26th September 2012 Dr Julian Tomkinson Hypertension 26th September 2012 Dr Julian Tomkinson

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

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

Any areas you would like clarifying today? Questions? Any areas you would like clarifying today?

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

Why is it important? 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.

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

QOF

How does hypertension present to the GP?

NICE Definitions 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

Emergencies in hypertension 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

Diagnosing hypertension 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

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

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 120/80 THOUGHTS?

Ambulatory blood pressure monitoring (ABPM) 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

Home blood pressure monitoring (HBPM) 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.

Scenario 1 continued What do you do next? Mrs Haifa Tenchun 48 years old 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 What do you do next?

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

What do patient’s think about BP? 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

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?

Assessing cardiovascular risk and target organ damage: 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… NOTES FOR PRESENTERS: These are not key priorities for implementation in this area, however this has been included as it is considered an important part of the treatment pathway. Please note these recommendations would be applied during the person’s initial blood pressure measurement and at the diagnosis stages of the patient pathway. Key points to raise: Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension, both for raised blood pressure and other modifiable risk factors. [2004] [1.3.1] Estimate cardiovascular risk in line with the recommendations on Identification and assessment of CVD risk in ‘Lipid modification’ (NICE clinical guideline 67)*. [2008] [1.3.2] *Clinic blood pressure measurements must be used in the calculation of cardiovascular risk. For all people with hypertension offer to: test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol examine the fundi for the presence of hypertensive retinopathy arrange for a 12-lead electrocardiograph to be performed. [2004, amended 2011] [1.3.3] Additional information: The recommendations in identification and assessment of CVD risk in ‘lipid modification’ are available here: http://egap.evidence.nhs.uk/CG67/section_1_1 For NICE guidance on the early identification and management of chronic kidney disease see ‘Chronic kidney disease’ (NICE clinical guideline 73, 2008).

Care pathway CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg Stage 1 hypertension CBPM ≥160/100 mmHg & ABPM/HBPM ≥ 150/95 mmHg Stage 2 hypertension Care pathway If target organ damage present or 10-year cardiovascular risk > 20% Offer antihypertensive drug treatment Consider specialist referral If younger than 40 years NOTES FOR PRESENTERS. Key priority recommendations are identified with [KPI] in these notes Step 1 treatment: Offer people aged under 55 years step 1 antihypertensive treatment with an angiotensin-converting enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB). If an ACE inhibitor is prescribed and is not tolerated (for example, because of cough), offer a low-cost ARB. [new 2011] [1.6.6] Do not combine an ACE inhibitor with an ARB to treat hypertension. [new 2011] [1.6.7] Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged over 55 years and to black people of African or Caribbean family origin of any age. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. [new 2011] [1.6.8] [KPI] If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.9] [KPI] For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.10] [KPI] Related recommendations: Recommendations 1.6.11 and 1.6.12 have not been updated and reviewed since ‘Hypertension’ (NICE clinical guideline 34, 2006). Step 2 treatment If blood pressure is not controlled by step 1 treatment, offer step 2 treatment with a CCB in combination with either an ACE inhibitor or an *ARB. [new 2011] [1.6.13] If a CCB is not suitable for step 2 treatment, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. [new 2011] [1.6.14] For black people of African or Caribbean family origin, consider an ARB* in preference to an ACE inhibitor, in combination with a CCB. [new 2011] [1.6.15] *Choose a low-cost ARB Additional information: the pathway above focuses on stage 1 and 2 hypertension. For the full care pathway see page 35 of the NICE guideline. Offer lifestyle interventions Offer patient education and interventions to support adherence to treatment Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

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?

Risk Calculators QRISK 2 / QRISK http://www.qrisk.org/index.php http://qrisk.org/lifetime JBS Ethrisk

