Transcript Hypertension Update

Jeannie Hayhurst
Cardiovascular Specialist Nurse
What is hypertension?
Facts and figures
 The most common continuing medical condition seen
by family doctors
 Not a disease but a condition that puts someone more at
risk of a disease
 It affects 25% of the adult population & about 50% of all
people over the age of 60yrs
 Prevalence is slightly higher in men than women: 31.5%
as opposed to 29% (Health Survey for England 2010)
 “Is one of the most preventable causes of premature
morbidity and mortality world-wide” (NICE 2011)
Sustained blood pressure ≥ 140/90 mmHg
New NICE guidelines 2011
 Changes to diagnosis
 Changes to treatment algorithm
 New targets
Measuring BP
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Devices must be validated, maintained and regularly recalibrated
Appropriate cuff size
Relaxed temperate setting, patient seated for 3-5 mins
Palpate pulse first
Measure BP in both arms
If difference between arms is >20mmHg repeat the measurements
If it remains >20mHg, measure subsequent BPs in the arm with the higher
reading (Consistent inter-arm differences of >20/10mmHg warrants specialist
referral)
 If BP is ≥ 140/90 take a second reading
 If the second reading is substantially different from the first take a third
reading
 Leave a minute between each reading
 Record the lower of the last two readings
 That the person has not hurried to the session
 That their bladder is empty!
 That they haven’t had a large meal, alcohol, caffeine,
cigarettes and exercise in previous 30 minutes
Don’t forget:
 BP rises on waking & then tends to fall through the
day.
 BP tends to be higher in colder weather
Confirming Diagnosis
 If clinic BP is <140/90 review 5 yrly
 If clinic BP is 140/90 or higher offer ABPM to
confirm diagnosis
 If unable to tolerate ABPM, HBPM is a suitable
alternative
 Whilst waiting to confirm diagnosis carry out invx
for target organ damage and CVD risk assessment
 If clinic BP ≥ 180/110 consider starting treatment
immediately
ABPM – to confirm diagnosis
 Ensure that at least two measurements per hour are
taken during the persons usual waking hours
 Use the average value of at least 14 measurements
taken during the persons usual waking hours to
confirm a diagnosis of hypertension
 24hr ABPM may be required for patients who might be
more at risk of “ non- dipping” i.e. whose BP does not dip at
night, as is normal. (these may be people with existing
target organ damage who appear controlled and patients
with Type 1 diabetes with microalbuminuria)
N.B Practices who do not have their own ABPM can refer
patients to Darwen or Barbara Castle HC using a D1 form
ABPM – patient information
 Provide patient with instructions on how to turn off and remove
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the device if day time only readings are required
Give advice on wearing appropriate clothing i.e. allowing access
to upper arm and easily removed
Advise that bathing or showering is not permissible whilst the
monitor is attached
When the cuff tightens advise that they try to relax, and keep
their arm still and at heart level if possible
Warn that the monitor may repeat the measurement a minute
later
Advise that driving with the monitor in place is permissible but
if possible try to pull over when a measurement is been taken
Tell the patient to try and have a normal day!
HBPM – to confirm diagnosis
 For each BP recording two consecutive measurements
are taken, seated, at least 1 minute apart
 BP is recorded twice daily, ideally morning and
evening
 Record measurements for at least 4 days, ideally 7 days
 Discard measurements taken on the first day and use
the average of the remaining measurements to confirm
a diagnosis
HBPM – things to note
 Monitors should be validated and maintained
 Wrist monitors are not recommended and can be
inaccurate but may be acceptable if the patient has
had bilateral mastectomies, has sustained injuries to
both upper arms or is grossly obese.
 Only about a third of patients fully comply with
instructions
 Observer bias/prejudice is possible
 Not appropriate for patients with arrhythmias
What the readings mean
(ABPM/HBPM)
 Daytime average <135/85mmHg
 Not hypertensive- recheck BP
within 5yrs
 Daytime average ≥135/85mmHg
CVD risk <20%/No target organ
damage
 Daytime average ≥135/35mmHg
CVD risk >20% /Target organ
damage
 Daytime average ≥150/90mmHg
 Stage 1 hypertension – No
treatment; reassess annually
 Stage 1 hypertension; treat
according to NICE ACD chart
 Stage 2 hypertension; treat
according to NICE ACD chart
NICE definitions
 Stage 1 hypertension:
• Clinic blood pressure (BP) is 140/90 mmHg or
higher and
• ABPM or HBPM average is 135/85 mmHg or higher.
 Stage 2 hypertension:
• Clinic BP 160/100 mmHg is or higher and
• ABPM or HBPM daytime average is 150/95 mmHg
or higher.
 Severe hypertension:
• Clinic systolic BP is 180 mmHg or higher or
• Clinic diastolic BP is 110 mmHg or higher.
Mammen Ninan
GPwSI Cardiology
November 2012
Effect of systolic and diastolic BP on mortality
Event free survival and relation to night time dipping of
BP
Modest reductions in SBP can substantially
reduce cardiovascular mortality
After
intervention
Before
intervention
% Reduction in Mortality
Reduction in SBP (mmHg)
Stroke
CHD
Total
2
-6
-4
-3
3
-8
-5
-4
5
-14
-9
-7
SBP = systolic blood pressure; CHD = coronary heart disease
Adapted from Whelton PK, et al. JAMA 2002;288:1882-1888.
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
What are the key elements
of effective BP control?
Are your current therapy choices delivering effective control of blood pressure
in all your hypertensive patients?
What is resistant Hypertension
 Failure to control BP to < 140/90 or <130/80 in
diabetics, in spite of being on 3 different
antihypertensive agents, one of which is a diuretic
Causes of Resistant Hypertension
 Suboptimal drug therapy
 White coat hypertension
 Coexisting conditions – esp. obesity/metabolic
syndrome/OSA
 Antagonising substances (usually sodium)
 Non-compliance
 Coexisting medications – eg NSAID’s, OCA
 Unrecognised secondary causes of hypertension
Important Secondary (identifiable) Causes of
Hypertension
 Sleep apnoea
 Drug induced/ related
 Chronic kidney disease
 Primary aldosteronism
 Renovascular disease
 Cushing’s Syndrome or steroid therapy
 Phaeochromocytoma
 Coarctation of the aorta
 Thyroid/ parathyroid disease
Case Study
 55 year old lady comes to surgery for foot pain, she is
slightly overweight with BMI of 28. Her BP was last
checked 10 years ago, and you check it to satisfy QOF,
and it is 158/108.
 Her mother had hypertension and had a stroke at the
age of 70 yrs. Patient is a non smoker, works in a GP
surgery as Practice Manager and admits to being
stressed at work
 Her urine dipstick is clear, ECG does not show any
signs of LVH