Sunday, February 12, 2012

Hypertension course - Day 2

After a too short night's sleep we started day two at 8:45 in the morning. The morning sessions covered treatment and current guidelines. Even though I was a bit tired, I managed to remember to take some pictures (for the blog), and write an extra presentation to replace a lecturer that could not attend.

There is massive data that shows that reducing the pressure under 140/90 mmHg is the first priority. Use what ever means necessary, just get the pressure down. Then there is data to show that renin-angiotensin-system-blockers may have some additional benefit. In type 1 diabetes this is indisputable. Type 1 diabetic patients should have an ACE-inhibitor or an ARB as soon as they show microalbuminuria, no matter what their pressure is. Unless you have a specific need for a beta-blocker you should start with a RAS-inihibitor and a calcium blocker.

The afternoon focused on target organ damage and associated diseases, such as diabetes, stroke and old age. To protect the heart and kidneys, ACE-inhibitors or ARBs are the best choices. To protect against renal failure and stroke it is quite clear that lower pressure is better down to 120/70, at least. For the heart, the nadir may be around 130/80, considering that the coronary arteries are perfused in diastole, this is not surprising. After stroke, certainly ischemic and maybe hemorrhagic, the pressure should not be treated the first couple of days, with the possible exception of systolic pressures above 220mmHg.

In the elderly, pulse pressure is a much stronger predictor of mortality than systolic pressure or diastolic pressure, so that 160/110 mmHg is actually better than 160/60 mmHg. Much better.

Hypertension is therapy resistant when treated with three antihypertensives at the maximal doses, including a thiazide-diuretic. It may then be time for renal nerve ablation, or to ask the patient if they eat a lot of salt. Another under-appreciated reason for uncontrolled blood pressure is doctor's-, or even investigator's-inertia. That is, the patient has an uncontrolled blood pressure, does not have the maximal dose, have not experienced any adverse events, and still the dosage isn't increased by the doctor.

All in all, it was a very successful course. 130 attendees, and some 20 lecturers. The next one will be in two years, in 2014.

On a side-note, free wifi on the airplane home is brilliant. All airlines should provide it, on all flights.

Actually, everywhere should provide free wifi.

Thursday, February 09, 2012

Course on hypertension

Finally, the first day of our hypertension course has come to an end, and I can go to a much needed repose. First I just have to finish my blogpost, and possibly check the twitter. So far it has been a very successful course. As is traditional we started with epidemiology, worked through pathophysiology and diagnosis. Treatment will come tomorrow.

Here is a brief summary of the conclusions from the first day:

Hypertension is developing better traction with the big agencies, WHO etc, as the largest modifiable risk factor for disease and death. Not only in the high-income countries, but globally.

Prehypertension (120-140 in systolic- and 70-90 in diastolic blood pressure) is an important risk factor for later hypertension and later cardiovascular morbidity and death. It should probably indicate a closer follow up and counceling about life-style, although, it is still not well studied enough to be an indication for pharmacological treatment.

Diastolic hypertension is the strongest risk factor for later cardiovascular morbidity and mortality in adolescents. In middle age systolic blood pressure takes over, and in greater ages the pulse pressure is stronger than either.

Hypertension is part of the cluster of risk factors sometimes known as the metabolic syndrome. Increased stress-hormone release may represent a common mechanism behind this syndrome.

High exercise blood pressure (>210 mmHg) in the absence of clinical hypertension may be a sign of masked hypertension.

Hypertension is both caused by, and leads to structural changes in the vasculature, which are important for the associated cardiovascular diseases and end organ damage.

Non-pharmacologic treatment, such as exercise, weight-loss and reduced salt-intake are effective components in the treatment and prevention of hypertension.

The work-up for a patient with hypertension should include ambulatory blood pressure if they are prehypertensive or if the indication for treatment is uncertain. For example, slight hypertension, no other risk factors and no target organ damage. A situation where current guidelines suggest to wait and see. A problem is that ambulatory measures are not included int the current guidelines. So, it is unclear how the results should be interpreted.

Secondary hypertension is a surprisingly common cause of hypertension, in particular hyperaldosteronism which may include 5-13% of all hypertensives.

Albuminuria is an important, independent risk-factor for cardiovascular morbidity all the way from sub-microalbuminuric levels.

In addition to these lectures we had some clinical cases and two panel discussions:

Is hypertension the most important global risk factor for disease and death?

Does living well improve your survival?

Both of these were answered with quite solid affirmative answers. Not really surprising given the audience and setting, but probably not wrong either.

Wednesday, February 08, 2012

ESH 2012 satellite symposium in Oslo

In connection with the CME course on hypertension in Oslo that will start tomorrow, the Norwegian society of hypertension together with the European society and the research group in Oslo have arranged a Research symposium so that some of the young researchers in Norway would have occasion to present their data. Not me. I am just here to pretend to listen while blogging. The sessions were focused on Coronary heart disease, Cardiac hypertrophy, Kidney disease and Diabetes and Atrial Fibrillation, all in more or less direct connection to hypertension, as well as hypertension as such.

After a night on call and then leaving home for my flight at 5:30 in the morning, I might have been less attentive than otherwise. But never the less, I thought I might mention some highlights:

Anabolic steroids causes heart disease (well known).
Early pressure intervention is probably bad after ischemic stroke (SCAST as reported last year). 
Long-time endurance training is associated with increased risk for atrial fibrillation (as we knew). 
Inflammation in reumatologic disease increases the development of atherosclerosis. 
Hypertension treatment in moderate aortic stenosis is probably not dangerous (needs more study). 
IL-18 plasma concentration is affected by a SNP in the 3'-UTR, which is also associated with hypertension, but not with cardiovascular disease in the studied population (The physiologist finds this interesting, the physician not so much). 
Antiviral treatment in HIV is associated with hypertension in those with more severe disease before the start of treatment. 
Blueberry extracts (anthocyanins) have no effect on blood pressure (None).

Now my brain is full and I have to get to my hotel and get something to eat before I die from undernutrition and sleep deprivation.