Title: Hypertension
1Hypertension
2Aim
- Consider the application of evidence based
practice in the management of hypertension in
primary care. - EBP defined as the integration of best
available research evidence with clinical
expertise and patient values (Sackett et al, 2000)
3Objectives
- Brief overview of NICE guidelines
- Consider what this means in practice
- Interpret Ambulatory BP Measurement
- Apply this in a clincal scenaria
4So what is hypertension all about?
5Patient Orientated Outcomes
6Disease Orientated Outcomes
7Others Orientated Outcomes
- GPs
- Practice nurses
- PCTs
- Secondary Care
- Patient groups (e.g. BHF)
- Professional groups (e.g. BHS)
- Drug Companies
- Government
8What NICE / CKS says
9What is hypertension?
- If blood pressure is 220/120 mmHg or higher, or
there are signs of accelerated (malignant)
hypertension (blood pressure 180/110 mmHg or
higher with signs of papilloedema and/or retinal
haemorrhage), arrange same-day admission. - Diagnose hypertension if systolic blood pressure
is 180 mmHg or higher or diastolic blood pressure
is 110 mmHg or higher and start
antihypertensive drug treatment immediately. - For other people, suspect hypertension if clinic
blood pressure is 140/90 mmHg or greater. Recheck
blood pressure on 23 occasions over the next few
weeks or months depending on clinical judgement.
10- If clinic blood pressures are persistently above
140/90 mmHg, offer ambulatory blood pressure
monitoring (or home blood pressure monitoring if
this is not acceptable to the person or
unavailable), to confirm the diagnosis of
hypertension.
11Diagnose stage 1 hypertension
- if clinic blood pressure is above or equal to
140/90 mmHg, and ABPM average is above or equal
to 135/85 mmHg. The decision to treat this level
of hypertension depends on an assessment of the
total cardiovascular disease risk see the
Scenario Newly diagnosed hypertension.
12Diagnose stage 2 hypertension
- If clinic blood pressure is above or equal to
160/100 mmHg, and ABPM average is above or equal
to 150/95 mmHg, or there is isolated systolic
hypertension with a systolic blood pressure of
160 mmHg or higher. - Start antihypertensive drug treatment
13Measurement considerations
- Techniques
- No of readings
- Cuffs
- Home BP
- Ambulatory
- See http//www.npc.nhs.uk/merec/cardio/cdhyper/res
ources/merec_briefing_no29.pdf - For all the basics and more (although a bit old)
14Investigations in brief(order of priority??)
- Urine dipstix (ACR?)
- UE, creatinine, eGFR
- Glucose (fasting / HBA1C?)
- TC HDL (fasting?)
- ECG
15Assess for target organ damage
- Arrange an ECG (electrocardiogram) in all people,
looking for evidence of cardiovascular disease. - If signs of left ventricular hypertrophy are
present, see the CKS topic on Heart failure -
chronic for recommended investigations. - Check serum urea, electrolytes, and estimated
glomerular filtration rate (eGFR), and dipstick
urine to check for proteinuria and haematuria. - If proteinuria is present, consider checking the
urine albumincreatinine ratio (ACR), ideally
tested on a first-void morning urine sample. - If the eGFR is lt 60 mL/min/1.73 m2 or the urine
ACR is gt 30 mg/mmol, see the CKS topic on
Chronic kidney disease - not diabetic for
information on confirming and managing chronic
kidney disease. - Check serum glucose level to screen for diabetes
mellitus. - Check serum total cholesterol and HDL cholesterol
levels to screen for hypercholesterolaemia. - Examine the fundi for the presence of
hypertensive retinopathy (arteriolar narrowing,
arteriovenous compression, retinal haemorrhages
or exudates, and papilloedema).
16Assess Cardiac Risk
- Offer antihypertensive drug treatment if the
person is aged less than 80 years with stage 1
hypertension with one or more of the following - Target organ damage, established cardiovascular
disease, renal disease, diabetes, and/or a 10
year cardiovascular risk of 20 or more. - Any age with stage 2 hypertension.
17Mx as per CKS.
- Reinforce Lifestyle advice.
- Offer antihypertensive drug treatment if the
person is - Aged less than 80 years with stage 1 hypertension
with one or more of the following - Target organ damage, established cardiovascular
disease, renal disease, diabetes, and/or a 10
year cardiovascular risk of 20 or more. - Any age with stage 2 hypertension.
