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Hypertension picked up mainly in check-ups

HYPERTENSION: Some form of screening for hypertension in general practice might prove very useful, since hypertension is being picked up largely by chance at check-ups.

In deciding that a person is hypertensive a certain ‘hold steady’ approach should apply, in the view of Dr Michael Conway, Consultant Cardiologist, St Luke’s Hospital, Kilkenny, and the Beacon Hospital, Dublin.

Unless the systolic and diastolic blood pressures are very high (for example, diastolic greater than 110 mmHg), the blood pressure should be checked several times with a sphygmomanometer over a period of days or weeks. In respect of choosing drug therapy, the decision depends on whether the hypertension is responsive or resistant. The drug classes to consider are identifiable from the ABCD aide memoire.

A is the ACE Inhibitor or the ARB. B is the Beta Blocker. C is the Calcium Channel Blocker (CCB) and D, the diuretic. Any of these can be used for the responder, though lately the ACE inhibitor type agents and CCBs have become more popular.

Dr Conway adds an ‘O’ to this aide memoire when considering the options for the patient with resistant hypertension.

This O refers to older drugs (such as alpha methyl dopa (Aldomet)) and others such as Doxazosin (Cardura). In respect of cost, the diuretics are cheapest and the American ALLHAT study appeared to show that this class is adequate as a starting therapy. CCBs in combination with ACE-Is or ARBs have lately appeared in single preparations. This is useful in respect of compliance.

Whilst proven not to be quite as effective as ACE-I and CCBs, beta blockers have a dual benefit for some, in that they are anti-anginal.

Atheroma is a risk in hypertensive patients and if practitioners decide to discontinue them, they must be alert to symptoms of myocardial ischaemia that may surface. ACE inhibitors, ARBs, calcium channel blockers or diuretics, might be added to the beta blockers if such a concern arises.

In relation to the individual drug groups, the CCBs have three sub classes of agents for controlling and reducing blood pressure. The first is verapamil. This is used to control supraventricular rhythm problems.

It also has an effect on dilatation and relaxation of arteries. The second group includes the Nifedipine type drugs, which are most effective at relaxation of arteries.

In the third group is Diltiazem. This is something of a mixture of the first two classes.
An inappropriate tightening or stiffening of the arteries is a feature of hypertension. Angiotensin Converting Enzyme (ACE) inhibitors block the ACE enzyme that is responsible for angiotensin I conversion to angiotensin II.

By blocking the ACE, the potent vasoconstrictor angiotensin II is reduced and in the process, blood pressure is lowered.

Some people still manage to produce the vasoconstrictor angiotensin II, despite the ACE enzyme having been blocked. They avoid the blockade of the ACE enzyme by using chymase enzymes to make the angiotensin II.

Angiotensin receptor antagonists or blockers (ARBs) block the final point where the angiotensin II works, which is the angiotensin II receptor. Dr Conway believes the day is coming when ARBs will be used as initial treatment.

Renin – a foundational molecule, from which angiotensin I is constructed – is at the very start of the chain in the renin-angiotensin-aldosterone system (RAAS).

New drugs such as the renin inhibitor aliskiren (Rasilez), block the first point in the pathway (renin, angiotensin I, angiotensin II, receptor). These drugs are currently available and show promise for controlling the RAAS.

Posted in Cardiovascular on 28 October 2009
Tags: hypertension

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abortion, accupuncture, ACE inhibitors, acne, ADHD, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anorexia, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, beta carotene, beta-blockers, bipolar disorder, birth, bleeding, blindness, blood pressure, body dysmorphic disorder, body mass, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cataracts, cervical cancer, chemotherapy, child psychiatry, children, cholesterol, clinical trial, clopidogrel, Clostridium difficile, cognitive behavioural therapy, colectomy, colic, colorectal cancer, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, Crohn's, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, DNA, Down's syndrome, eating disorders, echinacea, ECT, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, euthanasia, exercise, fat, fertility, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, haemodialysis, hearing, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, IBD, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, invasive candidiasis, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, Marfan syndrome, media, medical ethics, medical research, medication, meningitis, mental illness, metabolic syndrome, migraine, miscarriage, mortality rate, MRSA, multiple sclerosis (MS), NCHDs, nephrology, neurology, OAB, obesity, obstetrics, occupational health, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, practice, pre-eclampsia, pregnancy, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, radiotherapy, rectal cancer, reproductive health, research, resuscitation, rheumatoid arthritis, rheumatology, rhinitis, salt, SARS, schizophrenia, screening, seizures, self harm, sexual abuse, sexual health, sexually transmitted infections, SGA, sinusitis, skin cancer, sleep disorders, smoking, smoking ban, spinal injury, sports medicine, statins, stress, stroke, substance abuse, suicide, supplement, surgery, syncope, technology, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamins, weight, WHO, women's health, World Health Assembly

