Yarmouth Stroke Project Forum Hospital Stroke ServicesWhat Have We Learned Ambulatory Care Patti Sim

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Yarmouth Stroke Project ForumHospital Stroke
Services-What Have We Learned?Ambulatory Care -
Patti SimpsonHypertension - Commentary

• Tim Dean
• Director, Hypertension Unit
• QEII HSC

Canadian Hypertension Society www.CHS.MD (Text
and Slides)
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Yarmouth Stroke Project ForumObjectivesHypertens
ion

• Are you going to the Multidisciplinary Rounds?
  No, why would I go there? They dont relate to
  what I am trying to do.
• Who should measure blood pressure?
• The effect of lowering blood pressure.
• Lifestyle Issues
• Medications
• Barriers to success
• Overcoming barriers QEII Hypertension Unit
• The multidisciplinary and partnership approach

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Target organ damage due to Hypertension

• Cerebrovascular disease
• - transient ischemic attacks
• - ischemic or hemorrhagic stroke
• Coronary artery disease
• - myocardial infarction
• - angina pectoris
• - congestive heart failure
• Renal insufficiency
• Peripheral artery Disease
• - intermittent claudication

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The First Measurement of BP
Genest et al, eds. Hypertension Physiopathology
and Treatment 1983.
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Improper Position Patient's proper
position
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How Many Clinicians Follow Recommendations?
McKay, et al. J Hum Hypertens 19904639-45.
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Change in BP Measurement According to Technique
and Who Takes the BP
Prevalence of white coat hypertension using
different measurement techniques

• In another study, 57 of patients had a change
  in diagnosis when going from usual to
  standardized measurement

Myers, et al. Am J Hypertens 19958591-7.
Campbell et al. Blood Press Monit 1999471-6.
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Systolic Pressure, Stroke and CHD
Stroke mortality (n1233)
CHD mortality (n11,149)
32
16
16
8
8
4
Relative risk of stroke mortality
Relative risk of CHD mortality
4
2
2
1
135
168
lt120
125
135
148
168
120
125
148
Approximate mean SBP (mm Hg)
Multiple Risk Factor Intervention Trial (MRFIT)
n347,978 men Neaton et al. In Laragh et al
(eds). Hypertension Pathophysiology, Diagnosis,
and Management.2 ed. NY Raven, 1995127
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Diastolic Pressure, Stroke and CHD
Stroke and usual DBP (in 5 categories defined by
baseline DBP) 7 prospective observational
studies 843 events
CHD and usual DBP (in 5 categories defined by
baseline DBP) 9 prospective observational
studies 4856 events
4.00 2.00 1.00 0.50 0.25
4.00 2.00 1.00 0.50 0.25
Relative Risk of CHD
Relative risk of stroke
76 84 91 98 105
76 84 91 98 105
Approximate mean usual DBP (mm Hg)
Approximate mean usual DBP (mm Hg)
MacMahon et al. Lancet 1990335766
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Impact of High-Normal Blood Pressure on the Risk
of Cardiovascular Disease
CUMULATIVE INCIDENCE OF CV EVENTS IN MEN WITHOUT
HYPERTENSION ACCORDING TO BASELINE BLOOD PRESSURE
mmHg
(130-139)
(121-129)
(lt 120)
N Engl J Med 20013451291-7
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Impact of Lifestyle Therapies on Blood Pressure
in Hypertensive Adults
Result of aggregate and metaanalyses of short
term trials. Miller ER et al. J Clin Hyper 1999
Nov/Dec191-8.
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Summary Treatment of Systolic-Diastolic
Hypertension without Other Compelling Indications
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Yarmouth Stroke Project ForumHypertensionBarrier
s and Routes to Success

• Barriers to Success
• Lack of compliance with both lifestyle and
  medication issues
• Lack of understanding
• Lack of patient commitment
• Perceived lack of commitment of health care
  worker
• Lack of family support
• Monetary issues
• Lack of attention to multiple risk factors
• Side effects and our failure to explain them
• Routes to Success
• Clear therapeutic plan that patient understands -
  goals
• Multidisciplinary approach to management
• Clear demonstration of compassion and
  understanding
• Patients must be involved in planning and
  decisions
• Awareness of barriers
• See patients with difficult problems frequently

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Yarmouth Stroke Project ForumQEII Hypertension
Unit Out Patients

• People
• Education Nurse
• Runs Education Program 3x2 hour sessions
• Multiple community locations significant others
  attend
• Accompanied by program dietitian
• Components
• Mechanisms of hypertension
• Body weight
• Salt
• Exercise
• Stress
• Alcohol
• Smoking
• Runs Ambulatory Blood Pressure Monitoring Program
• 10 monitors going continously
• Runs Drug Procurement Program

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Yarmouth Stroke Project ForumQEII Hypertension
Unit Out Patients

• People (cont)
• Specialty Nurse Practitioner (Hypertension)
• Trained with Neurology, Nephrology, Cardiology,
  Endocrinology
• All patients referred by physicians
• Conducts complete assessments of patients
• Investigates as she feels appropriate
• Superb interpersonal, lifestyle and
  pharmacological skills
• Deals with most of the tough problems
• Physicians
• Patients Family Physicians Play a central role
• Four FRCPCs Someone is available to the Unit at
  all times, usually on site, and always by phone
• Location
• Outpatient Clinic
• Two Nurses and four physicians all in same
  geographical area
• Specialty Nurse Practitioner (Heart Function) in
  same clinic and cross covers with other two
  nurses. They all can run the Monitoring Program
  and two SNPs have drug skills in both areas.

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Yarmouth Stroke Project ForumQEII Hypertension
Unit Out Patients

• Patients
• 2500 to 3000 patients a year
• 2000 by physicians
• 1000 by nursing staff (Nurses get the hard ones)
• Management of patients is a four way partnership
• Patients
• Significant others
• Nursing staff and dietitian
• Physicians Patients Family Physicians and Unit
  Physicians
• Referral among groups is routine physicians,
  nurses, dietitian, social workers
• Referral to other groups is usual
• Communication
• Every contact with a patient is documented and a
  letter dictated to the Family Physician. This
  letter serves as a progress report and everyone
  in the Unit has access to it at each visit.

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Yarmouth Stroke Project ForumHypertension
Ambulatory CareRequirements for Success

• Family Physician, Community and Institutional
  Support
• Dedicated and skilled personnel
• A single geographical location for the major
  components of a Unit
• A multidisciplinary approach
• A partnership approach
• A shameless approach to the collection of
  financial support
• Compassionate, caring staff who truly enjoy
  working with each other and patients.
• A multiple risk factor reduction approach
• What is success 55 control rate. But dont
  forget, a 20 mmHg reduction of blood pressure
  reduces stroke rates by 40, regardless of where
  you start from.