Hypertension Blood Pressure Management Facts, Myths Legends

1. HypertensionBlood Pressure ManagementFacts, Myths & Legends Jill Bunker Clinical Nurse Specialist Hypertension and Cardiovascular Disease Prevention Peart-Rose Clinic & Clinical Investigation Unit 9th September 2007

2. High BP estimated to account for 6% of deaths woldwide 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 woldwide 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) Bryan Williams, Neil R Poulter, Morris J Brown, Mark Davies, Gordon T McInnes, John F Potter, Peter S Sever, Simon McG Thom; the BHS guidelines working party, for the British Hypertension Society. BMJ 328 634-640.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. 91 Supl. VHypertension-management of hypertension in adults in primary care (2004 and 2006). NICE. Clinical guideline 18 and 34www.nice.org.uk 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

6. Slide 43 When to treat? Both BHS and NICE agree the following that Hypertension is when blood pressure is equal to or greater than 140 systolic and or equal to greater than 90 mmHg diastolic A Sustained systolic BP of equal to or greater than 160 and/or diastolic equal to or greater than 100 needs medication (despite having non-pharmacological treatment) Blood Pressure must be treated if the patient has a systolic BP equal to or greater than 140 and/or a diastolic equal to or greater than 90 if patient has Target Organ Damage, CVD, Diabetes or 10 year CVD risk > 20% (see back of BNF to work this out) Slide 43 When to treat? Both BHS and NICE agree the following that Hypertension is when blood pressure is equal to or greater than 140 systolic and or equal to greater than 90 mmHg diastolic A Sustained systolic BP of equal to or greater than 160 and/or diastolic equal to or greater than 100 needs medication (despite having non-pharmacological treatment) Blood Pressure must be treated if the patient has a systolic BP equal to or greater than 140 and/or a diastolic equal to or greater than 90 if patient has Target Organ Damage, CVD, Diabetes or 10 year CVD risk > 20% (see back of BNF to work this out)

7. Slide 44 BHS TARGET BP Suggested target blood pressures during antihypertensive treatment. Systolic and diastolic blood pressures should both be attained, That is less than 140/85 This means the systolic must be less than 140 for and the diastolic must be less than 85 for diastolic blood pressure If a patient has a BP of 138/94 or 146/84 he has not reached target and needs additional treatment. Audit standard are the minimum recommended levels of blood pressure control. Despite best practice, it is recognised that the Audit Standard won�t be achievable in all treated hypertensives. NICE Target BP 140/90 or until further treatment inappropriate or declined. NICE make no comment about diabetics or audit standard Slide 44 BHS TARGET BP Suggested target blood pressures during antihypertensive treatment. Systolic and diastolic blood pressures should both be attained, That is less than 140/85 This means the systolic must be less than 140 for and the diastolic must be less than 85 for diastolic blood pressure If a patient has a BP of 138/94 or 146/84 he has not reached target and needs additional treatment. Audit standard are the minimum recommended levels of blood pressure control. Despite best practice, it is recognised that the Audit Standard won�t be achievable in all treated hypertensives. NICE Target BP 140/90 or until further treatment inappropriate or declined. NICE make no comment about diabetics or audit standard

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

11. MHRA Blood pressure measurement recommendations 2005  Auscultation method: e.g Greenlight; mercury Should be available in all clinical areas Taught to healthcare workers Auscultation method 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 Slide10 Although used less and less the mercury sphygs are still the gold standard as a machine that�s inexpensive and will take everybody�s blood pressure whatever size arm they�ve got. It�s been in use for over 100 years� We cannot discard them yet �The reasons you cannot discard them are these� �1.��� Automatic b.p. monitors do not work with people who have irregular or v.slow heartbeats or a tremor. 2.��� There are occasions when automatic monitors don�t work; there�s no apparent reason for this. Calibration: Mercury sphygs should be cleaned and calibrated yearly. Automated monitors they�ve been WENDY WRITE THIS . DrAndrew Coleman is consultant physicist at Guys and St Tomas�s and he presented at the NHA last month some research on accuracy of automatic monitors, mercury and anaeroids. And still anaeroids are failing �interestingly the validated automatic monitors were more accurate than the mercury sphygs. Dr C is in the process of developing independent calibration equipment which can be used on all monitors . He hopes this will be available from January and he promises to get in touch �we�ll put him in touch with you Slide10 Although used less and less the mercury sphygs are still the gold standard as a machine that�s inexpensive and will take everybody�s blood pressure whatever size arm they�ve got. It�s been in use for over 100 years� We cannot discard them yet �The reasons you cannot discard them are these� �1.��� Automatic b.p. monitors do not work with people who have irregular or v.slow heartbeats or a tremor. 2.��� There are occasions when automatic monitors don�t work; there�s no apparent reason for this. Calibration: Mercury sphygs should be cleaned and calibrated yearly. Automated monitors they�ve been WENDY WRITE THIS . DrAndrew Coleman is consultant physicist at Guys and St Tomas�s and he presented at the NHA last month some research on accuracy of automatic monitors, mercury and anaeroids. And still anaeroids are failing �interestingly the validated automatic monitors were more accurate than the mercury sphygs. Dr C is in the process of developing independent calibration equipment which can be used on all monitors . He hopes this will be available from January and he promises to get in touch �we�ll put him in touch with you

