Hypertension Nick Price 4.9.13

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)

Objectives

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

So what is hypertension all about?

Patient Orientated Outcomes

Disease Orientated Outcomes

Others’ Orientated Outcomes

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

What NICE / CKS says

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 2–3 occasions over the next few weeks or months depending on clinical judgement.

• 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.

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.

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

Measurement considerations

•Techniques•No of readings•Cuffs•Home BP•Ambulatory•See

http://www.npc.nhs.uk/merec/cardio/cdhyper/resources/merec_briefing_no29.pdf

For all the basics and more (although a bit old)

Investigations in brief(order of priority??)•Urine dipstix (ACR?)•U+E, creatinine, eGFR•Glucose (fasting / HBA1C?)•TC + HDL (fasting?)•ECG

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 albumin:creatinine ratio (ACR), ideally tested on a first-void morning urine sample.

• If the eGFR is < 60 mL/min/1.73 m2 or the urine ACR is >= 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).

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.

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.

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/resources/merec_briefing_no19.pdfThis is a comprehensive review on evidence of lifestyle measures – highly recommended, all be it, from 2002.

Cardiac Risk Assessments

On SystemOne – clinical tools – Q RiskOr http://www.qrisk.org/index.php

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.

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.

Combination / Alternative Rx (BNF)Under 55 Alternatives Under 55 combinations

1. ACE2. ARB3. Beta blocker

1. ACE + CCB2. ACE + thiazide3. ACE + CCB+ thiazide

(Generally avoid beta blocker and thiazide together – DM risk)

Combination / Alternative Rx (BNF)Over 55 / African Alternatives Over 55/African combinations

1. CCB2. Thiazide

1. CCB or thiazide with ACE

2. ACE + CCB+ thiazide

(CCB and ARB for African/Caribbean).

(Generally avoid beta blocker and thiazide together – DM risk)

• < 55yrs

A• > 55 or black patients

C or D

A+C or A+D

A+C+D

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.

A CaseData / recent results PMH etc

• Age 61• Female• Smokes 5/day• BMI 31• Clinic BP 170 /90• CHO/HDL ratio 5• Urine neg• U+E 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.

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? • Don’t be bullied by QoF / guidelines etc.