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Hypertension for nurses

Hypertension for nurses. 29 th October 2008. Cardiovascular disease. Leading causes of death 2002 WHO 2003 & Poole-Wilson. Clin Med JRCPL 2005; 5: 379-84. WHO global burden of disease major risk factors Ezzati et al, Lancet 2002; 360:1347-60. Total deaths: 55,861,000, year 2000. 7,141,000.

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Hypertension for nurses

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  1. Hypertension for nurses 29th October 2008

  2. Cardiovascular disease

  3. Leading causes of death 2002WHO 2003 & Poole-Wilson. Clin Med JRCPL 2005; 5: 379-84.

  4. WHO global burden of diseasemajor risk factorsEzzati et al, Lancet 2002; 360:1347-60.Total deaths: 55,861,000, year 2000 7,141,000 4,907,000 4,915,000 3,748,000 2,886,000 2,726,000 2,591,000 1,922,000 1,804,000 1,730,000 Thousands

  5. Renfrew 1972. Arbitrary dividing linesHawthorne, Greaves & Beevers, Brit Med J 1978.

  6. 100 88% 90 80 70 66% Percentdeadin 2 yr 60 50 40 36% 30 20 16% 8% 10 100-119 120-129 130-149 >150 MHT Diastolic blood pressure Survival of untreated hypertension Leishman, Brit Med J 1959; 1: 1361

  7. CHD mortality v usual blood pressureProspective Studies Collaboration, Lancet 2002; 360:1903-13

  8. Stroke mortality v usual blood pressureProspective Studies Collaboration, Lancet 2002; 360: 1903-13.

  9. JNC 7New classification of hypertensionJ Amer Med Ass 2003; 289: 2560-72

  10. Cardiovascular risk in “non-hypertensives”Vassan et al, New Eng J Med 2001; 345: 1291-7. Framingham.

  11. Hypertension Women Men High normal Free of CVD Normal BP With MI Hypertension With stroke High normal With other CVD Normal BP 0 10 20 30 40 Life expectancy at age 50 Framingham life expectancy 2005Franco et al, Hypertension 2005; 46: 280-6.

  12. Metropolitan Life Insurance Company A man age 36 with a blood pressure of 150/100 will die before he reaches the retirement age of 65.

  13. FRAMINGHAM Over the age of 45, systolic blood pressure is a better predictor of risk than diastolic pressure. Kannel WB, Am J Cardiol 1971; 27: 335.

  14. Systolic versus diastolicWere we taught wrongly? 1970s. Reliable long-term epidemiological surveys in Framingham and elsewhere. 1980s. Cox’s proportional hazard model enables differentiation. 1990s. Computer hardware and software readily available. So the current views are based on facts rather than opinions.

  15. The definition of hypertension “Hypertension should be defined in terms of a blood pressure level above which investigation and treatment do more good than harm” Grimley Evans & Rose, Br Med Bull 1971

  16. Thresholds. Low-risk patients: (No end-organ damage or diabetes & CVD risk < 20%). 160/100. High risk patients. (End-organ damage or diabetes or CVD risk > 20%): 140/90. Targets. Diabetics: 130//80. All other patients: 140/85. British Hypertension Society-IVJ Human Hypertens 2004;Thresholds and targets for treatment

  17. 100 Percent SBP >140 mmHg and/or DBP >90 mmHg Men Women 75 50 25 0 16-19 20-29 30-39 40-49 50-59 60-69 70-79 >80 Age Prevalence of hypertensionPrimatesta et al, Hypertension 2001;38: 827-32.Health Survey for England 1998.

  18. Percent at Target 160/95 Percent at Target 140/90 USA CAN ITAL SP ENG GER SW USA CAN ITAL SP ENG GER SW Hypertension control in seven countriesWolf-Maier et al, Hypertension 2004; 43: 10-7Age and gender adjusted hypertension control

  19. Opportunistic screening in general practiceBarber et al, Brit Med J 1979; i: 843.Men aged 35-69 years : 1 doctor 500 (80) 400 13.9%(68) Number of patients screened 300 23.3%(114) 200 77.5%(381)Screened 100 40.4%(199) 0 2nd Year 3rd Year Total Eligible 1st Year

  20. Diabetes in a BP clinicSalmasi et al, Amer J Hypertens 2004; 17: 483-8. London. Diabetes, n=24 Normal GTT, n=41 IGT or IFG, n=35

  21. Prevalence of hypertension and dyslipidaemia in men as a function of glucose toleranceIsomaa et al, Diabetes Care 2001; 24: 683-9. Dyslipidaemia Hypertension Patients (%)

