Transcript Hypertension

Hypertension NICE CG127
August 2011
 Hypertension is not a disease it is a risk factor for
cardiovasuclar disease (CVD)-it is a modifiable risk factor
Key Changes
 Ambulatory blood pressure is suggested as the investigation of
choice for all with suspected hypertension. Home readings are an
alternative,. Clinic BP readings are no longer recommended for the diagnosis of hypertension,
 Hypertension is now defined as stage 1 and stage 2. This affects
who we treat.
 The threshold blood pressure for offering drug therapy has
changed, partly reflecting the move to ambulatory BP monitoring.
 Diuretics have moved to third line drugs after ACE inhibitors and
calcium channel blockers
 The thiazide-like diuretic of choice is now indapamide or
chlortalidone rather than bendroflumethiazide or
hydrochlorothiazide.
NICE say that those already established on bendroflumethiazide or
hydrochlorothiazide need not be changed to chlortalidone or
indapamide
Ambulatory BP readings
 Use a device that records 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.
Home BP monitoring (HBPM)
 Take readings morning and 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.
CBPM ≥140/90 mmHg
& ABPM/HBPM
≥ 135/85 mmHg
CBPM ≥160/100 mmHg
& ABPM/HBPM
≥ 150/95 mmHg
Stage 1 hypertension
Stage 2 hypertension
Care pathway
If target organ damage present or
10-year cardiovascular risk > 20%
If younger than 40 years
Offer antihypertensive
drug treatment
Consider specialist
referral
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
Assessing CV risk
and target organ damage:
updated recommendations
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,
eGFR and cholesterol
–examine fundi for hypertensive retinopathy
–arrange a 12-lead ECG.
Aged under
55 years
Aged over 55 years
or black person of
African or Caribbean
family origin of any
age
C2
A
A+
C2
Summary of
antihypertensive
drug treatment
Step 1
Step 2
A+C+D
Step 3
Resistant hypertension
Step 4
Key
A – ACE inhibitor or low-cost
angiotensin II receptor
blocker (ARB)1
C – Calcium-channel
blocker (CCB)
D – Thiazide-like diuretic
A + C + D + consider further
diuretic3, 4 or alpha- or
beta-blocker5
Consider seeking expert advice
See slide notes for details of
footnotes 1-5
Drug therapy
 Aim for drugs to be taken once a day
 Do not use ACE inhibitors and Angiotensis receptor
antagonists together (no additional benefit and
increased risk of s/e)
 Treat women of child bearing age in line with NICE
guidelines on hypertension in pregnancy
 Treat isolated systolic BP in same way as if both were
raised SBP>160
 NICE prefer Chlortalidone 12.5mg-25mg daily or





indapamide 1.5mg MR od or 2.5mg od
What are the cost differences? Based on drug tariff
price (Dec 2010) monthly costs are:
Bendroflumethiazide (2.5mg) £0.79 for 28
Chlortalidone (50mg)
£1.77 for 28
Indapamide ordinary release
2.5mg £1.27 for 28 £2.01 for 56 cheapest.
Indapamide slow release 1.5mg £3.40 for 30
Monitoring drug treatment (1)
Use clinic blood pressure measurements to monitor
response to treatment. Aim for target blood pressure
below:
 140/90 mmHg in people aged under 80
 150/90 mmHg in people aged 80 and over
Monitoring
(2)
For people identified drug
as having atreatment
‘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:
 below 135/85 mmHg in people aged under 80
 below 145/85 mmHg in people aged 80 and over.
White-coat effect: a discrepancy of more than 20/10 mmHg between clinic
and average daytime ABPM or average HBPM blood pressure
measurements at the time of diagnosis.
Additional
recommendations
Lifestyle interventions
Offer guidance and advice about:
– diet (including sodium and caffeine intake) and exercise
– alcohol consumption
– smoking.
Patient education and adherence
Provide:
– information about benefits of drugs and side effects
– details of patient organisations
– an annual review of care.
Summary
 Ambulatory blood pressure investigation of choice
 Clinic BP readings no longer recommended for
diagnosis of hypertension
 Can be used to monitor treatment
 Hypertension defined as stage 1 and 2
 Thresholds of treatments has changed reflecting
ambulatory BP monitoring
 Diuretics have moved to 3rd line after ACE inhibitors
and calcium channel blockers
 Thiazide-like diuretic of choice is indapamide or
chlortalidone
 (no need to changed established)