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Hypertension

Hypertension. 26 th 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. Questions?.

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Hypertension

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  1. Hypertension 26th September 2012 Dr Julian Tomkinson

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

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

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

  5. 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

  6. 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.

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

  8. QOF

  9. How does hypertension present to the GP?

  10. 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

  11. 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

  12. 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

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

  14. Scenario2 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?

  15. 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

  16. 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.

  17. Scenario1 continued 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?

  18. Scenario1 continued Mrs Haifa Tenchun 48 years old How do we explain hypertension to a patient?

  19. 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

  20. Scenario1 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?

  21. 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…

  22. 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 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

  23. Scenario1 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?

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

  25. 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.

  26. CODING ON COMPUTER • USE CORRECT READ CODES – check with practice

  27. Scenario1 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

  28. Aged over 55 years or black person of African or Caribbean family origin of any age Summary of antihypertensive drug treatment Aged under55 years C2 A 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 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

  29. 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.

  30. 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

  31. Scenario1 continued Mrs Haifa Tenchun 49 years old What treatment do you recommend?

  32. Scenario1 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

  33. 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

  34. Monitoring antihypertensive drug treatment

  35. 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)

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

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

  38. Common / important side effects • ACE inhibitors egramipril? • Calcium channel blockers egamlodipine? • Angiotensin 2 blockers eglosartan? • Thiazide-like diuretics egindapamide?

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

  40. 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

  41. 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?

  42. 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.

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

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