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Hypertension

Hypertension. Martine Butters Clinical Trainer martine.butters@nottinghamcitycare.nhs.uk. Outcomes. To understand the significance of hypertension and the importance of NICE Guidelines. Blood Pressure (BP).

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Hypertension

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  1. Hypertension Martine Butters Clinical Trainer martine.butters@nottinghamcitycare.nhs.uk

  2. Outcomes To understand the significance of hypertension and the importance of NICE Guidelines

  3. Blood Pressure (BP) Blood pressure is the pressure against the walls of the arteries as blood is pumped around your body by your heart. As the heart pumps the blood out, the pressure is highest and when the heart is filling up again ready for the next pump, the blood pressure is lowest It is measured in millimetres of mercury (mmHg) and recorded as Systolic / Diastolic

  4. Blood Pressure Ideally we should have a BP of 120/80 or below Most UK adults have readings in the range of 120/80 to 140/90 According to NHS CHOICES, normal BP is between 90/60 and 140/90

  5. Blood Pressure NICE (2011) recommend a target of 140/90 or less in uncomplicated adults If BP is 140/90 or more, it requires assessment The 2005 Joint British Societies’ Guidelines on prevention of CVD recommend a BP target of 130/80 or less for people with diabetes, established CVD or chronic renal disease (Diabetes UK 2008)

  6. Hypertension A BP that is persistently higher than normal levels Common condition affecting around a quarter of the UK adult population (H&SCIC 2012/13) A sub group particularly affected is Western AfCs’ (PHE 2014) Associated with increased risk of developing disorders including CVD, renal disease & strokes 1 in 3 deaths are from CVD each year Monitoring and patient support is crucial

  7. Hypertension Guidelines Nice guideline 34, August 2011 http://www.nice.org.uk • Adults (aged 18 and over) X People with diabetes X Children and young people X Pregnant women

  8. NICE Guidelines (2011) NICE outline key responsibilities: Measure blood pressure Offer lifestyle intervention Patient education Pharmacological intervention Assess CVD risk

  9. Types of hypertension Primary: most common type, no obvious cause Secondary: underlying causative disorder for example renal disease Malignant Hypertension

  10. Hypertension • Stage 1: Clinic BP is 140/90 or higher and subsequent ABPM or HBPM daytime average BP is 135/85 or higher • Stage 2: Clinic BP is 160/100 or higher and subsequent ABPM or HBPM daytime average is 150/95 or higher • Severe Hypertension: Clinic systolic BP is 180 or higher or clinic diastolic BP is 110 or higher

  11. Risk factors for Hypertension Sometimes doesn’t have a clear cause Age Lifestyle Family History/Genetics Ethnic Group Adrenal problems Thyroid problems Diabetes CKD (Secondary Hypertension) Medications: OCP, Mental Health Drugs, Recreational Drugs

  12. Symptoms Is very often a silent condition that shows no symptoms Usually only get symptoms when the strain on the arteries leads to more serious problems such as angina, MI, CVA If very high may get: severe headache, confusion, vision problems, chest pain, blood in urine, pounding in chest & neck

  13. Diagnosis If clinic BP is 140/90 or higher, take a second measurement during the consultation If the second measurement is substantially different from the first, take a third Record the lower of the last two measurements as the clinic BP (NICE 2011) Aim is for clinic BP to below 140/90 (under 80) 150/90 (80 or over)

  14. Diagnosis If BP 140/90 or higher offer ABPM to confirm the diagnosis of hypertension Ensure that at least 2 measurements per hour are taken during the person’s usual waking hours Use the average value of at least 14 measurements to confirm the diagnosis

  15. Intervention: measure BP by HBPM NICE clinical guideline 127, August 2011 If unable to tolerate ABPM offer HBPM For each BP recording, 2 consecutive measurements are taken at least 1 minute apart & with the person seated Recorded twice daily, ideally morning & evening Recording continues for at least 4 days, ideally 7 Discard measurements taken on 1st day & use the average value of all the remaining measurements to confirm diagnosis

  16. NICE CG127 Aug 2011

  17. Health Check If confirmed hypertension offer; • Urine test for protein, send a sample for albumin:creatinine ratio • Reagent strip for haematuria • A 12-lead ECG • Blood Test; Glucose,U/ES,eGFR,Lipids,FBC • Examine fundi for hypertensive retinopathy • People aged under 40 with Stage 1 Hpt consider seeking specialist referral (causes & target organ damage)

