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26 th September 2012 Dr Julian Tomkinson.  To understand the diagnosis, impact and management of hypertension in General Practice.

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Presentation on theme: "26 th September 2012 Dr Julian Tomkinson.  To understand the diagnosis, impact and management of hypertension in General Practice."— Presentation transcript:

1 26 th September 2012 Dr Julian Tomkinson

2  To understand the diagnosis, impact and management of hypertension in General Practice

3  Overview of NICE guidelines  Applying to General Practice as we go along  Case examples / scenarios

4 Any areas you would like clarifying today?

5  3.01Healthy People: promoting health and preventing disease  3.12Cardiovascular Health  2.01 The GP consultation  2.02Patient Safety and Quality of Care  2.04 Enhancing Professional Knowledge

6  Major risk factor for stroke, MI, heart failure, CKD, cognitive decline and premature death  Untreated hypertension can cause vascular and renal damage leading to a treatment resistant state.  Each 2 mmHg rise in systolic blood pressure associated with increased risk of mortality: – 7% from heart disease – 10% from stroke.

7  At least ¼ of UK population have hypertension  More than ½ > 60’s have hypertension (~90% of cases are Primary & 10% are Secondary)

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9 How does hypertension present to the GP?

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11 Stage 1 hypertension:  Clinic BP ≥ 140/90 and ABPM or HBPM average ≥ 135/85 Stage 2 hypertension:  Clinic BP ≥ 160/100  ABPM or HBPM average ≥ 150/95 Severe hypertension:  Clinic systolic BP≥ 180  Clinic diastolic BP ≥ 110

12 If blood pressure is 220/120 mmHg or higher, or signs of accelerated (malignant) hypertension (BP 180/110 mmHg or higher with signs of papilloedema and/or retinal haemorrhage), arrange same-day admission

13 If the clinic BP is ≥ 140/90 offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension Home BP monitoring (HBPM) also possible

14 Scenario 1 O&G clinic – 48 year old lady with menorrhagia. BP raised 165/100 when checked – what do you say to her?

15 Scenario 2 Pt seen in surgery: letter from ophthalmology pre-op clinic ‘BP 180/90. Please treat this patient's BP and send them back for their cataract surgery when you have got BP under control’ BP today 120/80THOUGHTS?

16  When using ABPM, ensure that at least two measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00).  Use the average value of at least 14 measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension

17  For each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated and:  blood pressure is recorded twice daily, ideally in the morning and evening and  blood pressure recording continues for at least 4 days, ideally for 7 days Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension.

18 Scenario 1 continued Mrs Haifa Tenchun 48 years old Came to surgery 2 weeks ago after BP found raised in O&G clinic Came to surgery 2 weeks ago after BP found raised in O&G clinic You were running late and so simply arranged home BP measurement. Average is 148/92 You were running late and so simply arranged home BP measurement. Average is 148/92 What do you do next?

19 Scenario 1 continued Mrs Haifa Tenchun 48 years old How do we explain hypertension to a patient?

20  Many patients perceive stress as a major causative factor as well as family history, genetic make-up, race, personality traits  Specific habits such as alcohol consumption, smoking and salt intake  Frustrated when lifestyle changes didn’t work  Believed they hadn’t been given enough info about cause

21 Scenario 1 continued Mrs Haifa Tenchun 48 years old Mrs HT is grateful for your explanation and fill follow your advice: What are the next steps in management?

22 Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension. For all people with hypertension offer to: –test urine for presence of protein –take blood to measure glucose, electrolytes, creatinine, estimated glomerular filtration rate and cholesterol –examine fundi for hypertensive retinopathy –arrange a 12-lead ECG. CHECK OTHER SIG ISSUES SMOKING ALCOHOL BMI…

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24 Care pathway CBPM ≥160/100 mmHg & ABPM/HBPM ≥ 150/95 mmHg Stage 2 hypertension Consider specialist referral Offer antihypertensive drug treatment Offer lifestyle interventions If younger than 40 years If target organ damage present or 10-year cardiovascular risk > 20% Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication Offer patient education and interventions to support adherence to treatment CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg Stage 1 hypertension

25 Scenario 1 continued Mrs Haifa Tenchun 48 years old Review appointment: eGFR >90 u&e’s / glucose normal Cholesterol 5.0 HDl 1.0 Urine NAD Height 155cm Weight 80kg BMI 33.3 ECG normal Optician assessed eyes and no retinal damage WHAT NEXT?