12. MHRA Blood pressure 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 Slide10 Although used less and less the mercury sphygs are still the gold standard as a machine that�s inexpensive and will take everybody�s blood pressure whatever size arm they�ve got. It�s been in use for over 100 years� We cannot discard them yet �The reasons you cannot discard them are these� �1.��� Automatic b.p. monitors do not work with people who have irregular or v.slow heartbeats or a tremor. 2.��� There are occasions when automatic monitors don�t work; there�s no apparent reason for this. Calibration: Mercury sphygs should be cleaned and calibrated yearly. Automated monitors they�ve been WENDY WRITE THIS . DrAndrew Coleman is consultant physicist at Guys and St Tomas�s and he presented at the NHA last month some research on accuracy of automatic monitors, mercury and anaeroids. And still anaeroids are failing �interestingly the validated automatic monitors were more accurate than the mercury sphygs. Dr C is in the process of developing independent calibration equipment which can be used on all monitors . He hopes this will be available from January and he promises to get in touch �we�ll put him in touch with you Slide10 Although used less and less the mercury sphygs are still the gold standard as a machine that�s inexpensive and will take everybody�s blood pressure whatever size arm they�ve got. It�s been in use for over 100 years� We cannot discard them yet �The reasons you cannot discard them are these� �1.��� Automatic b.p. monitors do not work with people who have irregular or v.slow heartbeats or a tremor. 2.��� There are occasions when automatic monitors don�t work; there�s no apparent reason for this. Calibration: Mercury sphygs should be cleaned and calibrated yearly. Automated monitors they�ve been WENDY WRITE THIS . DrAndrew Coleman is consultant physicist at Guys and St Tomas�s and he presented at the NHA last month some research on accuracy of automatic monitors, mercury and anaeroids. And still anaeroids are failing �interestingly the validated automatic monitors were more accurate than the mercury sphygs. Dr C is in the process of developing independent calibration equipment which can be used on all monitors . He hopes this will be available from January and he promises to get in touch �we�ll put him in touch with you

13. Examples of recommended blood pressure monitors. Mercury sphygmomanometers � (gold standard). Greenlight 300 (accoson) Independently validated automated upper arm devices Consider MANDAUS 11 for community use (available BHS website) Slide 22 �Aneroid Monitors Hold up aneroid- This device uses a mercury-free guage and it has been shown in numerous studies to lose its accuracy over a short period of time. We were at a scientific meeting 5 years ago �Bradford District Nurses all used the anaeroids because they did not want to carry mercury in their cars. The Senior Nurse who carried out the study was questioning the measurement and calibration of aneroid devices. The findings were that over 600 devices were looked at and over half had not been calibrated. Also 40% of these devices were inaccurate and had to be replaced immediately. Do not fall for the advertising Always check with the BHS Website (A medical equipment catalogue says that Primus Stabil 3 has A level rating in BHS protocol testing. The catalogue company could not give me any information about this validation-in fact said it was company policy not to give out this information. I could not recommend this product without checking how well the validation had been conducted. It was a Russian study) Wrist Monitors Another popular device. This simply fits around the pt�s wrist, they press a button and it records a blood pressure. Many people buy these for home use because they�re reasonably cheap and comfortable to use. So what�s wrong with them? The position of the wrist is critical and you can get vastly differing readings. The new BHS guidelines do not recommend the use of wrist monitors� �� Finger Monitors are similar to the wrist monitors but make the readings even more distorted. � � � Slide 22 �Aneroid Monitors Hold up aneroid- This device uses a mercury-free guage and it has been shown in numerous studies to lose its accuracy over a short period of time. We were at a scientific meeting 5 years ago �Bradford District Nurses all used the anaeroids because they did not want to carry mercury in their cars. The Senior Nurse who carried out the study was questioning the measurement and calibration of aneroid devices. The findings were that over 600 devices were looked at and over half had not been calibrated. Also 40% of these devices were inaccurate and had to be replaced immediately. Do not fall for the advertising Always check with the BHS Website (A medical equipment catalogue says that Primus Stabil 3 has A level rating in BHS protocol testing. The catalogue company could not give me any information about this validation-in fact said it was company policy not to give out this information. I could not recommend this product without checking how well the validation had been conducted. It was a Russian study) Wrist Monitors Another popular device. This simply fits around the pt�s wrist, they press a button and it records a blood pressure. Many people buy these for home use because they�re reasonably cheap and comfortable to use. So what�s wrong with them? The position of the wrist is critical and you can get vastly differing readings. The new BHS guidelines do not recommend the use of wrist monitors� �� Finger Monitors are similar to the wrist monitors but make the readings even more distorted. � � �

