shahkur shabir gp registrar dr ella russell -gp trainer sunnybank medical centre oct 2011

SHAHKUR SHABIRGP REGISTRAR

 DR ELLA RUSSELL -GP TRAINER

 SUNNYBANK MEDICAL CENTRE

 OCT 2011

This is the pressure in the arteries when the heart contracts and rests between beats.

How many people in the UK have high Blood pressure.

  8 Million

12 Million

16 Million

How many people in the UK have high Blood pressure.

  8 Million

12 Million

16 Million

What percentage of hypertensives are younger than age 65?

50%

What percentage of patients with High BP on treatment are not controlled under BP 140/90?

50%

75%

90%

What percentage of patients with High BP on treatment are not controlled under BP 140/90?

50%

75%

90%

How many deaths occur per year in the UK from stroke and heart attacks due to poor blood pressure control?

  10000 40000 62000

How many deaths occur per year in the UK from stroke and heart attacks due to poor blood pressure control?

  10000 40000 62000

Primary Cause is UNKNOWN-  ESSENTIAL HYPERTENSION

Secondary Hypertension Causes include-

RENAL DISEASE: e.g Glomerulonephritis, Polycystic Kidneys, chronic pyelonephritis.

ENDOCRINE DISEASE:Cushing syndromeConns syndromePhaeochromocytomaAcromegaly

Coarctation of Aorta  Pre Eclampsia and Hypertension in Pregnancy  Drugs: Alcohol, Cocaine

Other factors: Excess alcoholExcess SaltNo exerciseStressSmoking

Usually patients are asymptomatic.  Occasionally patients may experience

headaches or visual disturbances.  Patients may have End organ damage:

-Left ventricular hypertrophy-TIA/CVA-Myocardial infarction-Renal impairment-PVD

MALIGNANT HYPERTENTION Symptoms:

Headache and BP Diastolic >140, renal failure, fits, coma, severe retinopathy.

If suspected admit as Medical Emergency.

Key changes:

1. Classifying Hypertension into stages

2. Recommending the use of Ambulatory Blood pressure monitoring (ABPM) & Home blood pressure monitoring (HBPM)

3. Calcium Channel Blockers are now considered to be superior to Thiazides

4. Bendroflumethizide is no longer the thiazide of choice

For NON hypertensive patients BP should be checked every 5 years- aim is <130/85.

IN THE CLINICIf the BP is higher than 140/90, repeat BP

twice in the same consult and take the lower reading.

 IfBP <140/90 NO ACTION

IfBP >140/90 24 hour ABPM or HBPM

NORMOTENSIVE ABPM/HBPM <135/85

STAGE 1 Hypertension- Clinic BP >= 140/90 & subsequent ABPM daytime average or HBPM >=135/85 

STAGE 2 Hypertension- Clinic BP >= 160/100 & subsequent ABPM daytime average or HBPM >=150/95

 SEVERE Hypertension- Clinic Systolic Bp >= 180

or Clinic diastolic BP >= 100- Refer immediatelyMay need treatment same day!

 In AF patients may not be suitable for ABPM OR

HBPM- so use serial Clinic BP readings

If the BP reading is >= 140/90 patients should be offered ABPM to Confirm diagnosis.

2 measurements per hour during waking hours 0800-2200

Use the average of minimum 14 measurements

If ABPM is declined or not tolerated of HBPM 

-BP should be recorded twice daily, ideally morning and evening.

-BP should be recorded minimum 4 days, ideally 7 days.

-Discard the first day measurements and use the average value of the remaining.

ALWAYS ADVISE ON LIFESTYLE MODIFICATION

Give Explanation of HTN and CVD risk. Stop Smoking Limit Alcohol consumption to recommended values Regular physical exercise Diet- Reduce salt intake, increase fruit/vegetable,

Reduce intake of saturated fat. Eat oily fish If Cardiovascular 10 year risk is >20% then a statin is

recommended.

Stage 1: ABPM/HBPM >= 135/85  Treat if <80 years and following apply- Cardiovascular disease Diabetes Renal disease 10 year cardiovascular risk equivalent to

20% or greater.

Stage 2: ABPM/HBPM >= 150/95

Offer drug treatment regardless of age.

For patient <40 age consider specialist referral to exclude secondary causes.

Patients <55 years:

Use ACE INHIBITOR (Enalapril/lisinopril)  Patients >55 years or African/caribbean

origin any age: Use CALCIUM CHANNEL BLOCKER

(Amlodipine) 

(A + C)

ACE INHIBITOR & CALCIUM CHANNEL BLOCKER

(if failure/high risk of failure- NO CCB, use Thiazide like diuretic)

( A + C + D) 

ACE + CCB + THIAZIDE-LIKE DIURETIC(not bendroflumethiazide)

 Remember old guidelines recommended

Bendroflumethiazide. 

Now NICE recommend using: 

-Indapamide- 1.5mg m/r or 2.5mg once daily-Chlortalidone- 12.5-25mg once daily

<80 years aim for <140/90

>80 years aim for 150/90

After STEP 3 IF Blood Pressure is >140/90 with optimal doses best tolerated.

Go to Step 4 or seek expert advice.

Consider further diuretic treatment 

If potassium <4.5- add spironolactoneIf potassium >4.5 add higher dose

thiazide like diuretic treatment Consider alpha or beta blocker.

SPECIALIST REFERRAL

Cost of ABPM machine? Average price is £1295.00 How many machines does the practice need? Practice has 3 machines

Servicing / Calibration is annual and is £8 per machine Replacement Cuffs are £46 each (factor in replacement every 3 years) No grants currently available for 24 hr BP

HCA will place Machines on patients

AUDIT FOR LAST 20 PATIENTS WHERE 24 HR BP MONITORING REQUESTED

Were all these referrals needed??

REASONS FOR 24 HR BLOOD PRESSURE MONITORING

IN THE LAST 20 REFERRALS

THANK YOU!

ANY QUESTIONS