  18. Severe Hypertension Consider starting antihypertensive therapy without waiting for ABPM/HBPM results May need immediate Specialist referral Whilst waiting for a diagnosis, carry out investigations for target organ damage and formal CVD risk

  19. Afro-Caribbeans’ • Hpt is the leading cause of death & disability in Western AfCs’ • Genetic link • Sensitivity of BP to salt intake is often increased and as the inability to excrete ingested salt is impaired, leads to an expansion of intravascular volume • Also tend to show low plasma renin levels, reason uncertain but maybe related to renal/sodium handling and reduced sympathetic nervous activity • Dietary salt restriction

  20. MalignantHypertension

  21. Malignant Hypertension Very high BP Comes on suddenly Diastolic is often above 120 mmHg Commoner in young black males Collagen Vascular problems Kidney problems Toxaemia of pregnancy

  22. Symptoms Blurred Vision Confusion Chest pain Headache Reduced Urine output Epistaxis TREAT IMMEDIATELY

  23. Lifestyle

  24. Intervention: lifestyle change • Diet • Exercise • Alcohol • Smoking • Local initiatives • Relaxation

  25. Hypertensive Medication

  26. NICE CG127 Aug 2011

  27. Afro-Caribbean's & Medication • ACE inhibitors act in part via the renin-angiotensin system by decreasing renin release from the kidney. As AfCs tend to have low renin, volume expansion hypertension, this type of drug less effective, particularly as monotherapy • CCBs recommended as first line treatment. • CCBs tend to provide more protection against stroke

  28. Medications The use of monotherapy is not always effective Add in a different class of drug rather than increasing initial drug dose

  29. ACE inhibitors Eg. Ramipril , Enalapril, Perindopril, Lisinopril

  30. Angiotensin II Antagonists Eg. Losartan,Valstartan, Candesartan, Irbesartan

  31. Beta-Blockers, Alpha-Blockers Eg. Atenolol, Metoprolol, Bisoprolol Doxazosin,Prazosin

  32. Calcium Channel Blockers Eg. Amlodipine, Felodipine, Diltiazem,Nifedipine

  33. Diuretics Eg. Bendroflumethiazide, Chlortalidone

  34. Medication Compliance

  35. Poor Compliance Insufficient pt education about the illness & low motivation to receive any treatment Complexity of treatment Adverse effects Often an asymptomatic condition Prescription costs Personal health beliefs

  36. Action Communication is paramount Refer to local Pharmacist Refer to Medicines Management Team Offer blister packs/dossette box Check meds i.e. packaging Suggest patients record their medication taking Simplifying the dosing regime

  37. Patient Education

  38. Patient Education Good communication skills Assess literacy skills ‘Tailor made’ for the patient Literature review Support Groups

  39. CardiovascularDisease

  40. Detecting risk factors: CVD Cardiovascular risk important in relation to Hpt More than 1 in 3 deaths from CVD every year Majority are potentially preventable Can affect heart, brain, lower limbs Focus on patients with established disease Find others who are ‘at risk’

  41. Risk Factors for Coronary Heart Disease Non-modifiable • Hypertension • Family history (males <55 females <60) immediate family • Gender – more common in men(women catch up after menopause) • Age • Ethnicity • High cholesterol levels • Diabetes • Hypothyroidism Modifiable • Hypertension • Smoking • Low physical activity • Obesity • Diet • High blood pressure • Stress

  42. Intervention: assess CVD risk Medical history Physical examination Family history Urine test for blood, sample for albumin:creatinine ratio Blood tests: Lipids, Plasma glucose, U&E, FBC, TFTs , Creatinine, eGFR 12 – lead ECG Formally assess CVD risk using a formal risk prediction tool

  43. Intervention: assess CVD risk

  44. Intervention: assess risk • Framingham Heart Study: 5000 men and women aged 30–62 followed up from 1971 • Limitations – no account of family history / ethnicity • Visual aid may be helpful to some patients • QRISK, has the advantages of including ethnicity & family history • Only provide an approximate risk • None should replace clinical judgement

  45. White Coat Syndrome

  46. Cause not fully known • Sweating, Tachycardia, Palpitations • More common in pregnancy & increasing age • Consider ABPM or HBPM in conjunction with clinic monitoring • Therapeutic patient relationship • Good communication skills

  47. Summary • Any questions? • Evaluations • Thank you for listening

  48. Inspection - Hands Sweating Cyanosis (blue tinge to nail bed – peripheral cyanosis) Pallor (white or pale nail bed) Clubbing (loss of nail bed angle)

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