14. Blood pressure measurementMyths, Facts & Legends

15. Slide 9 Q 2 : what size cuff? Eg. Home monitors with wrong size cuff Slide 9 Q 2 : what size cuff? Eg. Home monitors with wrong size cuff

16. Slide 10 Q 3 : too tight clothing Slide 10 Q 3 : too tight clothing

17. Slide 11 Q4 : where should a sphygmomanometer be positioned? Possibly Show mercury sphyg Slide 11 Q4 : where should a sphygmomanometer be positioned? Possibly Show mercury sphyg

18. Slide 8 Q1 : how do you position the arm? 1. When recording a blood pressure to increase accuracy the arm should be positioned a.����������������� Relaxed with the arm resting by side b.����������������� Well supported at shoulder height c.����������������� Well supported at heart level � Slide 8 Q1 : how do you position the arm? 1. When recording a blood pressure to increase accuracy the arm should be positioned a.����������������� Relaxed with the arm resting by side b.����������������� Well supported at shoulder height c.����������������� Well supported at heart level �

19. slide 12 Q 5 At what rate should the cuff be deflated on a mercury sphygmomanometer? ANSWER: A 2mm/Hg per secondslide 12 Q 5 At what rate should the cuff be deflated on a mercury sphygmomanometer? ANSWER: A 2mm/Hg per second

20. Slide 13 Q6: ANSWER C BP should be recorded to the nearest 2mm/Hg on mercury sphygmomanometerSlide 13 Q6: ANSWER C BP should be recorded to the nearest 2mm/Hg on mercury sphygmomanometer

21. Slide 14: Question 5 - Korotkoff sounds. If sounds go to zero, record sound changes (K4) and document K4 in notesSlide 14: Question 5 - Korotkoff sounds. If sounds go to zero, record sound changes (K4) and document K4 in notes

22. Measuring Blood Pressure Measure in both arms on 1st visit, always record in the highest arm thereafter. Consider standing BP in over 65, diabetic and those with symptoms of postural hypotension At least 2 measurements (1-2 minutes apart) More readings if >10mmHg difference in systolic If > 5mmHg difference in diastolic Slide 26 TECHNIQUE FOR TAKING BLOOD PRESSURE Estimate systolic pressure It�s really important to palpate the pulse to avoid missing auscualtory gap.� In a study of 169 patients 21% had ausculatory gap. (Cited in NICE Aug 2004) And therefore could underestimate BP cos not going above gap to find phase 1. Inflate cuff 20-30 mmHg. Above estimated systolic (BP technique from NICE-palpate cuff to 20mmhg mercury above estimatedsystolic pressure) Deflate 2-3 mmHg. per second or pulse beat Record systolic pressure � phase 1-when repetitive tapping sounds are heard. Ausculatory gap answer- take systolic when first clear tapping sounds are made.At least 2 sounds to be heard.. still record phase 1 when first tapping sounds occur. phase 2= softer sound or swish can disappear together then call ausculatory gap this is phase 2. Diastolic pressure-when sounds disappear (phase 5) Slide 26 TECHNIQUE FOR TAKING BLOOD PRESSURE Estimate systolic pressure It�s really important to palpate the pulse to avoid missing auscualtory gap.� In a study of 169 patients 21% had ausculatory gap. (Cited in NICE Aug 2004) And therefore could underestimate BP cos not going above gap to find phase 1. Inflate cuff 20-30 mmHg. Above estimated systolic (BP technique from NICE-palpate cuff to 20mmhg mercury above estimatedsystolic pressure) Deflate 2-3 mmHg. per second or pulse beat Record systolic pressure � phase 1-when repetitive tapping sounds are heard. Ausculatory gap answer- take systolic when first clear tapping sounds are made.At least 2 sounds to be heard.. still record phase 1 when first tapping sounds occur. phase 2= softer sound or swish can disappear together then call ausculatory gap this is phase 2. Diastolic pressure-when sounds disappear (phase 5)