  22. Brit. Med. Bull. 1994: 50: 272-90 = fatal events T = treatment C = control Total numbers of individuals affected 1200 1000 800 600 400 200 1104 964 934 835 T C 768 670 667 T C 560 525 T C 470 T C 234 170 140 158 T C STROKE 38% SD 4 8.7 <0.0001 CHD 16% SD 4 38.8 0.0001 REMAINING VASCULAR DEATHS ALL VASCULAR DEATHS* 4.8 <0.00021 ALL OTHER DEATHS % reduction in odds: No. of SD: 2P=value * includes any deaths from unknown causes

  23. BP control in general practiceHudson. Practice Nurse 1993; 1: 14. Holmes Chapel

  24. Nurse run BP clinicCurzio et al, J Human Hypertens 1990; 4: 665-70. Western Infirmary, Glasgow Nurse run clinic: (n=198) – drop out rate = 8% Conventional clinic: (n-198) – drop out rate = 34% SBP DBP 0 1 2 3 4 Years follow up

  25. Nurse management of hypertensionRudd et al, Amer J Hypertens 2004; 17: 921-7. CaliforniaEarly counselling and telephone follow-up p<0.01 p<0.01

  26. Nurse-run hypertension OP clinicCurzio et al. J Human Hypertens 1990; 4: 665.

  27. Nurse management of hypertensionRudd et al, Amer J Hypertens 2004; 17: 921-7. CaliforniaEarly counselling and telephone follow-up P<0.05

  28. Part 2What causes the bloody thing?

  29. The aetiology of hypertension

  30. Oestrogen-only oral contraceptives Liquorice Oral & topical corticosteroids Cold cures & nasal decongestants Cyclosporin Erythropoetin Methysergide Monoamine oxidase inhibitors Narcotic abuse Alcohol excess Sibutramine NSAIDS & coxibs Lithium Drug-induced hypertension and interactions with antihypertensive drugs

  31. Ever popular terms like “ idiopathic” and “essential” are actually nonsensical as all diseases must have causes Geoffrey Rose, Reflections on changing times. Brit Med J 1990; 301: 683-7

  32. Family history and hypertensionStamler et al, JAMA 1979; 241: 43-6.Percent of population with DBP 95 mmHg or more.

  33. 0.15* Systolic BP 0.27* 0.09 0.24* 0.08 0.38* 0.19 0.16 A N N A 0.18 Diastolic BP 0.26* 0.13† 0.21† 0.10 0.53* 0.27* 0.29* A N N A Montreal Adoption StudyMongeau et al, Clin Exper Hypertens 1986; 8: 653-60 Correlation coefficients; * p<0.001, † p<0.01

  34. Stress and hypertension Whilst acutely stressful stimuli cause an acute rise in blood pressure, there is no convincing evidence that chronic stress causes hypertension

  35. Meta-analysis of salt intake v systolic BP Law et al, BMJ 1991; 302: 811 160 140 Age 20-29 120 100 160 140 Age 40-49 120 SBP 100 180 Age 60-69 160 140 Developed 120 Underdeveloped 100 0 100 200 300 400 Sodium Intake (mmol/24h)

  36. The effect on systolic BP (A) and diastolic BP (B) of reduced sodium intake and the DASH Diet. Sacks FM, New Eng J Med 2001; 344: 3-10 412 subjects - normotensive + hypertensive - randomised to diet rich in veg & low fat & 3 levels of salt intake. 7.1 mmHg  normotensives 11.5 mmHg  hypertensives

  37. Exercise and blood pressureWallace et al, Amer J Hypertens 1997; 10: 728-34. Indiana25 untreated mildly hypertensive patients

  38. Kaiser Permanente multiphasic health examination dataKlatsky et al, New Eng J Med 1977; 296 1194-2000.

  39. Effects of obesityWestern EuropeHaslam & James. Lancet 2005; 366: 1197-209.

  40. Obesity and hypertensionHaemodynamic profileWeir et al, Amer J Med 1991; 90 (suppl A): 5-14 • High cardiac output • Expanded plasma volume • Increased salt sensitivity and intake • Normal or decreased renin-angiotensin activity • Normal or decreased peripheral resistance • Raised sympathetic nervous system activity, plasma adrenalin & noradrenalin • Insulin resistance

  41. Blood pressure change with diet Reisin et al, Ann Intern Med 1983; 98: 315-9 +15 +10 +5 r = .49 p < 0.05 Change in MAP(mmHg) 0 -5 -10 -15 -20 -20 -15 -10 -5 0 5 +10 +15 Change in weight (kg)

  42. Unmodifiable Family history Modifiable Salt salt salt Fruit & vegetables Animal fat Obesity Alcohol excess Lack of exercise Underlying renal adrenal diseases SummaryCauses of hypertension

  43. Millions of undiagnosed, untreated & undertreated hypertensives The existing structure of health-care delivery has failed to solve the problem The primary health-care team can potentially improve things. It’s time the nurses took over. ……but only if they receive adequate postgraduate training.

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