Hypertension Workshop Blackburn with Darwen PCT

Jeannie HayhurstCardiovascular Specialist Nurse

What is hypertension? Facts and figures The most common continuing medical condition seen by

family doctorsNot a disease but a condition that puts someone more at

risk of a diseaseIt affects 25% of the adult population & about 50% of all

people over the age of 60yrsPrevalence is slightly higher in men than women: 31.5%

as opposed to 29% (Health Survey for England 2010)“Is one of the most preventable causes of premature

morbidity and mortality world-wide” (NICE 2011)

Sustained blood pressure ≥ 140/90 mmHg

New NICE guidelines 2011Changes to diagnosisChanges to treatment algorithmNew targets

Measuring BP Devices must be validated, maintained and regularly recalibrated Appropriate cuff size Relaxed temperate setting, patient seated for 3-5 mins Palpate pulse first Measure BP in both arms If difference between arms is >20mmHg repeat the measurements If it remains >20mHg, measure subsequent BPs in the arm with the higher

reading (Consistent inter-arm differences of >20/10mmHg warrants specialist referral)

If BP is ≥ 140/90 take a second reading If the second reading is substantially different from the first take a third

reading Leave a minute between each reading Record the lower of the last two readings

Check the following if reading is raised:

That the person has not hurried to the session

That their bladder is empty!That they haven’t had a large meal, alcohol,

caffeine, cigarettes and exercise in previous 30 minutes

Don’t forget:BP rises on waking & then tends to fall

through the day.BP tends to be higher in colder weather

Confirming DiagnosisIf clinic BP is <140/90 review 5 yrlyIf clinic BP is 140/90 or higher offer

ABPM to confirm diagnosisIf unable to tolerate ABPM, HBPM is a

suitable alternativeWhilst waiting to confirm diagnosis carry

out invx for target organ damage and CVD risk assessment

If clinic BP ≥ 180/110 consider starting treatment immediately

ABPM – to confirm diagnosis Ensure that at least two measurements per hour are

taken during the persons usual waking hoursUse the average value of at least 14 measurements

taken during the persons usual waking hours to confirm a diagnosis of hypertension

24hr ABPM may be required for patients who might be more at risk of “ non- dipping” i.e. whose BP does not dip at night, as is normal. (these may be people with existing target organ damage who appear controlled and patients with Type 1 diabetes with microalbuminuria)

N.B Practices who do not have their own ABPM can refer patients to Darwen or Barbara Castle HC using a D1 form

ABPM – patient informationProvide patient with instructions on how to turn off and remove

the device if day time only readings are requiredGive advice on wearing appropriate clothing i.e. allowing access

to upper arm and easily removed Advise that bathing or showering is not permissible whilst the

monitor is attachedWhen the cuff tightens advise that they try to relax, and keep

their arm still and at heart level if possibleWarn that the monitor may repeat the measurement a minute

laterAdvise that driving with the monitor in place is permissible but

if possible try to pull over when a measurement is been takenTell the patient to try and have a normal day!

HBPM – to confirm diagnosisFor each BP recording two consecutive

measurements are taken, seated, at least 1 minute apart

BP is recorded twice daily, ideally morning and evening

Record measurements for at least 4 days, ideally 7 days

Discard measurements taken on the first day and use the average of the remaining measurements to confirm a diagnosis

HBPM – things to noteMonitors should be validated and maintainedWrist monitors are not recommended and can

be inaccurate but may be acceptable if the patient has had bilateral mastectomies, has sustained injuries to both upper arms or is grossly obese.

Only about a third of patients fully comply with instructions

Observer bias/prejudice is possibleNot appropriate for patients with

arrhythmias

What the readings mean (ABPM/HBPM)Daytime average

<135/85mmHg

Daytime average ≥135/85mmHg CVD risk <20%/No target organ damage

Daytime average ≥135/35mmHg CVD risk >20% /Target organ damage

Daytime average ≥150/90mmHg

Not hypertensive- recheck BP within 5yrs

Stage 1 hypertension – No treatment; reassess annually

Stage 1 hypertension; treat according to NICE ACD chart

Stage 2 hypertension; treat according to NICE ACD chart

NICE definitionsStage 1 hypertension:• Clinic blood pressure (BP) is 140/90 mmHg or

higher and• ABPM or HBPM average is 135/85 mmHg or higher.

Stage 2 hypertension: • Clinic BP 160/100 mmHg is or higher and• ABPM or HBPM daytime average is 150/95 mmHg

or higher.

Severe hypertension: • Clinic systolic BP is 180 mmHg or higher or• Clinic diastolic BP is 110 mmHg or higher.

Hypertension UpdateMammen Ninan

GPwSI CardiologyNovember 2012

Effect of systolic and diastolic BP on mortality

Event free survival and relation to night time dipping of BP

Management of HT

Modest reductions in SBP can substantiallyreduce cardiovascular mortality

SBP = systolic blood pressure; CHD = coronary heart disease

% Reduction in Mortality

Reduction in SBP (mmHg) Stroke CHD Total

2 -6 -4 -3

3 -8 -5 -4

5 -14 -9 -7

Adapted from Whelton PK, et al. JAMA 2002;288:1882-1888.

Afterintervention

Beforeintervention

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

What are the key elements of effective BP control?

Are your current therapy choices delivering effective control of blood pressure in all your hypertensive patients?

What is resistant Hypertension

Failure to control BP to < 140/90 or <130/80 in diabetics, in spite of being on 3 different antihypertensive agents, one of which is a diuretic

Causes of Resistant Hypertension Suboptimal drug therapyWhite coat hypertension Coexisting conditions – esp.

obesity/metabolic syndrome/OSAAntagonising substances (usually sodium)Non-complianceCoexisting medications – eg NSAID’s,

OCAUnrecognised secondary causes of

hypertension

Important Secondary (identifiable) Causes of HypertensionSleep apnoeaDrug induced/ relatedChronic kidney diseasePrimary aldosteronismRenovascular diseaseCushing’s Syndrome or steroid therapyPhaeochromocytomaCoarctation of the aortaThyroid/ parathyroid disease

Case Study55 year old lady comes to surgery for foot

pain, she is slightly overweight with BMI of 28. Her BP was last checked 10 years ago, and you check it to satisfy QOF, and it is 158/108.

Her mother had hypertension and had a stroke at the age of 70 yrs. Patient is a non smoker, works in a GP surgery as Practice Manager and admits to being stressed at work

Her urine dipstick is clear, ECG does not show any signs of LVH