23. Slide 28 BHS Measure every 5 years all adults up to 80 years Measure annually those high normal (130-139 or 85-89) and anyone noted to have high readings at any time Slide 18 Confirmation of hypertension If BP high �repeat monthly over 4-6 months. (Unless BP very high, then measure more frequently) Do not treat on the basis of an isolated reading NICE BP confirmation If Initial BP > 140/90 repeat monthly for 2 months Slide 28 BHS Measure every 5 years all adults up to 80 years Measure annually those high normal (130-139 or 85-89) and anyone noted to have high readings at any time Slide 18 Confirmation of hypertension If BP high �repeat monthly over 4-6 months. (Unless BP very high, then measure more frequently) Do not treat on the basis of an isolated reading NICE BP confirmation If Initial BP > 140/90 repeat monthly for 2 months

24. BHS Guidelines Definitions Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring SLIDE 33 Emma to do this ..MenuSLIDE 33 Emma to do this ..Menu

25. Slide 34 Mr Big needs routine IX �..these tests help identify diabetes, evidence of hypertensive damage to the heart and kidneys, and secondary causes of hypertension such as kidney disease The routine investigations recommended are Urine for protein and blood. Positive result identifies patients with possible kidney damage needing further investigation Creatinine and electrolytes.- a raised creatinine may indicate renal disease or renovascular hypertension. A creatinine that rises significantly, shortly after starting an ACE-I may indicate renovascular disease. A Low potassium may indicate renovascular disease or may be due to hyperaldosteronism (conns is the other name for that) Blood glucose to check for diabetes or cushings syndrome. Cholesterol profile is used to assess cardiovascular risk. To assess risk use Total cholesterol:HDL ratio. Using new risk assessment charts. If ECG-to identify left ventricular hypertrophy or other abnormalities You�ll be pleased to know these guidelines are the same for both NICE & BHSSlide 34 Mr Big needs routine IX �..these tests help identify diabetes, evidence of hypertensive damage to the heart and kidneys, and secondary causes of hypertension such as kidney disease The routine investigations recommended are Urine for protein and blood. Positive result identifies patients with possible kidney damage needing further investigation Creatinine and electrolytes.- a raised creatinine may indicate renal disease or renovascular hypertension. A creatinine that rises significantly, shortly after starting an ACE-I may indicate renovascular disease. A Low potassium may indicate renovascular disease or may be due to hyperaldosteronism (conns is the other name for that) Blood glucose to check for diabetes or cushings syndrome. Cholesterol profile is used to assess cardiovascular risk. To assess risk use Total cholesterol:HDL ratio. Using new risk assessment charts. If ECG-to identify left ventricular hypertrophy or other abnormalities You�ll be pleased to know these guidelines are the same for both NICE & BHS

