
• Women of child bearing age: CCB
• Stable Angina
• 1st line BB
• 2nd line CCB
• Heart Failure
• 1st line ACE-I, BB +/- MRA
Cardiovascular Risk Assessment:
10yr vs Lifetime risk
SPRINT TRIAL
Systolic Blood Pressure Interventional Trial
• Intensive (< 120mmHg) vs Standard (<140mmHg) BP Control
• Multicentre Study in USA
• 9361 patients:
• > 50 yrs
• SBP 130-180mmHg
• ↑CV risk:
• CKD (eGFR 20-60ml/min)
• 10 yr Framingham risk > 15%
• > 75 yrs
• Diabetics and prior stroke patients excluded
(Avg 2 drugs)
(Avg 3 drugs)
Primary Outcome:
Composite of:
- Myocardial infarction
- Acute coronary syndrome,
- Stroke,
- Heart failure, or
- Death from CVD
Primary Outcome According to Subgroups
Serious Adverse Events
Key Points
 Increasing prevalence:
 vast majority of cases are > 45 yrs old; 78% of > 75 yr olds
 Most patients remain either undiagnosed or undertreated
 Improved outcomes with treatment:
 50% reduction in heart failure
 40% reduction in stroke
 Diagnosis:
 ABPM (or HBPM) if elevated clinic readings > 140/90
 Lower ABPM cut off (Average daytime: > 135/85)
 Monitoring:
 Clinic BP (or HBPM/ABPM if ‘white coat’ hypertension)
Key Points
 BP targets:
 140/90 (or 150/90 in those > 80 years)
 Optimise drug treatment + lifestyle before adding additional Rx
 Appropriate assessment CVD risk and intervene to reduce total
CVD risk
 Majority will require combination treatment
 Monotherapy highly likely to be inadequate therapy
 Drug treatment should be tailored to the individual taking into account
cardiovascular risk, co-morbidity, adverse effects of medication and
patient preference (Compliance issues = asymptomatic disease)