Hypertension

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Hypertension

• Nick Price 4.9.13

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Aim

• 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)

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Objectives

• Brief overview of NICE guidelines
• Consider what this means in practice
• Interpret Ambulatory BP Measurement
• Apply this in a clincal scenaria

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So what is hypertension all about?
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Patient Orientated Outcomes
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Disease Orientated Outcomes
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Others Orientated Outcomes

• GPs
• Practice nurses
• PCTs
• Secondary Care
• Patient groups (e.g. BHF)
• Professional groups (e.g. BHS)
• Drug Companies
• Government

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What NICE / CKS says
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What 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.

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• 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.

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Diagnose 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.

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Diagnose 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

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Measurement 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)

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Investigations in brief(order of priority??)

• Urine dipstix (ACR?)
• UE, creatinine, eGFR
• Glucose (fasting / HBA1C?)
• TC HDL (fasting?)
• ECG

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Assess 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).

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Assess 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.

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Mx 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.

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Rx? 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.

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Cardiac Risk Assessments

• On SystemOne clinical tools Q Risk
• Or http//www.qrisk.org/index.php

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Drugs 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.

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For 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.

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Combination / Alternative Rx (BNF)

• Under 55 Alternatives

• Under 55 combinations

1. ACE
2. ARB
3. Beta blocker

• ACE CCB
• ACE thiazide
• ACE CCB thiazide
• (Generally avoid beta blocker and thiazide
  together DM risk)

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Combination / Alternative Rx (BNF)

• Over 55 / African Alternatives

• Over 55/African combinations

1. CCB
2. Thiazide

• CCB or thiazide with ACE
• ACE CCB thiazide
• (CCB and ARB for African/Caribbean).
• (Generally avoid beta blocker and thiazide
  together DM risk)

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• lt 55yrs
• A

• gt 55 or black patients
• C or D

AC or AD
ACD
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ABPM

• 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.

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A Case

• Data / recent results

• PMH etc

• 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.

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Summary 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.