«Previous article | Next article»

Hypertension picked up mainly in check-ups

HYPERTENSION: Some form of screening for hypertension in general practice might prove very useful, since hypertension is being picked up largely by chance at check-ups.

In deciding that a person is hypertensive a certain ‘hold steady’ approach should apply, in the view of Dr Michael Conway, Consultant Cardiologist, St Luke’s Hospital, Kilkenny, and the Beacon Hospital, Dublin.

Unless the systolic and diastolic blood pressures are very high (for example, diastolic greater than 110 mmHg), the blood pressure should be checked several times with a sphygmomanometer over a period of days or weeks. In respect of choosing drug therapy, the decision depends on whether the hypertension is responsive or resistant. The drug classes to consider are identifiable from the ABCD aide memoire.

A is the ACE Inhibitor or the ARB. B is the Beta Blocker. C is the Calcium Channel Blocker (CCB) and D, the diuretic. Any of these can be used for the responder, though lately the ACE inhibitor type agents and CCBs have become more popular.

Dr Conway adds an ‘O’ to this aide memoire when considering the options for the patient with resistant hypertension.

This O refers to older drugs (such as alpha methyl dopa (Aldomet)) and others such as Doxazosin (Cardura). In respect of cost, the diuretics are cheapest and the American ALLHAT study appeared to show that this class is adequate as a starting therapy. CCBs in combination with ACE-Is or ARBs have lately appeared in single preparations. This is useful in respect of compliance.

Whilst proven not to be quite as effective as ACE-I and CCBs, beta blockers have a dual benefit for some, in that they are anti-anginal.

Atheroma is a risk in hypertensive patients and if practitioners decide to discontinue them, they must be alert to symptoms of myocardial ischaemia that may surface. ACE inhibitors, ARBs, calcium channel blockers or diuretics, might be added to the beta blockers if such a concern arises.

In relation to the individual drug groups, the CCBs have three sub classes of agents for controlling and reducing blood pressure. The first is verapamil. This is used to control supraventricular rhythm problems.

It also has an effect on dilatation and relaxation of arteries. The second group includes the Nifedipine type drugs, which are most effective at relaxation of arteries.

In the third group is Diltiazem. This is something of a mixture of the first two classes.
An inappropriate tightening or stiffening of the arteries is a feature of hypertension. Angiotensin Converting Enzyme (ACE) inhibitors block the ACE enzyme that is responsible for angiotensin I conversion to angiotensin II.

By blocking the ACE, the potent vasoconstrictor angiotensin II is reduced and in the process, blood pressure is lowered.

Some people still manage to produce the vasoconstrictor angiotensin II, despite the ACE enzyme having been blocked. They avoid the blockade of the ACE enzyme by using chymase enzymes to make the angiotensin II.

Angiotensin receptor antagonists or blockers (ARBs) block the final point where the angiotensin II works, which is the angiotensin II receptor. Dr Conway believes the day is coming when ARBs will be used as initial treatment.

Renin – a foundational molecule, from which angiotensin I is constructed – is at the very start of the chain in the renin-angiotensin-aldosterone system (RAAS).

New drugs such as the renin inhibitor aliskiren (Rasilez), block the first point in the pathway (renin, angiotensin I, angiotensin II, receptor). These drugs are currently available and show promise for controlling the RAAS.

Posted in Cardiovascular on 28 October 2009
Tags: hypertension