1. NICE/BHS Hypertension Guideline Review 28 June 2006 John Barker ESH Clinical Hypertension Specialists European Society of Hypertension Specialist Accreditation UK Hypertension Referral Centres Clinical Excellence Awards Clinical Research Therapeutics Validated Blood Pressure Monitor Lists How to Measure Blood Pressure Publications Latest BHS Management Guidelines NICE/BHS Guidelines Other Guidelines CVD Risk Charts and Calculators How to Measure Blood Pressure Factfiles Hypertension Management Guidelines Blood Pressure-related Papers Factfiles Healthy Eating Other Related Publications BHS Live! - 3 VALUE BHS Statement on the ALLHAT Trial Statement from the ASCOT Executive BHS-PCCS Live ONTARGET ESH Clinical Hypertension Specialists European Society of Hypertension Specialist Accreditation UK Hypertension Referral Centres Clinical Excellence Awards Clinical Research Therapeutics Validated Blood Pressure Monitor Lists How to Measure Blood Pressure Publications Latest BHS Management Guidelines NICE/BHS Guidelines Other Guidelines CVD Risk Charts and Calculators How to Measure Blood Pressure Factfiles Hypertension Management Guidelines Blood Pressure-related Papers Factfiles Healthy Eating Other Related Publications BHS Live! - 3 VALUE BHS Statement on the ALLHAT Trial Statement from the ASCOT Executive BHS-PCCS Live ONTARGET ESH Clinical Hypertension Specialists European Society of Hypertension Specialist Accreditation UK Hypertension Referral Centres Clinical Excellence Awards Clinical Research Therapeutics Validated Blood Pressure Monitor Lists How to Measure Blood Pressure Publications Latest BHS Management Guidelines NICE/BHS Guidelines Other Guidelines CVD Risk Charts and Calculators How to Measure Blood Pressure Factfiles Hypertension Management Guidelines Blood Pressure-related Papers Factfiles Healthy Eating Other Related Publications BHS Live! - 3 VALUE BHS Statement on the ALLHAT Trial Statement from the ASCOT Executive BHS-PCCS Live ONTARGET ESH Clinical Hypertension Specialists European Society of Hypertension Specialist Accreditation UK Hypertension Referral Centres Clinical Excellence Awards Clinical Research Therapeutics Validated Blood Pressure Monitor Lists How to Measure Blood Pressure Publications Latest BHS Management Guidelines NICE/BHS Guidelines Other Guidelines CVD Risk Charts and Calculators How to Measure Blood Pressure Factfiles Hypertension Management Guidelines Blood Pressure-related Papers Factfiles Healthy Eating Other Related Publications BHS Live! - 3 VALUE BHS Statement on the ALLHAT Trial Statement from the ASCOT Executive BHS-PCCS Live ONTARGET

2. 1.Have they got HT? 2.Assess risk of Cardiovascular Disease 3.Lifestyle and blood pressure smoking diet and exercise 4.Antihypertensives 5.Monitoring

3. When to measure BP Every 5 yrs to age 80 Annually 130-139 over 85-89

4. Measure BP Warm relaxed environment Position Both arms If raised twice! Come back…. Monthly – sooner if higher 140/90

5. 1.Have they got HT? 2.Assess risk of Cardiovascular Disease 3.Lifestyle and blood pressure smoking diet and exercise 4.Antihypertensives 5.Monitoring

6. Levels 140 / 90 160 / 100 Recheck Treat

7. Levels - treatment High Risk Endorgan Damage Diabetes Target 140 / 90

8. Diabetes T1/2 - 2004 No Nephropathy Nephropathy – start ACE Proteinuria Rx at 140 / 90 Aim 130 / 80 Aim 125 / 75

9. Diabetes T2 – 2008

10. Measure BP annually if not hypertensive or with renal disease. If BP > target, repeat measurement within: ● 1 month if > 150/90 mmHg ● 2 months if > 140/80 mmHg ● 2 months if > 130/80 mmHg and kidney, eye or cerebrovascular damage Diabetes T2 – 2008

12. Other increased risk? FH Man<55, Lady<65 FH More than one relative South Asian Man BMI >40 > age 75 HDL M<1, L<1.2 Trig >1.7 BMI >30 Impaired Gluc Toll Multiply by… 1.3 (NICE 1.5) 1.5 to 2.0 1.4 Higher

13. Other increased Risk Endorgan Damage CVD disease Co-morbidity –Diabetes –Chronic Kidney Disease

14. Risk - Refer Accellerated HT –180/110 –Papilloedema or –symptoms Phaeochromocytom a Unusual Postural Hypotension Secondary cause suspected

15. Tests Urine – protein Plasma –Glucose –U+E / Creatinine –Cholesterol / HDL ECG

16. 1.Have they got HT? 2.Assess risk of Cardiovascular Disease 3.Lifestyle and blood pressure smoking diet and exercise 4.Antihypertensives 5.Monitoring

17. Lifestyle Diet and Exercise Alcohol Coffee / Caffeine Salt Smoking

18. 1.Have they got HT? 2.Assess risk of Cardiovascular Disease 3.Lifestyle and blood pressure smoking diet and exercise 4.Antihypertensives 5.Monitoring

19. Antihypertensives – newly diagnosed <55>55, Black / African

20. Antihypertensives Betablockers Thiazides Pregnancy Alpha Blockers

21. 1.Have they got HT? 2.Assess risk of Cardiovascular Disease 3.Lifestyle and blood pressure smoking diet and exercise 4.Antihypertensives 5.Monitoring

22. Monitoring Annual Monthly (if not stable) Less than monthly if High risk

23. AKT Question? A 29 yr gentleman presents for diabetic review He does not report any particular issues Retinal screen shows some minor diabetic retinopathy He is currently on basal bolus regimen 10 units of long acting insulin and 3-5units of short acting prior to meals BP 130 / 70 His HbA1C is 5.3 Alb / Creat ratio is 4

24. AKT Question? Journal Pre Breakfast Post lunch Pre evening meal Night time 4.3 8.0 6.0 7

25. AKT Question? What therapeutic option should be taken? Bispoprolol dipeptidyl peptidase-IV inhibitor (DPP-IV) Increase bolus insulin Ramipril Increase basal insulin

26. AKT Answer Add ACE inhibitor as has nephropathy Hopefully his BP will tollerate it!