26 th september 2012 dr julian tomkinson. to understand the diagnosis, impact and management of...
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Hypertension26th September 2012
Dr Julian Tomkinson
To understand the diagnosis, impact and management of hypertension in General Practice
Aims
Overview of NICE guidelines
Applying to General Practice as we go along
Case examples / scenarios
Method
Any areas you would like clarifying today?
Questions?
3.01 Healthy People: promoting health and preventing disease
3.12 Cardiovascular Health2.01 The GP consultation2.02 Patient Safety and Quality of Care2.04 Enhancing Professional Knowledge
GP Curriculum
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.
Why is it important?
At least ¼ of UK population have hypertension
More than ½ > 60’s have hypertension
(~90% of cases are Primary & 10% are Secondary)
Prevalence
QOF
How does hypertension present to the GP?
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
NICE Definitions
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
Emergencies in hypertension
Diagnosing hypertension
If the clinic BP is ≥ 140/90offer ambulatory blood pressure monitoring (ABPM) to confirm the
diagnosis of hypertension
Home BP monitoring (HBPM) also possible
Scenario 1
O&G clinic – 48 year old lady with menorrhagia. BP raised 165/100 when checked – what do you say to her?
Scenario 2Pt 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 120/80THOUGHTS?
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
Ambulatory blood pressure monitoring (ABPM)
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.
Home blood pressure monitoring(HBPM)
Scenario 1 continuedMrs 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?
Scenario 1 continuedMrs Haifa Tenchun 48 years old
How do we explain hypertension to a patient?
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
What do patient’s think about BP?
Scenario 1 continuedMrs Haifa Tenchun 48 years old
Mrs HT is grateful for your explanation and fill follow your advice:
What are the next steps in management?
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…
Assessing cardiovascular risk and target organ damage:
Care pathway
CBPM ≥160/100 mmHg & ABPM/HBPM ≥ 150/95 mmHg
Stage 2 hypertension
Consider specialist referral
Offer antihypertensive drug treatment
Offer lifestyle interventions
If younger than 40 years
If target organ damage present or 10-year cardiovascular risk > 20%
Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication
Offer patient education and interventions to support adherence to treatment
CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg
Stage 1 hypertension
Scenario 1 continuedMrs Haifa Tenchun 48 years oldReview 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?
QRISK 2 / QRISKhttp://www.qrisk.org/index.phphttp://qrisk.org/lifetime JBS Ethrisk
Risk Calculators
Lifestyle interventionsOffer 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 adherenceProvide:
–information about benefits of drugs and side effects
–details of patient organisations
–an annual review of care.
Additional recommendations
USE CORRECT READ CODES – check with practice
CODING ON COMPUTER
Scenario 1 continuedMrs Haifa Tenchun 49 years oldReviews:6 months (practice nurse) 165/95 BMI 3412 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
Step 4
Summary of antihypertensive drug treatment
Aged over 55 years or black person of African or Caribbean family origin of any age
Aged under55 years
C2A
A + C2
A + C + D
Resistant hypertension
A + C + D + consider further diuretic3, 4 or alpha- or
beta-blocker5
Consider seeking expert advice
Step 1
Step 2
Step 3
KeyA – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic
See slide notes for details of footnotes 1-5
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.
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
Initiating Drug Treatment
Scenario 1 continued
Mrs Haifa Tenchun 49 years old
What treatment do you recommend?
Scenario 1 continued
Mrs Haifa Tenchun 49 years old
Start ramipril 1.25mg. What review arrangements do you make?
u+e’s normal after 2 weeksBP 135/85
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
Reviewing new medication for hypertension?
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)
Monitoring antihypertensive drug treatment
It is estimated that between50–80% of patients with
hypertension do not take all of their prescribed medication
Compliance
improving patient education, providing counselling, involving families and other members of the health care team
Compliance improved by
ACE inhibitors eg ramipril?
Calcium channel blockers eg amlodipine?
Angiotensin 2 blockers eg losartan?
Thiazide-like diuretics eg indapamide?
Common / important side effects
48 year old man sent from A&E with BP 180/100 Smoker minimal alcohol BMI 30
Scenario 2
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
Scenario 2 continued
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 160/901995 157/862000 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?
Scenario 3
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.
Driving
NICE 2011http://guidance.nice.org.uk/CG127 Prodigy guidance:http://prodigy.clarity.co.uk/hypertension_not_diabetic/management/scenario_diagnosis/view_full_scenario#-505271 QRISKhttp://www.qrisk.org/ Patient.co.ukhttp://www.patient.co.uk/health/High-Blood-Pressure-(Hypertension).htm
References