Clinical management & prevention strategies.

1. Dr. G.S. Jogdand, M.D. Ph.D. Professor & Head, Community Medicine Department Kieran McGlade Nov 2001 Department of General Practice QUB

5. Classification of hypertension Kieran McGlade Nov 2001 Department of General Practice QUB Category Systolic B.P. Diastolic B.P. Normal <130 mm. Hg. < 85 mm. Hg. High normal 130-139 mm. Hg. 85-90 mm. Hg. Hypertension Stage 1. Mild 140- 159 mm. Hg. 90- 99 mm. Hg. Stage 2. Moderate 160- 179 mm. Hg. 100-109 mm. Hg. Stage 3. Severe > 180 mm. Hg. > 110 mm. Hg.

6. Rule of halves in Hypertension Kieran McGlade Nov 2001 Department of General Practice QUB

12. Kieran McGlade Nov 2001 Department of General Practice QUB 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.

13. Kieran McGlade Nov 2001 Department of General Practice QUB The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibres have undergone hypertrophy.

16. Kieran McGlade Nov 2001 Department of General Practice QUB 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.

23. Kieran McGlade Nov 2001 Department of General Practice QUB

24. Kieran McGlade Nov 2001 Department of General Practice QUB Compelling and possible indications and contraindications 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

25. Kieran McGlade Nov 2001 Department of General Practice QUB 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

26. Kieran McGlade Nov 2001 Department of General Practice QUB * Verapramil + beta-blocker = absolute contra-indication Diuretic  - blocker CCB ACE inhibitor  - blocker Diuretic -  -    - blocker  -  * -  CCB -  * -   ACE inhibitor  -  -   - blocker     -

37. Thank You Kieran McGlade Nov 2001 Department of General Practice QUB