Hypertension Role of Ambulatory BP Monitoring Case One •  58 year old female •  Atypical chest pain •  Past history of hypertension, IGT, dyslipidaemia with signiﬁcant obesity. •  MedicaFon: Telmisartan 40mg with Hydrocholorothiazide, Prazosin 5mg od, AtorvastaFn 10mg od, Allopurinol. Case One •  ECG Case One •  Stress echo negaFve •  ResFng Study found: –  No deﬁnite LVH. –  Good systolic funcFon. –  Moderate diastolic dysfuncFon (pseudonormal transmitral doppler, reversal with valsalva, E/E’ average 14). –  Mild LA dilaFon. Case One Case Two •  Presented with heart failure •  Previous CABG for leV main stem disease but angiography ﬁnding patent graVs. •  Severe LV dilaFon and severe LV impairment at echocardiography. •  History of hypertension. Case Two •  UpFtrated medicaFon: –  Metoprolol CR 190mg od, Cilazapril 5mg mane, SimvastaFn, MeYormin, low dose Aspirin. –  SFll hypertensive ?”white-‐coat” syndrome Case two Ambulatory BP monitor Comparison of Modes of BP measurement NEJM 2006 ECG criteria for LVH LIFE study OVA study Ova Study Case 3 Dr Selwyn Wong Case 3 -‐HTN Case – 27 Male Diagnosed 2006 – started on Nifedipine, then Cilazapril, then referred. BP 160/90mmHg Secondary causes HTN invesFgated (Cushings, Conn’s, renal disease, RAS, phaeochromocytoma, aorFc coarct) Echo – no coarctaFon but moderate concentric LVH Abnormal renin-‐aldosterone – referred for saline supression test Beta-‐blocker added Lost to follow-‐up unFl 2010 HTN Case – 27 Male Re-‐referred 2010 BP 160/100mmHg, possible family Hx Headaches Isradipine, Inhibace plus, Metoprolol, Losartan Echo – moderate-‐severe LVH Repeat hormonal secondary cause screen – abnormal RA Referred to endocrinologist! Spirinolactone added with eﬀect but abnormal LFTs Renal denervaFon 2012 – with reasonable success Case 4 Dr Warwick Jaﬀe Case 4 -‐ Diﬃcult Hypertension •  Female Aged 65 currently, reviewed in 2009 •  Hypertension for 15 years on inhibace plus •  Previous catecholamines, renal scan and aldosterone levels normal in 2001 •  Hyperlipidaemia on Lipitor 20mg •  Recent AF – dilFazem 180mg and warfarin at MMH, feeling SOB and Fred •  BP 170/100, •  ECG AF 120/min •  Echo – mild LVH, LA mildly enlarged •  Changed to Sotalol, cardioverted 48 hours later, Felodipine added to her treatment as BP 180/100 Cont •  Review 2 weeks later, feeling a bit Fred •  ECG QT interval >600msec •  Electrophysiology, change to ﬂecainide and Betaloc, conFnue on inhibace plus and Felodipine, stay on warfarin •  Called by GP BP 190/100, paFent tearful and convinced she is headed for a stroke 2009 Progress •  Advised to stay on Felodopine, Betaloc, inhibace plus and ﬂecainide and warfarin •  BP in GP’s oﬃce around 180/100 every Fme taken, by mid 2010 GP increasingly worried •  How would you manage this? 2010 Actual management •  Dosan added and increased to 4mg, Felodipine stopped as ankles swelling •  Further AF, in MMH, reverted spontaneously •  At MMH Metoprolol increased to 95 mg, inhibace plus stopped, given AccureFc in the morning, and Accupril in the evening •  Renal artery Doppler done at MMH -‐ normal •  GP follow up 1 month later, BP 210/120. •  ? What would you do Cont •  Called Cardiology – meds, Dosan 4mg, Accuteric in morning, Accupril 20mg at night, metoprolol 95mg •  Spironolactone 25mg added, change Accuteric to Accupril, Renal referral suggested •  Renal Physician -‐ Aldosterone 290, renin <2, RaFo > 600 creaFnine 75 •  “salt sensiFve” expansion, increase diureFcs, Bendroﬂuazide added Progress BP improved Changed to spironolactone 25mg bd Accupril reduced to 10mg daily FaFgue, blurred vision, bad dreams, metoprolol stopped and switched to dilFazem 180mg with resoluFon of symptoms •  Review April 2012, BP 150/80 on dilFazem 180mg, Accupril 10mg and Spironolactone 25mgbd, ASA 100 •  Severe necks pains only relieved by Diclofenac, GP would not prescribe it because of her “heart problems” •  Using her husband’s Arcoxia with some relief. •  •  •  •  Case 5 -‐ When to treat in a younger paFent •  •  •  •  •  •  •  •  •  •  Female Aged 50 Stressful life, Slim acFve person AsymptomaFc No past illnesses of note Mother stroke at 60 (smoker and hypertension), brother 54 on BP tablets Lipids TC 4.6, HDL 2.0, non smoker, renal funcFon normal BP usually 140-‐150/80-‐90 in oﬃce, advised about salt Home measurements – similar range ? Should she be treated ? Is there any advantage of one drug over another