CONSULTATION

[heyam]

i have no quiz but i want to consult those who have experiance in treating HTN in elderly esp systolic HTN
what is best way to mange them
what are the tratment of choice
isit rt to start with combination therapy ?
URGENT please
thank you

[montasir almobarak]

dear hyam this is the new guidlines try it its really usefull

the source is passmedicine

The 2011 NICE guidelines recognise that in the past there was overtreatment of 'white coat' hypertension. The use of ambulatory blood pressure monitoring (ABPM) aims to reduce this. There is also good evidence that APBM is a better predictor of cardiovascular risk than clinic blood pressure readings. See the following study for more details:

Verdecchia P. Prognostic value of ambulatory blood pressure: current evidence and clinical implications. Hypertension 2000; 35: 844-851

Hypertension: diagnosis and management
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NICE published updated guidelines for the management of hypertension in 2011. Some of the key changes include:
classifying hypertension into stages
recommending the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM)
calcium channel blockers are now considered superior to thiazides
bendroflumethiazide is no longer the thiazide of choice

Blood pressure classification

This becomes relevant later in some of the management decisions that NICE advocate.

Stage 1 hypertension Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
Stage 2 hypertension Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
Severe hypertension Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg

Diagnosing hypertension

If a BP reading is >= 140 / 90 mmHg patients should be offered ABPM to confirm the diagnosis.

Patients with a BP reading of >= 180/110 mmHg should be considered for immediate treatment.

Ambulatory blood pressure monitoring (ABPM)
at least 2 measurements per hour during the person’s usual waking hours (for example, between 08:00 and 22:00)
use the average value of at least 14 measurements

If ABPM is not tolerated or declined HBPM should be offered.

Home blood pressure monitoring (HBPM)
for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
BP should be recorded twice daily, ideally in the morning and evening
BP should be recorded for at least 4 days, ideally for 7 days
discard the measurements taken on the first day and use the average value of all the remaining measurements

Managing hypertension

ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)
treat if < 80 years of age and any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater

ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension)
offer drug treatment regardless of age

For patients < 40 years consider specialist referral to exclude secondary causes.

Step 1 treatment
patients < 55-years-old: ACE inhibitor (A)
patients > 55-years-old or of Afro-Caribbean origin: calcium channel blocker

Step 2 treatment
ACE inhibitor + calcium channel blocker (A + C)

Step 3 treatment
add a thiazide diuretic (D, i.e. A + C + D)
NICE now advocate using either chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide

NICE define a clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best tolerated doses as resistant hypertension. They suggest step 4 treatment or seeking expert advice

Step 4 treatment
consider further diuretic treatment
if potassium < 4.5 mmol/l add spironolactone 25mg od
if potassium > 4.5 mmol/l add higher-dose thiazide-like diuretic treatment
if further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker

If BP still not controlled seek specialist advice.

Blood pressure targets

[Clinic BP ABPM / HBPM
Age < 80 years 140/90 mmHg 135/85 mmHg
Age > 80 years 150/90 mmHg 145/85 mmHg

New drugs

Direct renin inhibitors
e.g. Aliskiren (branded as Rasilez)
by inhibiting renin blocks the conversion of angiotensinogen to angiotensin I
no trials have looked at mortality data yet. Trials have only investigated fall in blood pressure. Initial trials suggest aliskiren reduces blood pressure to a similar extent as angiotensin converting enzyme (ACE) inhibitors or angiotensin-II receptor antagonists
adverse effects were uncommon in trials although diarrhoea was occasionally seen
only current role would seem to be in patients who are intolerant of more established antihypertensive drugs

[heyam]

thank you Einas ....i found it very useful....

[alsamtan]

thanks heyam & einas , i realy enjoy the topics

[Muntasir]

Thanks alot for this informative material

[Dr.Sudan]

In short:
Recently updated guidelines on blood pressure tend to recommend starting therapy with either an ACE inhibitor or calcium antagonist, with calcium antagonists probably more effective as initial therapy in afro-caribbean patients due to racial differences in renin levels. An ACE inhibitor or diuretic may then be added to the calcium antagonist. Beta-blockers have fallen out of favour a little, and the beta-blocker diuretic combo is not recommended due to an association with incident diabetes in BP lowering meta-analyses