Primary – 90-95% of cases – also termed “essential” of “idiopathic ”
Secondary – about 5% of cases
Renal or renovascular disease
Acromegaly and hypothyroidism
Coarctation of the aorta
Hormonal / oral contraceptive
This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy.
The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.
H O T
Hypertension Optimal Treatment
Largest intervention trial in hypertension. Published in 1998
Conducted in General Practice. 18,790 patients in 26 countries
Followed up for an average of 3.8 years
H O T Findings
Lowest incidence of major CV events occurred at a mean achieved DBP of 83 mmhg. This target (compared to mean achieved of 105 mmHg was associated with a 30% reduction in main CV events.
In diabetes – Diastolic< or = 80mmhg 51 % lower risk compared to 90 mmHg
Global heart threat from diabetes: A global explosion in the number of cases of diabetes is threatening to reverse the reduction in deaths from heart disease in many western countries, including the United Kingdom. To coincide with World Diabetes Day on 14 November, Diabetes UK is calling for action to be taken to reduce the 20,000 deaths per year from coronary heart disease (CHD) among people with diabetes in the UK.
Hypertension and Diabetes
Hypertension co-exists with type II in about 40% at age 45 rising to 60% at age 75.
70% of type II patients die from cardio-vascular disease.
At least 60% of patients will require 2 or 3 antihypertensive agents to achieve tight control.
Identification of hypertensive patients
Stepping up therapy
Motivation and compliance
Investigation of the New Hypertensive
History and examination
Exclude secondary Hypertension
Urea and electrolytes
FBP and ESR
Chest x-ray no longer routinely indicated
Clinical clues to renal vascular disease
Hypertension under 50 Yrs of age.
Generalised vascular (esp peripheral) disease.
Mild – moderate renal dysfunction.
Sudden onset pulmonary oedema.
Bendrofluazide + Atenolol or ACE
Calcium Channel blocker
Assessment of overall cardiovascular risk
Recognition of co-morbidities
Existing contra- indications
Coronary Risk Calculator
Launch risk calculator program
Compelling and possible indications and contrindications for the major classes of antihypertensive drugs INDICATIONS CONTRAINDICATIONS * ACE inhibitors may be beneficial in chronic renal failure but should be used with caution. Close supervision and specialist advice are needed when there is established and significant renal impairment † Caution with ACE inhibitors and angiotensin II receptor antagonists in peripheral vascular disease because of association with renovascular disease. ‡ If ACE inhibitor indicated -blockers may worsen heart failure, but in specialist hands may be used to treat heart failure British Hypertension Society Guidelines 2000 CLASSS OF DRUG COMPELLING POSSIBLE POSSIBLE COMPELLING -blockers Prostatism Dyslipidaemia Postural Hypotension Unrinary incontinence Angiotensin converting enzyme (ACE) inhibitors Heart failure Left ventricular dysfunction Chronic renal disease * Type II diabetic nephropathy Renal impairment * Peripheral vascular disease † Pregnancy Renovascular disease Angiotensin II receptor antagonists Cough induced by ACE inhibitor ‡ Heart failure Intolerance of other antihypertensive drugs Peripheral vascular disease Pregnancy Renovascular disease blockers Myocardial infarction Angina Heart failure Heart failure Dyslipidaemia Peripheral vascular disease Asthma or COPD Heart block Calcium antagonists (dihydropyridine) Isolated systolic hypertension (ISH) in elderly patients Angina Elderly patients _ _ Calcium antagonists (rate limiting) Angina Myocardial infarction Combination with blockade Heart block Heart failure Thiazides Elderly patients including ISH _ Dyslipidaemia Gout
Therapeutic targets Therapeutic targets * Measured in clinic Mean daytime ABPM or home measurement Blood Pressure No diabetes Diabetes No diabetes Diabetes Optimal <140/85 <140/80 <130/80 <130/75 Audit Standard <150/90 <140/85 <140/85 <140/80 The audit standard reflects the minimum recommended levels of BP control. Despite best practice, it may not be achievable in some treated hypertensive patients. NB: Both systolic and diastolic targets should be reached British Hypertension Society Guidelines