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Newer hypertension guidelines

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Newer hypertension guidelines

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    1. New(er) hypertension guidelines Dr Laura Thomson FY2 Donald Singer Professor of Clinical Pharmacology & Therapeutics Francesco Cappuccio Professor of Cardiovascular Medicine & Epidemiology

    2. How many BP readings? 3 – in sinus rhythm more if there are multiple ectopics or AF

    3. Case Presentation Grand Round 15/11/2011 F2 Laura Thomson

    4. 53 yr old male – Rolls-Royce inspector GP referral to AE in Jan 2010 PC: incoordination HPC: on waking in the morning was ‘bumping into things’ sat down but missed the chair could not see keys on computer son reported he was leaning to the left felt disorientated + clumsy No collapse/LOC No history of head injury

    5. Unclear of all events - amnesia Denied current headache Headaches for over a year, 2/week Frontal 7-8/10, sharp pain, usually in the morning No nausea/photophobia/seizures Reported diplopia since the morning No speech problems, no limb weakness No rash, neck stiffness, fever No chest pain, SOB, palpitations

    6. PMHx: One episode - fit aged 20 - documented as epileptic FHx: Nil known Meds: Nil regular SHx: Lives with wife, independent ADL Occupation:- Inspector Rolls Royce Never smoker 5 cans lager/week Cycles 50 miles a week

    7. O/E: Weight: 93.8 kg Ht 1.70m BMI 33.9 kg/m^2 BP: 258/138mmHg (T: 35.5, P: 70, RR: 18, Sats: 99 % OA) Left arm BP: 218/101mmHg Right arm BP: 226/112mmHg Alert, GCS 15/15 HS I + II + O, JVP ? Chest clear, abdo soft and non-tender Normal gait Diplopia on left lateral gaze, no nystagmus Upper and lower limbs, equal power, normal sensation, reflexes present, ? plantars Left pronator drift

    9. Bloods ECG: LVH

    10. Brain imaging Dr Sherlala Consultant Neuro-radiologist

    11. CT head:

    12. Diagnoses Intra-cerebral haemorrhage Rt basal ganglia area Severe hypertension Raised cholesterol Overweight

    13. Further investigations Urinalysis Plasma aldosterone: 299 pmol/L [NR 28 – 445 – supine] 10/2/10 24hr Urinary sodium 103 mmol [Ideal range: ? ] 24 hr Urinary creatinine 108 mmol [13.2-17.6] 3 x 24hr Urinary catecholamines – normal range

    14. Target 24hr sodium excretion? < 100 mmol/day

    15. Initial treatment in AE 25/01/10 BP: 258/138 mmHg Amlodipine 10 mg STAT Neuro review 25/01/10 BP: 218/101 Labetalol 10 mg - BP: 197/97 Labetalol 10 mg - BP: 154/87 Hypertension clinic 26/01/10 BP 189/116 Rt; 197/120 Lt Omron 3 readings Nifedipine SR 20 mg TDS Simvastatin 40mg at night

    17. Discussion Detection Complications – short and long-term Investigation – secondary causes, complications, refine selection of treatment Treatment Potential for lifestyle impact Drug selection and combination

    19. Ambulatory blood pressure Why? Device and protocol Interpretation

    20. ABPM – as companion diagnostic Diagnosing hypertension White coat hypertension Clues to secondary cause Labile blood pressure Nocturnal dipping Clue to adherence Predicting risk of complications

    21. ABPM

    22. Labile blood pressure

    23. Nocturnal dipping > 10% decrease at night

    24. NICE 2011 Hypertension Guidelines I am aware of the 2011 guidelines I am aware of the main changes from 2006 I am confident about how to use the new 2011 guidelines

    26. Definitions Stage 1 hypertension: CBP >140/90 and ABPM or HBPM >135/85 mmHg Stage 2 hypertension: CBP >160/100 and ABPM or HBPM daytime >150/95 mmHg Severe hypertension: C SBP >180 or C DBP >110 mmHg

    27. Key priorities for implementation Diagnosis Initiating and monitoring antihypertensive drug treatment Choosing antihypertensive drug treatment

    28. If C.B.P. >140/90 mmHg, offer ABPM to confirm the diagnosis ABPM: at least two measurements per hour, at least 14 measurements HBPM: two consecutive seated measurements, at least 1 minute apart BP twice a day for at least 4 days measurements on the first day are discarded Diagnosis

    29. Offer drug treatment to: stage 1 hypertension, aged <80 and meet identified criteria stage 2 hypertension at any age If <40 with stage 1 hypertension and without evidence of TOD, CVD, CKD or diabetes, consider: specialist evaluation of secondary causes of hypertension further assessment of potential TOD Initiating drug treatment

    30. Use C.B.P. measurements to monitor response to treatment. Aim for target <140/90 mmHg in people <80y <150/90 mmHg in people aged >80y For people with ‘white-coat effect’* consider ABPM or HBPM as an adjunct to C.B.P. to monitor response to treatment. Aim for ABPM/HBPM target <135/85 mmHg in people <80y <145/85 mmHg in people >80y Monitoring drug treatment

    33. Cost-effectiveness of the various BP-lowering drug classes for the management of hypertension in primary care Comparator ‘do nothing’ Only first line drug considered Effects modelled: prevention of fatal and non-fatal CVD events; AE: onset of HF and diabetes Health outcomes expressed as QALYs (one QALY = one year of healthy life) Incremental Cost-Effectiveness Ratio (ICER) = additional cost of using one drug per additional QALY gained compared to no intervention or another drug. NICE guide: ICER should be less than the maximum amount to pay for QALY of £20K-to-30K. NICE-BHS Guidelines – update 2011

    35. Discussion How do our diagnosis and treatment pathways for people with hypertension need to change in order to bring them in line with this guidance? What innovative ways can we think of to enhance our capacity to deliver ABPM to people who need it? What action do we need to take to ensure our blood pressure monitoring devices are properly validated, maintained and regularly calibrated? Who within our team needs briefing or training to ensure consistent implementation?

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