- Consider whether antiplatelet or statin drug
treatment is appropriate they are indicated in
most people with hypertension who are at high
risk of cardiovascular disease (off-label use for
antiplatelets for primary prevention). Note
this is inconsistent with more recent advice re
antiplatelets in primary prevention. - Consider offering details of organizations where
people with hypertension can share views and
obtain information, such as the Blood Pressure
Association www.bpassoc.org.uk.
18Rx? Reinforce Lifestyle advice
- Low alcohol
- Low caffeine
- (Smoking)
- Exercise or physical activity
- Low salt diet
- Relaxation?
- (Mediterranean diet ? not on CKS but RR 0.28!)
- Where appropriate, consider offering referral
for - Smoking cessation.
- Exercise and physical activity programmes.
- Weight loss programmes.
- Dietary advice.
- See http//www.npc.nhs.uk/merec/therap/lifestyle/r
esources/merec_briefing_no19.pdf - This is a comprehensive review on evidence of
lifestyle measures highly recommended, all be
it, from 2002.
19Cardiac Risk Assessments
- On SystemOne clinical tools Q Risk
- Or http//www.qrisk.org/index.php
20Drugs for people who are younger than 55 years of
age and not of black African or Caribbean ethnic
origin
- start an angiotensin-converting enzyme inhibitor
(ACE inhibitor) or a low-cost angiotensin II
receptor antagonist (AIIRA). - If ACE inhibitors or AIIRAs are not suitable,
start a low-dose thiazide-type diuretic or
calcium-channel blocker. - A beta-blocker can be considered for initial
treatment for - Younger people who cannot use or tolerate ACE
inhibitors and AIIRAs. - Women who might become pregnant or are planning a
pregnancy (see the CKS topic on Pre-conception -
advice and management). - People with evidence of increased sympathetic
drive, such as sweating or palpitation symptoms.
21For people who are 55 years of age or older and
those who are of black African or Caribbean
ethnic origin (of any age),
- offer a calcium-channel blocker. If a
calcium-channel blocker is not suitable due to
oedema or drug intolerance, or if there is
evidence of heart failure or a high risk of heart
failure, offer a low-dose thiazide-type diuretic. - For people aged 80 years and older, offer the
same treatment as people aged 55 years and older,
taking into account any co-morbidities and other
drugs the person is taking.
22Combination / Alternative Rx (BNF)
- ACE
- ARB
- Beta blocker
- ACE CCB
- ACE thiazide
- ACE CCB thiazide
- (Generally avoid beta blocker and thiazide
together DM risk)
23Combination / Alternative Rx (BNF)
- Over 55 / African Alternatives
- Over 55/African combinations
- CCB
- Thiazide
- CCB or thiazide with ACE
- ACE CCB thiazide
- (CCB and ARB for African/Caribbean).
- (Generally avoid beta blocker and thiazide
together DM risk)
24- gt 55 or black patients
- C or D
AC or AD
ACD
25ABPM
- Use the average value of at least 14 ambulatory
blood pressure monitoring (ABPM) measurements
taken during the person's usual waking hours, to
confirm a diagnosis of hypertension NICE,
2011a. - If clinic blood pressure is above or equal to
140/90 mmHg and ABPM average is above or equal to
135/85 mmHg, diagnose stage 1 hypertension. - If clinic blood pressure is above or equal to
160/100 mmHg and ABPM average is above or equal
to 150/95 mmHg, diagnose stage 2 hypertension. - For more information on how to diagnose
hypertension using ABPM measurements, see the
section on Diagnosis.
26A Case
- Age 61
- Female
- Smokes 5/day
- BMI 31
- Clinic BP 170 /90
- CHO/HDL ratio 5
- Urine neg
- UE etc normal
- ECG normal.
- Qrisk2 21
- Summary
- 1995 TAH for menorrhagia
- 2010 Varicose eczema with mild oedema
- Last consultations
- saw practice nurse for a check up, BP 170/90
told to see Dr. - ABPM, ECG, urine and bloods arranged.
27(No Transcript)
28Summary think carefully
- Measurements
- Interventions
- Explaining to patients
- Empowering vs disempowering patients
- Use risk calculators
- Non drug Rx is probably at least as effective as
a whole stack of medication - Integrate your patients values into the
management plan. - Consider co-morbities and side effects in choice
of Rx - The differences between drugs are minimal
- Remember compliance / concordance / adherence?
- Dont be bullied by QoF / guidelines etc.