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Encouragepatientsto:

Limitsaltintaketo<6g/day(approximately1.5teaspoons).Saltsubstitutesarenotadvisableas theycontainhighlevelsofpotassium Stopsmoking Avoidexcessivealcoholconsumption Participate in an exercise-training programme (cardiac rehabilitation) if they have stable CHF (NYHAclassII–III).

Psychologicalinterventions

DepressioniscommoninCHFandcognitivebehaviourtherapy(CBT)canbeconsidered.

Pharmacologicalmanagement

The pharmacological therapies in Fig. 5.1 have been shown to improve mortality in HFrEF(ejectionfraction<40%).

Fig. 5.1 Pharmacological treatment flowchart for heart failure with reduced ejection fraction. ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker; CRT, cardiac resynchronization therapy;ICD,implantablecardioverterdefibrillator;MRA,mineralocorticoidreceptorantagonist.

Prognostictherapy

First-linetherapy

Allpatientsshouldbestartedon(Table5.2):

ACEinhibitor,oranARBifintolerant Beta-blocker.

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Table5.2First-linetreatmentforheartfailurewithreducedejectionfraction

Drug Howtouse Monitoring Important

sideeffects

ACE inhibitor

Startwithalowdose,e.g.ramipril2.5mgOD Increase dose every 2 weeks until maximum tolerated doseormaximumdosereached

U&E 1–2 weeks after initiationandeachtitration Blood pressure before and aftereachdosechange Review monthly for 3 months,thentwiceayear

Angioedema Cough Electrolyte imbalance Kidney injury Hypotension

ARB

Startwithalowdose,e.g.losartan12.5mgOD Increase dose every 2 weeks until maximum tolerated doseormaximumdosereached

Electrolyte imbalance Kidney injury Hypotension

Betablockers

Startwithalowdose,e.g.bisoprolol2.5mgOD Switchto abeta-blockerlicensed for CHF ifalreadyon anothertypeforcomorbidity,e.g.atenolol

AsforACEinhibitor/ARB Heart rate after each dose change

Worsening symptoms Bradycardia Hypotension

Source:datafromNICENG106.

Second-linetherapy

Mineralocorticoid receptor antagonistsare offeredasanadditional therapyifsymptoms persist, e.g.spironolactone25mgOD Contraindicationsincludesignificanthyperkalaemiaandrenaldysfunction(stage3chronickidney disease(CKD)orworse) MonitorU&Eandbloodpressurebeforestartingandaftereverydosechange.Monitormonthlyfor 3months,andthentwiceayear.

Specialistmedication

Hydralazineorisosorbidedinitrate Sacubitrilwithvalsartan Ivabradine Digoxin.

Symptomatictherapy

Diuretics (usually loop, occasionally thiazides) are used to manage fluid overload or congestion,e.g.furosemide40mgODinitiallyinpatientswitheitherHFrEForHFpEF.

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Surgicalmanagement

Cardiacresynchronizationtherapy(CRT)andimplantablecardioverterdefibrillator

(ICD)

CRT and ICD therapy are indicated for patients who have HFrEF, with left ventricular ejectionfraction≤35%.

CRT encompasses CRT-D (with defibrillator) and CRT-P (pacing only). The choice betweenICD,CRT-D,andCRT-PdependsonthepresenceofLBBB,QRSduration,and NYHAclass.

Valvereplacement

Somepatientsmaybenefitfromatranscathetermitralvalverepair1if:

TheyhavesymptomaticheartfailuredespitemaximalmedicaltherapyAND Moderate–severeorseveresecondaryMR(e.g.secondarytoamyocardialinfarction).

Cardiactransplantation

Patients with drug-refractory severe CHF and refractory cardiogenic shock should be referredtospecialistCHFcentrestobeassessedfortheirsuitabilityfortransplantation.

Monitoringandfollow-up

Aminimumof6-monthlyclinicalreviewsshouldbeoffered.

Patientsshouldbeeducatedtomonitortheirweightathome,andtoreportanyclinical deterioration(>1.5–2kgweightgainin2days)toexpediteanearlyassessment.

Specialconsiderations

Chronickidneydisease

ConcomitantrenaldiseaseiscommoninCHF.Thisgroupofpatientsareatahigherrisk of hyperkalaemia with ACE inhibitor, ARB, diuretic, and mineralocorticoid receptor antagonist use. Consider lower and/or slower titration of doses if eGFR is <45mL/min/1.73m2,andliaisewiththerenalteamifeGFRis<30mL/min/1.73m2.

Heartfailurewithpreservedejectionfraction

Empagliflozin has been demonstrated to reduce the risk of hospitalization and

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cardiovasculardeathduetoHFpEF2.

Furtherreading

1.ScottishIntercollegiateGuidelinesNetwork(SIGN)(2016). ManagementofChronicHeart Failure.

Edinburgh:SIGN;2016.Availableat:https://www.sign.ac.uk/assets/sign147.pdf

1StoneGW, LindenfeldJL,AbrahamWT, etal.Transcathetermitralvalverepairinpatientswithheart

failure.NEnglJMed.2018;379:2307–18.

2AnkerSD,ButlerJ,FilippatosG,etal.Empagliflozininheartfailurewithapreservedejectionfailure.

NEnglJMed.2021;385:1451–61.

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Chapter6

Hypertension

Guideline: NICE NG136 (Hypertension in adults: diagnosis and

management):https://www.nice.org.uk/guidance/ng136

OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Hypertension is known as the ‘silent killer’. This is because it is most commonly asymptomaticbutchronically,and occasionallyacutely,itcan leadto end-organdamage which is life-limiting. In the majority of cases, hypertension is primary (essential hypertension),butsomecasesmaybeduetoasecondarycause(Table6.1).

