Transcript Hypertension - Bradfordvts

Hypertension
Nick Price 4.9.13
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)
Objectives
•
•
•
•
Brief overview of NICE guidelines
Consider what this means in practice
Interpret Ambulatory BP Measurement
Apply this in a clincal scenaria
So what is hypertension all about?
Patient Orientated Outcomes
Disease Orientated Outcomes
Others’ Orientated Outcomes
•
•
•
•
•
•
•
•
GPs
Practice nurses
PCTs
Secondary Care
Patient groups (e.g. BHF)
Professional groups (e.g. BHS)
Drug Companies
Government
What NICE / CKS says
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.
• 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.
• 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.
• 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.
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.
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 treatment
Measurement considerations
•
•
•
•
•
•
Techniques
No of readings
Cuffs
Home BP
Ambulatory
See
http://www.npc.nhs.uk/merec/cardio/cdhyper/
resources/merec_briefing_no29.pdf
For all the basics and more (although a bit old)
Investigations in brief(order of
priority??)
•
•
•
•
•
Urine dipstix (ACR?)
U+E, creatinine, eGFR
Glucose (fasting / HBA1C?)
TC + HDL (fasting?)
ECG
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.
• 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 < 60 mL/min/1.73 m2 or the urine ACR is >= 30 mg/mmol,
see the CKS topic on Chronic kidney disease - not diabetic for information
on confirming and managing chronic kidney disease.
• 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).
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:
• 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.
Mx – as per CKS.
• ‘Reinforce’ Lifestyle advice.
• Offer antihypertensive drug
treatment if the person is:
• Aged less than 80 years with
stage 1 hypertension with one or
more of the following:
• 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.
• ‘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.
• 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.
Rx? ‘Reinforce 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
This is a comprehensive review
on evidence of lifestyle measures
– highly recommended, all be it,
from 2002.
Cardiac Risk Assessments
On SystemOne – clinical tools – Q Risk
Or http://www.qrisk.org/index.php
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).
• If ACE inhibitors or AIIRAs are not suitable, start a low-dose
thiazide-type diuretic or calcium-channel blocker.
• A beta-blocker can be considered for initial treatment for:
• 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).
• People with evidence of increased sympathetic drive, such as
sweating or palpitation symptoms.
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 calciumchannel 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 lowdose thiazide-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.
Combination / Alternative Rx (BNF)
Under 55 Alternatives
Under 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)
Combination / Alternative Rx (BNF)
Over 55 / African Alternatives
1. CCB
2. Thiazide
Over 55/African combinations
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)
• < 55yrs
• > 55 or black patients
A
C or D
A+C or A+D
A+C+D
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].
• 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.
A Case
Data / recent results
PMH etc
•
•
•
•
•
•
•
•
•
•
Summary
• 1995 TAH for menorrhagia
• 2010 – Varicose eczema with
mild oedema
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%
Last consultations –
• saw practice nurse for a ‘check
up’, BP 170/90 – told to see
Dr.
• ABPM, ECG, urine and bloods
arranged.
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.