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