Transcript Primary care team meeting

Primary care team meeting
Hypertension
Dr Som Desilva
What do we need to discuss?
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Managing hypertension in surgery
New guidance on diagnosis
Home BP vs ABP
When and what investigations are needed
What drug treatments and who should titrate
Also
• What is best way for titration to take place
• If any problems who should Nurse or HCA go
to
• Monitoring of hypertension
• Long term care planning - update
New changes from NICE
• Ambulatory blood pressure is suggested as the
investigation of choice for all with suspected
hypertension.
• Home readings are an alternative, if ambulatory
cannot be used.
• Clinic BP readings are no longer recommended
for the diagnosis of hypertension, however they
can (and should) be used to monitor responses
to treatment.
Hypertension is now defined as
This affects who we treat.
• Stage 1 hypertension - Think of it as
borderline hypertension on ABPM –
BP 135-149/85-94 treat only if 10y CVD risk
>20% or end organ damage
(fundoscopy/ecg/renal)
• Stage 2 hypertension - >150/95 – Offer
treatment straight away.
What BP should we worry about?
• IF BP
IN CLINIC
• Repeat during consultation.
• If 2nd reading substantially different from 1st,
take a 3rd reading.
• Record the lower of the last 2 readings. IF still
high then arrange 24h BP or home BP monitor
What if BP very high?
• When lower of 3 readings of BP >>
• ?accelerated hypertension – should consider
immediate drug treatment with out waiting
for results of home bp/24h bp
• Should speak to on-call GP
What’s treatment?
• Lifestyle advice to all – DIET, SMOKING,
ALCOHOL & CAFFEINE, EXERCISE
• DRUG TREATMENT
WHAT INVESTIGATIONS?
• Once diagnosis has been established
• ECG
• Bloods –Nice recommends FBC U+E RBS eGFR
Total cholesterol&HDL
• ACR
• Dipstick urine for haematuria
• Fundoscopy
I would recommend
• TFT - thyroxicosis rare but can cause elevated
bp – esp if there is little variation in day and
night time blood pressure – (bp is being driven
along by secondary cause)
• In younger pts -> ie less than 50 consider:
Renal U/S with renal artery calibre (NOT BEST
FOR RAS BT EASIER THAN RENAL MRA)
24h Urine for catecholamines
10Y of CARDIOLOGY
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NEVER FOUND A PHEO – but still looking!!!!
2 THYROTOXIC PATIENTS
2 LUNG CANCERS
3 RENAL TUMOURS
1 HYDRONEPHROSIS
1 SECONDARY ADRENAL TUMOUR
How to do ABPM
• Ambulatory BP readings (ABPM)
• Use a device that measures at least 2
measurements/hour during waking hours.
• You need to have at least 14 readings to
average.
• In the past we added 10/5 to ABPM before
making decisions – there is no need to do this
now, since the decision flow charts are based
on ABPM not clinic readings.
How to do Home BP monitor
• Home BP monitoring (HBPM)
• Take readings morning & evening for at least
4d, preferably 7d.
• On each occasion take 2 readings ≥1min apart,
whilst seated.
• Discard the first day’s readings, and average
the remaining readings.
What drugs
• Depends on age and ethnicity
• Ace-I >> CCB >> ACE+CCB >>diuretic >> Alpha
blocker >> beta blocker >>ARB if not already
on >> Methyl dopa
DRUG TREATMENTS
Age >55 OR BLACK PERSON
Age <55
ACE-I (OR ARB IF ACE
NOT TOLERATED)
CCB (CALCIUM CHANNEL
BLOCKER)
ACE-I + CCB
ACE-I + CCB + THIAZIDE LIKE DIURETICS
ACE-I + CCB + DIURETIC +
SPIRONALACOTONE /HIGHER DOSE DIURETIC
OR ALPHA BLOCKER OR BETA BLOCKER
Diuretics :
Indapamide or
chlortalidone NOT
bendroflumethiazide
When should we titrate up drugs?
• Use clinic BP readings to monitor response to treatment.
• Ambulatory/home readings can be used in those with known ‘white
coat’ hypertension (defined as a discrepancy of >20/10 between
clinic and average ambulatory or home readings at time of
diagnosis).
• Increase drug therapy if these targets are not achieved.
• Aim for:
• Clinic BP readings of:
Ambulatory/home average readings
of:
• <80y <140/90
<80y <135/85
• >80y <150/90
>80y <145/85
So who and what do we organise?
GP s
HCA
nurse
Suspected bp
Arrange
home/abpm
Investigations – ecg
and bloods etc
Results –who
looks at them
Confirms diag
Start treatment
Monitor bp
When stable- 9m fu in bp
clinic
Up titrate bp
management
• What we don’t want is hypertensive patients
taking up gp appts for confirmation of
diagnosis and titration!
• Or do we want pts coming to gp at diagnosis
to confirm/agree a management plan –
monitored by HCA or nurse over next 6m??
Discuss??
• What about the other clinics – CD clinics now
filled up with mixture of diseaseS on different
days
• DIAB – BE /DJ - try and find Som during week
• What about COPD/ASTHMA/IHD/STROKE
• HOW ABOUT A GP OF THE WEEK??
• QUERY GOES TO ON CALL GP
• GOOD TO SORT OUT WHILE PT IN BUILDING