Hypertension Blood Pressure Management Facts, Myths Legends

1. HypertensionBlood Pressure ManagementFacts, Myths & Legends Jill Bunker MSc & Wendy Callister Clinical Nurse Specialist Hypertension and Cardiovascular Disease Prevention Peart-Rose Clinic & Clinical Investigation Unit 24th September 2008

2. High BP estimated to account for 6% of deaths worldwide It�s the most common treatable risk factor for CVD Majority of patients BPs remain uncontrolled Hypertension is sufficiently common to be a public health concern BP control dependent on individual doctors and nurses High BP estimated to account for 6% of deaths worldwide It�s the most common treatable risk factor for CVD Majority of patients BPs remain uncontrolled Hypertension is sufficiently common to be a public health concern BP control dependent on individual doctors and nurses

3. British Hypertension Society Guidelines for hypertension management (BHS-IV): summary (2004) Joint British Societies� Guidelines on Prevention of Cardiovascular Disease in Clinical Practice (2006) British Cardiac Society, British Hypertension Society, Diabetes UK. HEART UK, Primary Care Cardiovascular Society, The Stroke Association.Hypertension-management of hypertension in adults in primary care (2004 and 2006). NICE. Clinical guideline 18 and 34 Different Guidelines ..

4. Topics to be covered Definition, Thresholds for intervention and treatment goals Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring

5. Classification of blood pressure levels of the British Hypertension Society High normal becoming increasingly importantHigh normal becoming increasingly important

8. BHS Guidelines Definitions Definition, Thresholds for intervention and treatment goals Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring

10. FACTInaccurate blood pressure tests could affect millions

12. MHRA BP measurement recommendations 2005  Auscultation method: e.g Greenlight; mercury Should be available in all clinical areas Taught to all healthcare workers Used to check oscillometric (automatic) monitors Always used in certain clinical conditions: arrhythmias; pre-eclampsia; certain vascular disorders 2. Non-mercury auscultation method: Available in all clinical areas (e.g. Accoson Greenlight 300) Mercury Spillage kits: Available in all clinical areas if using mercury

13. MHRA BP measurement recommendations 2005  Oscillometric monitors (automatic): Don�t assume it�s suitable for use in diagnosis of hypertension Oscillometric (automatic) method not suitable for all: Arrythmias; pre-eclampsia; certain vascular diseases Aneroid monitors: Aneroid dial gauges easily prone to damage from dropping, causing significant errors in zero & calibration 7. Calibration/Servicing Calibrate and service all your monitors regularly

14. Examples of recommended BP monitors. Mercury sphygmomanometers � (gold standard). Greenlight 300 (accoson) Independently validated automated upper arm devices Consider MANDAUS 11 for community use (details available BHS website) � � � �

15. Measuring Blood Pressure

17. BHS Guidelines Definitions Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring

19. Evaluation of hypertensive patients Causes of hypertension (in 5% of patients) Drugs (NSAIDS, oral contraceptions, steroids, liquorice, some cold cures) Renal disease (present, past or family history, proteinuria or haematuria: palpable kidney(s) � polycystic, hydronephrosis, or neoplasm) Renovascular disease (abdominal or loin bruit) Phaeochromocytoma (paroxysmal symptoms) Conn�s syndrome (muscle weakness, polyuria, hypokalaemia) Coarctation (radio-femoral delay or weak femoral pulses) Cushing�s (general appearance)

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24. BHS Guidelines Definitions Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring

25. This table can be found in the BHS guidelines It shows what level of systolic BP reduction can be expected with life style changes This table can be found in the BHS guidelines It shows what level of systolic BP reduction can be expected with life style changes

26. BHS Guidelines Definitions Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring

27. Home/self BP monitoring Advise patients on accurate, independently validated, well maintained monitors Advise use of appropriate cuff size Wrist monitors are not recommended Suggested measurement routine for patients Measure BP for 7 days prior to appointment Record BP twice a day. Morning and evening Discard first 24 hours of readings Take an average of at least 12 of these readings

29. Interpreting results For both 24 hour Ambulatory BP monitoring and Home Monitor readings Add 10/5 mmHg to average daytime pressure. e.g. day-time average pressure = 158/89 add 10/5 adjusted reading = 168/94 Home BP <130/85 probably considered normal.

31. Reasons for inadequate control of BP? Ineffective drugs? Resistant hypertension? Guideline confusion? Drug costs? Drug side-effects? Poor adherence/compliance? Physician inertia?

32. Compliance/Adherence issues Side-effects? Asymptomatic disease? feel worse with treatment may not protect from � Cost? Memory? Understanding?

33. For information on� Hypertension Management Guidelines, Recommendations for combining blood pressure lowering drugs, BP measuring recommendations, Validated BP monitors, CVD risk prediction chartCHD risk calculator www.bhsoc.org.uk