1. Hypertension Nick Price 4.9.13

2. 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)

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

4. So what is hypertension all about?

5. Patient Orientated Outcomes

6. Disease Orientated Outcomes

7. Others’ Orientated Outcomes GPs Practice nurses PCTs Secondary Care Patient groups (e.g. BHF) Professional groups (e.g. BHS) Drug Companies Government

8. What NICE / CKS says

9. 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.accelerated (malignant) hypertension 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.antihypertensive drug treatment 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.

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.ambulatory blood pressure monitoring

11. 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.Scenario: Newly diagnosed hypertension

12. 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 treatmentantihypertensive drug treatment

13. Measurement considerations Techniques No of readings Cuffs Home BP Ambulatory See http://www.npc.nhs.uk/merec/cardio/cdhyper/ resources/merec_briefing_no29.pdf http://www.npc.nhs.uk/merec/cardio/cdhyper/ resources/merec_briefing_no29.pdf For all the basics and more (although a bit old)

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

15. 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. Heart failure - chronic 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 = 30 mg/mmol, see the CKS topic on Chronic kidney disease - not diabetic for information on confirming and managing chronic kidney disease.Chronic kidney disease - not diabetic 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).

16. 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:antihypertensive drug treatmentstage 1 hypertension 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.stage 2 hypertension

17. Mx – as per CKS. ‘Reinforce’ Lifestyle advice.Lifestyle advice Offer antihypertensive drug treatment if the person is:antihypertensive drug treatment Aged less than 80 years with stage 1 hypertension with one or more of the following: stage 1 hypertension 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.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.antiplateletstatin 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.www.bpassoc.org.uk

18. Rx? ‘Reinforce Lifestyle advice’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/t herap/lifestyle/resources/merec _briefing_no19.pdf http://www.npc.nhs.uk/merec/t herap/lifestyle/resources/merec _briefing_no19.pdf This is a comprehensive review on evidence of lifestyle measures – highly recommended, all be it, from 2002.

19. Cardiac Risk Assessments On SystemOne – clinical tools – Q Risk Or http://www.qrisk.org/index.phphttp://www.qrisk.org/index.php

20. 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).angiotensin-converting enzyme inhibitorangiotensin II receptor antagonist If ACE inhibitors or AIIRAs are not suitable, start a low-dose thiazide-type diuretic or calcium-channel blocker. thiazide-type diureticcalcium-channel blocker A beta-blocker can be considered for initial treatment for:beta-blocker 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).Pre-conception - advice and management People with evidence of increased sympathetic drive, such as sweating or palpitation symptoms.

21. 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.calcium-channel blockerthiazide-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.

22. Combination / Alternative Rx (BNF) Under 55 AlternativesUnder 55 combinations 1.ACE 2.ARB 3.Beta blocker 1.ACE + CCB 2.ACE + thiazide 3.ACE + CCB+ thiazide (Generally avoid beta blocker and thiazide together – DM risk)

23. Combination / Alternative Rx (BNF) Over 55 / African Alternatives Over 55/African combinations 1.CCB 2.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)

24. < 55yrs A > 55 or black patients C or D A+C or A+D A+C+D

25. 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].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. Diagnosis

26. A Case Data / recent resultsPMH 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.

28. 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.