Hypertension Workshop Blackburn with Darwen PCT

1. Hypertension Workshop Blackburn with Darwen PCT Jeannie Hayhurst Cardiovascular Specialist Nurse

2. What is hypertension? Facts and figures • The most common continuing medical condition seen by family doctors • Not a disease but a condition that puts someone more at risk of a disease • It affects 25% of the adult population & about 50% of all people over the age of 60yrs • Prevalence 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

3. New NICE guidelines 2011 • Changes to diagnosis • Changes to treatment algorithm • New targets

4. 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

5. 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

6. Confirming Diagnosis • If clinic BP is <140/90 review 5 yrly • If clinic BP is 140/90 or higher offer ABPM to confirm diagnosis • If unable to tolerate ABPM, HBPM is a suitable alternative • Whilst waiting to confirm diagnosis carry out invx for target organ damage and CVD risk assessment • If clinic BP ≥ 180/110 consider starting treatment immediately

7. ABPM – to confirm diagnosis • Ensure that at least two measurements per hour are taken during the persons usual waking hours • Use 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

8. ABPM – patient information • Provide patient with instructions on how to turn off and remove the device if day time only readings are required • Give 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 attached • When the cuff tightens advise that they try to relax, and keep their arm still and at heart level if possible • Warn that the monitor may repeat the measurement a minute later • Advise that driving with the monitor in place is permissible but if possible try to pull over when a measurement is been taken • Tell the patient to try and have a normal day!

9. HBPM – to confirm diagnosis • For 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

10. HBPM – things to note • Monitors should be validated and maintained • Wrist 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 possible • Not appropriate for patients with arrhythmias

11. 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

12. NICE definitions • Stage 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.

13. Hypertension Update Mammen Ninan GPwSI Cardiology November 2012

14. Effect of systolic and diastolic BP on mortality

15. Event free survival and relation to night time dipping of BP

16. Management of HT

17. Modest reductions in SBP can substantiallyreduce cardiovascular mortality Afterintervention Beforeintervention SBP = systolic blood pressure; CHD = coronary heart disease Adapted from Whelton PK, et al. JAMA 2002;288:1882-1888.

21. Aged over 55 years or black person of African or Caribbean family origin of any age Summary of antihypertensive drug treatment Aged under55 years C2 A Step 1 Key A – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic A + C2 Step 2 A + C + D Step 3 Resistant hypertension A + C + D + consider further diuretic3, 4 or alpha- or beta-blocker5 Consider seeking expert advice Step 4 See slide notes for details of footnotes 1-5

22. 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?

24. 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

25. Causes of Resistant Hypertension • Suboptimal drug therapy • White coat hypertension • Coexisting conditions – esp. obesity/metabolic syndrome/OSA • Antagonising substances (usually sodium) • Non-compliance • Coexisting medications – eg NSAID’s, OCA • Unrecognised secondary causes of hypertension

26. Important Secondary (identifiable) Causes of Hypertension • Sleep apnoea • Drug induced/ related • Chronic kidney disease • Primary aldosteronism • Renovascular disease • Cushing’s Syndrome or steroid therapy • Phaeochromocytoma • Coarctation of the aorta • Thyroid/ parathyroid disease

27. Case Study • 55 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