clinical knowledge summaries cks hypertension (not people with diabetes) managing hypertension in...
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Clinical Knowledge Summaries
CKS Hypertension (not people
with diabetes)Managing hypertension in primary care
Educational slides based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Key learning points and objectives• To be able to:
o Describe the benefits of lowering blood pressure.o Outline which antihypertensives should be
prescribed initially. o Describe when to continue or stop a beta-blocker.o Describe how to adjust treatment. o Recognise when referral or admission is required.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
If BP is very high in clinic? • Arrange same-day admission if:
o BP is 220/120 mmHg or higher.o BP is 180/110 mmHg or higher with signs
of accelerated (malignant) hypertension (papilloedema and/or retinal haemorrhage).
• Start antihypertensives immediately if no signs of accelerated hypertension and:o Systolic BP is 180 mmHg or higher, or o Diastolic BP is 110 mmHg or higher.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Management following ABPM and HBPM• Offer antihypertensive treatment if the
person is:o Younger than 80 years with stage 1 hypertension
and has one or more of the following:o Target organ damage, established cardiovascular
disease, renal disease, diabetes, and/or a 10 year cardiovascular risk of 20% or more.
o Any age with stage 2 hypertension.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Initial management• For all people with hypertension:
o Assess and manage cardiovascular risk.o Reinforce lifestyle advice such as:• Stopping smoking.• Moderation in alcohol, salt, and caffeine consumption.
o Give advice on weight loss (if appropriate).
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Life style and non-drug measures• Advise:
o Moderation in alcohol consumption.o Moderation in consumption of coffee and other
caffeine-rich products.o Reducing salt consumption, or using a salt
substitute.o Stopping smoking — offer referral to smoking
cessation services. o About local initiatives that provide support and
promote lifestyle change (e.g. run by healthcare teams or patient organizations).
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Life style and non-drug measures• Advise that:
o Sustained relaxation therapies may reduce BP (e.g. stress management, meditation).
o Information on self-care can be obtained from the Blood Pressure Association (www.bpassoc.org.uk).
• Consider offering referral for:o Smoking cessation.o Exercise and physical activity programmes.o Weight loss programmes.o Dietary advice.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Benefits of antihypertensives in general• People using antihypertensives can expect:
o To extend their life by between 8 and 11 months if they are 50 years of age.
o To extend their life by between 3 and 5 months if they are 70 years of age.
o Greater absolute risk reductions if they have higher baseline risks for coronary heart disease or stroke.
o Greater risk reduction for stroke than for coronary heart disease.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Target clinic blood pressures
• Target clinic blood pressures (BP):
o Aim for a BP lower than 140/90 mmHg for people under 80 years.
o Aim for a BP lower than 150/90 mmHg for people 80 years and older.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Starting antihypertensives• If younger than 55 years of age (not of black African
or Caribbean ethnic origin) start:o An angiotensin-converting enzyme (ACE) inhibitor, oro A low-cost angiotensin II receptor antagonist (AIIRA).
• If ACE inhibitors or AIIRAs are not suitable:o Start a low-dose thiazide-type diuretic or a calcium channel
blocker (CCB). • A beta-blocker can be considered as initial
treatment for:o Younger people who cannot use or tolerate ACE inhibitors and
AIIRAs.o Women who might become pregnant or are planning a
pregnancy.o People with evidence of increased sympathetic drive (e.g.
sweating).
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Starting antihypertensives• If 55 years of age or older and of black African or
Caribbean ethnic origin (any age):o Offer a CCB, or o A low-dose thiazide-type diuretic, if:
• A CCB is not suitable (e.g. oedema or intolerant), • There is heart failure, or• A high risk of heart failure.
• If aged 80 years and older:o Offer the same treatment as people aged 55 years and older.o Take into account any co-morbidities and other drugs being
taken. • For people with isolated systolic hypertension:
o Offer the same treatment as people with both raised systolic and diastolic blood pressure (BP).
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
On a beta-blocker for another indication• If BP is well controlled and:
o There is a compelling indication for a beta-blocker (e.g. symptomatic angina), continue the beta-blocker.
o There is no compelling indication for a beta-blocker, discuss and consider adding or switching to another antihypertensive drug, according to the stepwise approach.
• Always gradually step the dose down if stopping a beta-blocker.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
On a beta-blocker for another indication• If BP is not controlled:
o Consider continuing the beta-blocker and adding a new antihypertensive drug according to the stepwise approach.
• If a beta-blocker is being considered for long-term use with a thiazide diuretic:o Discuss with the person the benefits of treatment
versus the risk of developing diabetes.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Which antihypertensive?
• NICE recommend using an ACE inhibitor, an AIIRA, a calcium channel blocker, or a beta blocker that can be taken once a day, is generic, and minimizes cost.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Calcium channel blockers• If a rate-limiting calcium-channel blocker is being
considered: o Once-daily formulations of diltiazem or verapamil are
recommended.
