Primary care team meeting

Hypertension

Dr Som Desilva

What do we need to discuss?

• Managing hypertension in surgery• New guidance on diagnosis• Home BP vs ABP• When and what investigations are needed• What drug treatments and who should titrate

Also

• What is best way for titration to take place• If any problems who should Nurse or HCA go

to • Monitoring of hypertension

• Long term care planning - update

New changes from NICE

• Ambulatory blood Ambulatory blood pressure is suggested as the investigation of choice for all with suspected hypertension.

• Home readings Home readings are an alternative, if ambulatory cannot be used.

• Clinic BP readings are no longer recommended for the diagnosis of hypertension, however they can (and should) be used to monitor responsesresponses to treatment.

Hypertension is now defined as

This affects who we treat.

• Stage 1 hypertension - Think of it as borderline hypertension on ABPM – BP 135-149/85-94 treat only if 10y CVD risk >20% or end organ damage (fundoscopy/ecg/renal)

• Stage 2 hypertension - >150/95 – Offer treatment straight away.

What BP should we worry about?

• IF BP

• Repeat during consultation.• If 2nd reading substantially different from 1st,

take a 3rd reading.• Record the lowerlower of the last 2 readings. IF still

high then arrange 24h BP or home BP monitor

IN CLINICIN CLINIC

What if BP very high?

• When lower of 3 readings of BP >>

• ?accelerated hypertension – should consider immediate drug treatment with out waiting for results of home bp/24h bp

• Should speak to on-call GP

What’s treatment?

• Lifestyle advice to all – DIET, SMOKING, ALCOHOL & CAFFEINE, EXERCISE

• DRUG TREATMENT

WHAT INVESTIGATIONS?

• OnceOnce diagnosis has been established• ECG• Bloods –Nice recommends FBC U+E RBS eGFR

Total cholesterol&HDL• ACR• Dipstick urine for haematuria• Fundoscopy

I would recommend

• TFT TFT - thyroxicosis rare but can cause elevated bp – esp if there is little variation in day and night time blood pressure – (bp is being driven along by secondary cause)

• In younger pts -> ie less than 50 consider:Renal U/S Renal U/S with renal artery calibre (NOT BEST

FOR RAS BT EASIER THAN RENAL MRA)24h Urine for catecholamines24h Urine for catecholamines

10Y of CARDIOLOGY

• NEVER FOUND A PHEO – but still looking!!!!• 2 THYROTOXIC PATIENTS• 2 LUNG CANCERS• 3 RENAL TUMOURS• 1 HYDRONEPHROSIS• 1 SECONDARY ADRENAL TUMOUR

How to do ABPM

• Ambulatory BP readings (ABPMAmbulatory BP readings (ABPM)• Use a device that measures at least 2

measurements/hour during waking hours.• You need to have at least 14 readings to

average.• In the past we added 10/5 to ABPM before

making decisions – there is no need to do this now, since the decision flow charts are based on ABPM not clinic readings.

How to do Home BP monitor

• Home BP monitoring (HBPM)Home BP monitoring (HBPM)• Take readings morning & evening for at least

4d, preferably 7d.• On each occasion take 2 readings ≥1min apart,

whilst seated.• Discard the first day’s readings, and average

the remaining readings.

What drugs

• Depends on age and ethnicity• Ace-I >> CCB >> ACE+CCB >>diuretic >> Alpha

blocker >> beta blocker >>ARB if not already on >> Methyl dopa

Age <55Age <55

ACE-I (OR ARB IF ACE NOT TOLERATED)ACE-I (OR ARB IF ACE NOT TOLERATED)

CCB (CALCIUM CHANNEL BLOCKER)CCB (CALCIUM CHANNEL BLOCKER)

Age >55 OR BLACK PERSONAge >55 OR BLACK PERSON

ACE-I + CCBACE-I + CCB

ACE-I + CCB + THIAZIDE LIKE DIURETICSACE-I + CCB + THIAZIDE LIKE DIURETICS

DRUG TREATMENTSDRUG TREATMENTS

ACE-I + CCB + DIURETIC +SPIRONALACOTONE /HIGHER DOSE DIURETICOR ALPHA BLOCKER OR BETA BLOCKER

ACE-I + CCB + DIURETIC +SPIRONALACOTONE /HIGHER DOSE DIURETICOR ALPHA BLOCKER OR BETA BLOCKER

Diuretics :Indapamide or chlortalidone NOT bendroflumethiazide

Diuretics :Indapamide or chlortalidone NOT bendroflumethiazide

When should we titrate up drugs?• Use clinic BP readings to monitor response to treatment.

• Ambulatory/home readings can be used in those with known ‘white coat’ hypertension (defined as a discrepancy of >20/10 between clinic and average ambulatory or home readings at time of diagnosis).

• Increase drug therapy if these targets are not achieved.• Aim for:• Clinic BP readings of: Ambulatory/home average readings of:• <80y <140/90<80y <140/90 <80y <135/85 <80y <135/85• >80y <150/90 >80y <145/85

So who and what do we organise?

HCAnurse

Suspected bp Arrange home/abpm

GP s

Results –who looks at them

Confirms diag

Start treatment

Investigations – ecg and bloods etc

Monitor bp

Up titrate bpWhen stable- 9m fu in bp clinic

management

• What we don’t want is hypertensive patients taking up gp appts for confirmation of diagnosis and titration!

• Or do we want pts coming to gp at diagnosis to confirm/agree a management plan – monitored by HCA or nurse over next 6m??

Discuss??

• What about the other clinics – CD clinics now filled up with mixture of diseaseS on different days

• DIAB – BE /DJ - try and find Som during week• What about COPD/ASTHMA/IHD/STROKE• HOW ABOUT A GP OF THE WEEK??• QUERY GOES TO ON CALL GP• GOOD TO SORT OUT WHILE PT IN BUILDING