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Table6.1Secondarycausesofhypertension

Renovascular Bilateralrenaldisease,e.g.glomerulonephritis,interstitialnephritis,diabeticnephropathy

Renalarterystenosis

Coarctationoftheaorta

Endocrine Thyrotoxicosis

Conn’ssyndrome

Phaeochromocytoma

Acromegaly

Cushing’ssyndrome

Druginduced Ciclosporin,cocaine,contraceptives

Other Obstructivesleepapnoea

Diagnosis

History

Patientswithaccelerated(malignant)hypertension(Box6.1)mayreportheadacheormay havesignsorsymptomsofsecondarycausesofhypertension.

Examination

Feel the pulse prior to measuring blood pressure. Automated blood pressure machines shouldbeavoidedinpatientswithanirregularpulse.

If thebloodpressureisraisedin onearm andhypertensionissuspected,measurethe blood pressurein the other arm as well. If there is a difference in readings >15mmHg, repeat the measurements. If the difference of >15mmHg persists, use the arm with the higher reading in future to assess the blood pressure (Fig. 6.1). Consider pathological causes for blood pressure discrepancy >15mmHg between the arms, e.g. peripheral arterial disease, aortic dissection or aneurysm, Takayasu’s arteritis, subclavian steal syndrome,andthoracicinletsyndrome.

Ifthebloodpressureis>140/90mmHgonthefirstreading,repeatthemeasurement.If thesecond measurementissignificantlydifferent, performa thirdmeasurementanduse thelowerbloodpressureofthelasttworeadings(Fig.6.1).

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Fig.6.1 Diagnosing hypertension. ABPM, ambulatory blood pressure monitoring; HBPM,home blood pressuremonitoring.

Investigations

Diagnosis

SeeTable6.2andBox6.1.

Ambulatorybloodpressuremonitoring(ABPM)

Twomeasurementsshouldbetakenperhourduringwakinghours,generatingatleast14 measurementstodiagnosehypertension.

Homebloodpressuremonitoring(HBPM)

This is an alternative for those unable to tolerateABPM. Two measurements are taken twice daily for 4–7 days. Hypertension can be confirmed by averaging all the measurements(excludemeasurementsonday1).

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Table6.2Definitionsofhypertension(bothrequiredfordiagnosis)

Stage Clinicreading ABPMorHPBM

1 ≥140/90mmHg ≥135/85mmHg

2 ≥160/100mmHg ≥150/95mmHg

3(severe) ≥180mmHgsystolic,or

≥120mmHgdiastolic

N/A

Source:datafromNICENG136.

If stage 3 hypertension is accompanied by retinalhaemorrhage or papilloedema, this is accelerated(malignant)hypertensionandisamedicalemergency(seeBox6.1).

Assessingcardiovascularrisk

SerumHbA1c,totalcholesterol,andhigh-densitylipoproteincholesterolshouldbemeasured.

Assessingtargetorgandamage

SeeTable6.3.

Box6.1Whotorefertohospitalurgently(sameday)

Bloodpressure>180/120mmHgand:

Signsofretinalhaemorrhageorpapilloedema(accelerated/malignanthypertension)OR New-onsetconfusionOR ChestpainOR SignsofheartfailureOR

Acutekidneyinjury(AKI) Phaeochromocytoma is suspected (classic triad of symptoms is headache, palpitations, and sweatingalthoughtheabsenceofthesesymptomsdoesnotexcludeit).

Source:datafromNICENG136.

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Table6.3Investigatingfortargetorgandamage

Target organ

Investigation Changeswhichmaybeseenduetohypertension

Eyes Fundoscopy Changesofhypertensiveretinopathy,e.g.arteriovenousnipping,haemorrhage,cotton

woolspots,papilloedema

Heart 12-leadECG Leftventricularhypertrophy

Kidneys Urineanalysis Raisedalbumin:creatinineratio(ACR),proteinuria

Haematuria

Bloods Raisedcreatinine,reducedestimatedglomerularfiltrationrate(eGFR)

Source:datafromNICENG136.

Chronicmanagement

Patienteducation

Unwanted side effects of antihypertensive treatment are common. Information on the importanceofgood blood pressure controlshouldbeprovided to patientsto encourage compliance.

Lifestyleandsimpleinterventions

Manysimplelifestyleinterventions, such as having a healthybalanceddiet,can help to reducebloodpressure.Adviceshouldinclude:

Adequateexercise(minimumof30minutesofmoderateintensityexercise,5daysaweek)

Avoidingexcessivesaltinthediet Avoidingexcessivecaffeineconsumption Alcoholintakeshouldbewithinrecommendedlimits Smokingcessationishelpfulinreducingoverallcardiovascularrisk.

Pharmacologicalmanagement

Stage 1 or 2 hypertension may be diagnosed following a raised clinic blood pressure readingANDaraisedABPMorHBPMreading.

Treatif:

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Age<80years,stage1hypertension,with:

Targetorgandamage(Table6.2) Establishedcardiovasculardisease Renaldisease Diabetes

≥10%10-yearcardiovascularrisk Stage2or3hypertension Targetorgandamageisfoundonexamination(commencetreatmentpriortoABPM/HBPMresult).

Considerdrugtreatmentinstage1hypertensionif:

Age>80yearsandbloodpressureis>150/90mmHg Age<60yearsand10-yearcardiovascularriskisestimatedtobe<10%

ChoiceofpharmacologicaltherapyissummarizedinFig.6.2.

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