26  QRISK 2 / QRISK  JBS  Ethrisk

27 Lifestyle interventions Offer guidance and advice about: – diet (including sodium and caffeine intake) and exercise – alcohol consumption – smoking. (Hypertension).htm Patient education and adherence Provide: – information about benefits of drugs and side effects – details of patient organisations – an annual review of care.

28  USE CORRECT READ CODES – check with practice

29 Scenario 1 continued Mrs Haifa Tenchun 49 years old Reviews: 6 months (practice nurse)165/95 BMI months (practice nurse)166/98 BMI 34 (asked to make appointment to see GP) What would you say / do now? Home readings arranged and BP 155/98

30 Step 4 Aged over 55 years or black person of African or Caribbean family origin of any age Aged under 55 years C2C2 A A + C 2 A + C + D Resistant hypertension A + C + D + consider further diuretic 3, 4 or alpha- or beta-blocker 5 Consider seeking expert advice Step 1 Step 2 Step 3 Key A – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB) 1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic See slide notes for details of footnotes 1-5

31  Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following: − target organ damage − established cardiovascular disease − renal disease − diabetes − a 10-year cardiovascular risk equivalent to 20% or greater.

32  who have stage 2 hypertension at any age.  If aged under 40 with stage 1 hypertension and without evidence of target organ damage, cardiovascular disease, renal disease or diabetes NB consider specialist evaluation of secondary causes of hypertension & further assessment of potential target organ damage

33 Scenario 1 continued Mrs Haifa Tenchun 49 years old What treatment do you recommend?

34 Scenario 1 continued Mrs Haifa Tenchun 49 years old Start ramipril 1.25mg. What review arrangements do you make? u+e’s normal after 2 weeks BP 135/85

35  Ask about adverse effects  Check clinic blood pressure  If blood pressure is within the target range and treatment is well tolerated: ◦ Either, review the person in 12 months depending on clinical judgement. ◦ Or, if the blood pressure has been well controlled for a prolonged period of time and the person's cardiovascular risk is low, consider withdrawing or reducing drug treatment  If blood pressure is above the target range: ◦ Check and confirm ◦ consider secondary hypertension ◦ Consider increasing / changing medication

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37 For patients identified as having a ‘white-coat effect’ consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor response to treatment. Aim for ABPM/HBPM target average of  < 135/85 mmHg in people aged under 80  < 145/85 mmHg in people aged 80 and over (White Coat Hypertension (WCH) is reported to occur in as many as 25% of the population)

38 It is estimated that between 50–80% of patients with hypertension do not take all of their prescribed medication

39  improving patient education, providing counselling, involving families and other members of the health care team

40  ACE inhibitors eg ramipril?  Calcium channel blockers eg amlodipine?  Angiotensin 2 blockers eg losartan?  Thiazide-like diuretics eg indapamide?

41  48 year old man sent from A&E with BP 180/100  Smoker minimal alcohol  BMI 30

42  Home readings average 180/99  eGFR 65 Cholesterol / HDl ratio 2.9  ECG suggests left ventricular hypertrophy  Negative catecholoamine screen  USS abdomen normal  Echo marked left ventricular hypertrophy  Admits to heavy use of anabolic steroids  Start ramipril and titrate up to 10mg  No significant response add amlodipine 5g  Add indapamide still hypertensive  Await cardiology

43 You visit Mr Siegfried Avant age 82 at home  Letter from hospital shows he had a CVA 3 weeks ago and has been left with a left sided hemiparesis  Looking at the notes before you leave you see: / / /100 (comment in notes check 1 month) /95 (1 month later 150/89 with remark ‘watch BP’) /100 (see 1 week) THOUGHTS?

44  The DVLA's medical rules regarding hypertension are: ◦ For group 1 entitlement (cars, motorcycles):  Driving may continue unless treatment causes unacceptable side effects.  The DVLA need not be notified. ◦ For group 2 entitlement (lorries, buses):  Disqualifies from driving if resting systolic blood pressure is consistently 180 mmHg or more and/or resting diastolic blood pressure is consistently 100 mmHg or more.  Re-licensing may be permitted when blood pressure is controlled provided that treatment does not cause side effects which may interfere with driving.  The person should check with their insurer that they are still covered for driving.  The latest information from the DVLA regarding medical fitness to drive can be obtained atwww.dvla.gov.uk/medical/ataglance.www.dvla.gov.uk/medical/ataglance

45  NICE  Prodigy guidance: io_diagnosis/view_full_scenario#  QRISK  Patient.co.uk


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