• Do not prescribe verapamil with a beta-blocker • Risk of reduced cardiac output and heart failure.
• Diltiazem can be used with caution with a beta-blocker:• It has a smaller negative inotropic effect than verapamil.• Monitor the person's pulse and blood pressure carefully
due to the risk of bradycardia.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Which thiazide diuretic?• If already taking bendroflumethiazide and BP
is well controlled, continue treatment with this.
• If starting a thiazide-type diuretic:o Indapamide or chlortalidone are preferred
because there is most trial data to support their use.
• NICE found a lack of trial data to support bendroflumethazide, but could not confirm that it was ineffective.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Follow up• If being treated with lifestyle measures only,
follow up:o Every 3 or 4 months, until blood pressure is well
controlled, or antihypertensive drug treatment is started.
o Annually, when the blood pressure is well controlled.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Follow up• When starting drug treatment:
o Recheck BP every 4 weeks.• If starting a thiazide diuretic:
o Check urea and electrolytes, and the eGFR at baseline and every 4-6 weeks.
• If starting an ACE inhibitor or an AIIRA:o Check urea and electrolytes, and the eGFR at
baseline and 1-2 weeks after starting treatment.• If starting a CCB no specific blood tests are
required.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Adjusting drug treatment• Use clinic BP to monitor response:
o If the person has a 'white coat effect', consider ambulatory or home blood pressure monitoring.
• If BP is not adequately controlled on the maximum licensed or tolerated doses of one antihypertensive drug:o Check concordance.o Ensure that the person is taking the maximum
licensed or highest tolerated dose of antihypertensive medication.
o Consider secondary causes for hypertension and whether specialist advice may be helpful.
o Consider adding additional drugs in a stepwise manner.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Adjusting drug treatment• If on monotherapy, add a second drug.
o If on an ACE inhibitor or an AIIRA:o Add a CCB.o If the person cannot take a CCB, add a thiazide diuretic.
o If on a CCB or a thiazide diuretic:o Add an ACE inhibitor or an AIIRA.o If the person cannot take an ACE inhibitor or an AIIRA
consider combining a CCB with a thiazide diuretic. • If on dual therapy prescribe a third
antihypertensive such as:o An ACE inhibitor or an AIIRAo A calcium-channel blocker, and o A thiazide-type diuretic.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Adding a third drug?
• NICE acknowledged that little evidence was available to guide clinical practice.
• The Guideline Development Group concluded that the most straightforward choice was to recommend:o Combining an ACE inhibitor or an AIIRA plus
calcium-channel blocker plus thiazide type-diuretic.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Adding a fourth drug?• If BP is not controlled on 3 drugs:
o If serum potassium is:o > 4.5 mmol/L, consider increasing the dose of a thiazide
diuretic.o 4.5 mmol/L or lower, consider adding another diuretic
such as low-dose spironolactone (off-label).o If further diuretic treatment is not tolerated,
contraindicated, or ineffective add an alpha-blocker or a beta-blocker.
• Again evidence is lacking to guide treatment choice.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Adjusting drug treatment• If BP is not controlled on 4 drugs:
o Seek specialist advice (may not be possible to reach target BP).
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
When to refer?• Consider referral if:
o BP is not adequately controlled on optimal primary care treatment, or
o Secondary hypertension is suspected which cannot be managed in primary care, or
o Postural hypotension is symptomatic, or systolic blood pressure decreases by 20 mmHg or more on standing up, or
o There is a consistent difference in blood pressure readings between arms of more than 20/10 mmHg, or
o 'White coat' hypertension is suspected and ambulatory blood pressure monitoring or home monitoring is not available.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
When to admit?
• Admit, or refer immediately, those people with:o Accelerated (malignant) hypertension. • BP is 180/110 mmHg or higher with signs
of papilloedema and/or retinal haemorrhage.o Hypertensive encephalopathy.o Suspected phaeochromocytoma and severe
hypertension.o Severe hypertension and impending vascular
complication.
Based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.
Summary• Target clinic BP is:
o Lower than 140/90 mmHg if less than 80 years.o Lower than 150/90 mmHg if older than 80 years.
• Offer lifestyle advice:o Initially, and then periodically, to people being
assessed or treated for hypertension.• If younger than 55 years of age (not of black
African or Caribbean ethnic origin) start:o An angiotensin-converting enzyme (ACE) inhibitor,
oro A low-cost angiotensin II receptor antagonist
(AIIRA).
Summary• If 55 years of age or older and of black African or
Caribbean ethnic origin (any age):o Offer a CCB, or o A low-dose thiazide diuretic (indapamide or chlortalidone
preferred).• If aged 80 years and older:
o Offer the same treatment as people aged 55 years and older.
• A beta-blocker can be considered as initial treatment for:o Younger people who cannot use or tolerate ACE inhibitors and
AIIRAs.o Women who might become pregnant or are planning a
pregnancy.o People with evidence of increased sympathetic drive (e.g.
sweating).
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