26. Evaluation of hypertensive patients Causes of hypertension 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) Slide 35 Evaluation of hypertensive patients Causes of HT �95% pts have essential HT �we don�t know what causes it and so about 5% have sec causes- the Causes of hypertension can be Drugs induced (non-steroidal anti-inflammatory drugs, oral contraceptions, steroids, liquorice, some cold cures) Renal disease (consider this if have present, past or family history, proteinuria or haematuria: palpable kidney(s) � polycystic, hydronephrosis, or neoplasm) Renovascular disease (consider if have abdominal or loin bruit) Phaeochromocytoma (consider if have paroxysmal symptoms) Conn�s syndrome (consider if they have tetany, muscle weakness, polyuria, hypokalaemia) Coarctation of the aorta (consider if they have radio-femoral delay or weak femoral pulses) Cushing�s syndrome (consider by general appearance) Are any causing this man�s HT� Identifiable causes are more likely when hypertension suddenly worsen, or presents as accelerated (or malignant) HT. That is BP>180/110 with papilloedema and/or retinal haemorrhage Or the patient is aged under 30 Or the BP not responding to treatmentJill. Mr Big has had his risk factors his bp is terribly high, he may have �95% pts have essential HT but the other 5% could have sec causes-list them Are any causing this man�s HT�Slide 35 Evaluation of hypertensive patients Causes of HT �95% pts have essential HT �we don�t know what causes it and so about 5% have sec causes- the Causes of hypertension can be Drugs induced (non-steroidal anti-inflammatory drugs, oral contraceptions, steroids, liquorice, some cold cures) Renal disease (consider this if have present, past or family history, proteinuria or haematuria: palpable kidney(s) � polycystic, hydronephrosis, or neoplasm) Renovascular disease (consider if have abdominal or loin bruit) Phaeochromocytoma (consider if have paroxysmal symptoms) Conn�s syndrome (consider if they have tetany, muscle weakness, polyuria, hypokalaemia) Coarctation of the aorta (consider if they have radio-femoral delay or weak femoral pulses) Cushing�s syndrome (consider by general appearance) Are any causing this man�s HT� Identifiable causes are more likely when hypertension suddenly worsen, or presents as accelerated (or malignant) HT. That is BP>180/110 with papilloedema and/or retinal haemorrhage Or the patient is aged under 30 Or the BP not responding to treatmentJill. Mr Big has had his risk factors his bp is terribly high, he may have �95% pts have essential HT but the other 5% could have sec causes-list them Are any causing this man�s HT�

28. Slide 39 suggested indications 1 The BHS recommends that patients in primary care be referred to a specialist centre in the following circumstances When you think urgent treatment is needed patients with accelerated hypertension (that is severe hypertension with grade III-IV retinopathy) If someone has particularly severe hypertension (that is BP >220/120mmHg) if you think complications are imminent(for example, transient ischaemic attack, left ventricular failure) Slide 39 suggested indications 1 The BHS recommends that patients in primary care be referred to a specialist centre in the following circumstances When you think urgent treatment is needed patients with accelerated hypertension (that is severe hypertension with grade III-IV retinopathy) If someone has particularly severe hypertension (that is BP >220/120mmHg) if you think complications are imminent(for example, transient ischaemic attack, left ventricular failure)

29. Slide 40 cont. If you think there�s a possible underlying cause It is recommended you refer patients to a specialist if you think there maybe an underlying cause of ht from any clues in your routine history taking, examination and investigations eg. a patient with a low potassium raised sodium may have conn�s Elevated serum creatinine Proteinuria or haematuria A patient who has sudden onset of hypertension or worsening of hypertension Someone who is on 3 or more drugs with uncontrolled BP Young age (suggest anyone with hypertension aged under 20 ; and anyone needing treatment aged under 30) Slide 40 cont. If you think there�s a possible underlying cause It is recommended you refer patients to a specialist if you think there maybe an underlying cause of ht from any clues in your routine history taking, examination and investigations eg. a patient with a low potassium raised sodium may have conn�s Elevated serum creatinine Proteinuria or haematuria A patient who has sudden onset of hypertension or worsening of hypertension Someone who is on 3 or more drugs with uncontrolled BP Young age (suggest anyone with hypertension aged under 20 ; and anyone needing treatment aged under 30)

30. Slide 41 (cont.) theraputic and special sits Other reasons for referring are patients with therapeutic problems Therapeutic problems a patient who is unable to tolerate the various drugs he has tried and you are running out of options a patient who is unable to take the drugs due to multiple contraindications patients you believe are not taking there tablets or who are resistant to taking drugs Then finally those special situations If a patient has unusual blood pressure variability. You know when the blood pressure is always vastly different on each occasion you take it. People who take a lot of alcohol can have widely differing BP in the course of a series of readings-so always worth considering there alcohol intake. Especially if it�s a Monday morning Possible �white coat� hypertension-that is patient feels his BP is only raised when sees DR or nurse Anyone who has hypertension and becomes pregnantSlide 41 (cont.) theraputic and special sits Other reasons for referring are patients with therapeutic problems Therapeutic problems a patient who is unable to tolerate the various drugs he has tried and you are running out of options a patient who is unable to take the drugs due to multiple contraindications patients you believe are not taking there tablets or who are resistant to taking drugs Then finally those special situations If a patient has unusual blood pressure variability. You know when the blood pressure is always vastly different on each occasion you take it. People who take a lot of alcohol can have widely differing BP in the course of a series of readings-so always worth considering there alcohol intake. Especially if it�s a Monday morning Possible �white coat� hypertension-that is patient feels his BP is only raised when sees DR or nurse Anyone who has hypertension and becomes pregnant