Additional recommendations Lifestyle interventions Offer guidance and advice about: diet (including sodium and caffeine intake) and exercise alcohol consumption smoking. http://www.patient.co.uk/health/High-Blood-Pressure- (Hypertension).htm Patient education and adherence Provide: information about benefits of drugs and side effects details of patient organisations an annual review of care. NOTES FOR PRESENTERS: These are not key priorities for implementation in this area however this has been included as it is considered an important part of the treatment pathway. Note these recommendations did not require updating in 2011. Please note these recommendations should be applied throughout the patient pathway. Key points to raise: Lifestyle interventions Recommendations 1.4.1–1.4.8 in the NICE guideline have not been updated and reviewed since ‘Hypertension’ (NICE clinical guideline 18, 2004). Patient education and adherence Recommendations 1.7.1–1.7.3 in the NICE guideline cover recommendations concerning patient education and adherence to treatment. These have not been updated and reviewed since ‘Hypertension’ (NICE clinical guideline 18, 2004). Because evidence supporting interventions to increase adherence is inconclusive, only use interventions to overcome practical problems associated with non-adherence if a specific need is identified. Target the intervention to the need. Interventions might include: suggesting that patients record their medicine-taking encouraging patients to monitor their condition simplifying the dosing regimen using alternative packaging for the medicine using a multi-compartment medicines system. This recommendation is taken from ‘Medicines adherence’ (NICE clinical guideline 76). [2009] [1.7.4] Additional information For NICE guidance on the prevention of obesity and cardiovascular disease see ‘Obesity’ (NICE clinical guideline 43, 2006) and ‘Prevention of cardiovascular disease at population level’ (NICE public health guidance 25, 2010).

CODING ON COMPUTER USE CORRECT READ CODES – check with practice

Scenario 1 continued Mrs Haifa Tenchun 49 years old Reviews: 6 months (practice nurse) 165/95 BMI 34 12 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

Summary of antihypertensive drug treatment Aged over 55 years or black person of African or Caribbean family origin of any age Aged under 55 years Summary of antihypertensive drug treatment A C2 Step 1 Key A – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic A + C2 Step 2 A + C + D Step 3 NOTES FOR PRESENTERS. Key priority recommendations are identified with [KPI] in these notes. Step 3 treatment Before considering step 3 treatment, review medication to ensure step 2 treatment is at optimal or best tolerated doses. [new 2011] [1.6.16] If treatment with three drugs is required, the combination of ACE inhibitor (or angiotensin-II receptor blocker), calcium-channel blocker and thiazide-like diuretic should be used. [2006] [1.6.17] Step 4 treatment Regard clinic blood pressure that remains higher than 140/90 mmHg after treatment with the optimal or best tolerated doses of an ACE inhibitor or an ARB plus a CCB plus a diuretic as resistant hypertension, and consider adding a fourth antihypertensive drug and/or seeking expert advice. [new 2011] [1.6.18] For treatment of resistant hypertension at step 4: Consider further diuretic therapy with low-dose spironolactone4 (25 mg once daily) if the blood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia. Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5 mmol/l. [new 2011] [1.6.19] [KPI] When using further diuretic therapy for resistant hypertension at step 4, monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter. [new 2011] [1.6.20] If further diuretic therapy for resistant hypertension at step 4 is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker. [new 2011] [1.6.21] If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained. [new 2011] [1.6.22] Footnotes (1) Choose a low-cost ARB. (2) A CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has oedema, evidence of heart failure or a high risk of heart failure. (3) Consider a low dose of spironolactone4 or higher doses of a thiazide-like diuretic. (4) At the time of publication (August 2011), spironolactone did not have a UK marketing authorisation for this indication. Informed consent should be obtained and documented. (5) Consider an alpha- or beta-blocker if further diuretic therapy is not tolerated, or is contraindicated or ineffective. Resistant hypertension A + C + D + consider further diuretic3, 4 or alpha- or beta-blocker5 Consider seeking expert advice Step 4 See slide notes for details of footnotes 1-5

Initiating drug treatment 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.

Initiating Drug Treatment 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

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

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

Reviewing new medication for hypertension? 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

Monitoring antihypertensive drug treatment

Monitoring antihypertensive drug treatment 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)

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

Compliance improved by improving patient education, providing counselling, involving families and other members of the health care team

Common / important side effects ACE inhibitors eg ramipril? Calcium channel blockers eg amlodipine? Angiotensin 2 blockers eg losartan? Thiazide-like diuretics eg indapamide?

Scenario 2 48 year old man sent from A&E with BP 180/100 Smoker minimal alcohol BMI 30

Scenario 2 continued 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

You visit Mr Siegfried Avant age 82 at home Scenario 3 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: 1989 160/90 1995 157/86 2000 160/100 (comment in notes check 1 month) 2002 154/95 (1 month later 150/89 with remark ‘watch BP’) 2007 170/100 (see 1 week) THOUGHTS?

Driving 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.

References NICE 2011 Prodigy guidance: QRISK Patient.co.uk http://guidance.nice.org.uk/CG127 Prodigy guidance: http://prodigy.clarity.co.uk/hypertension_not_diabetic/management/scenar io_diagnosis/view_full_scenario#-505271 QRISK http://www.qrisk.org/ Patient.co.uk http://www.patient.co.uk/health/High-Blood-Pressure-(Hypertension).htm