31. BHS Guidelines Definitions Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring Slide 39 Menu Everyone has non pharmacological intervention. Lifestyle measures Slide 49 menu We are now going explore what life style changes would be beneficial to Mr Big There are some differences between NICE and BHSSlide 39 Menu Everyone has non pharmacological intervention. Lifestyle measures Slide 49 menu We are now going explore what life style changes would be beneficial to Mr Big There are some differences between NICE and BHS

32. Slide 15: Question 7 -Stopping smoking reduces high blood pressure -true or false? A true B false Answer A smoking. Smoking is one of the contributory factors for cardiovascular disease � telling someone that stopping smoking will bring the bp down is misleading Slide 15: Question 7 -Stopping smoking reduces high blood pressure -true or false? A true B false Answer A smoking. Smoking is one of the contributory factors for cardiovascular disease � telling someone that stopping smoking will bring the bp down is misleading

33. Slide 51 Lifestyle interventionThis table is in the British Hy Guidelines It shows what level of Bp reduction can be expected with lifestyle changes eg . If Mr Big could do 30mins exercise a day he could reduce his systolic bp by 4 to 9 mmHg. Slide 51 (new slide added 10.3.5) Lifestyle intervention for systolic BP reduction This table can be found in the BHS guidelines It shows what level of systolic BP reduction can be expected with life stle changes Slide 51 Lifestyle interventionThis table is in the British Hy Guidelines It shows what level of Bp reduction can be expected with lifestyle changes eg . If Mr Big could do 30mins exercise a day he could reduce his systolic bp by 4 to 9 mmHg. Slide 51 (new slide added 10.3.5) Lifestyle intervention for systolic BP reduction This table can be found in the BHS guidelines It shows what level of systolic BP reduction can be expected with life stle changes

34. BHS Guidelines Definitions Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring Slide 39 Menu Everyone has non pharmacological intervention. Lifestyle measures Slide 49 menu We are now going explore what life style changes would be beneficial to Mr Big There are some differences between NICE and BHSSlide 39 Menu Everyone has non pharmacological intervention. Lifestyle measures Slide 49 menu We are now going explore what life style changes would be beneficial to Mr Big There are some differences between NICE and BHS

35. 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 Slide 63 What are you going to say to him? Suggested measurement Not �set in stone� expert opinion Slide 63 Home BP monitoring is becoming more and more popular so the BHS experts have come up with some advice for us. Mr Big needs to use a validated well maintained monitor. Warn him they can be inaccurate and home monitoring is additional information and does not take the place of monitoring by a health professional. Example my patient who took own bp didn�t get it checked had a stroke because monitor was under reading. Mr Big will need to buy a large cuff for accurate measurement As wendy said Wrist monitors are not recommended Suggested measurement routine for patientsAsk Mr Big to Measure his BP for 7 days prior to appointment Ask him to record it twice a day. Morning and evening You should discard the first 24 hours of readings Then Take an average of at least 12 of the remaining readingsSlide 63 What are you going to say to him? Suggested measurement Not �set in stone� expert opinion Slide 63 Home BP monitoring is becoming more and more popular so the BHS experts have come up with some advice for us. Mr Big needs to use a validated well maintained monitor. Warn him they can be inaccurate and home monitoring is additional information and does not take the place of monitoring by a health professional. Example my patient who took own bp didn�t get it checked had a stroke because monitor was under reading. Mr Big will need to buy a large cuff for accurate measurement As wendy said Wrist monitors are not recommended Suggested measurement routine for patientsAsk Mr Big to Measure his BP for 7 days prior to appointment Ask him to record it twice a day. Morning and evening You should discard the first 24 hours of readings Then Take an average of at least 12 of the remaining readings

36. Slide 64 indications for ABPM- when is it a sensible idea? The BHS also recognises that Ambulatory blood pressure monitoring can help in treatment decisions and have suggested when it maybe useful If you suspect someone has �white coat� hypertension - that is, there BP goes up when they see a Dr or nurse In Treatment decisions- When your trying to make a decision on whether to start stop or increase drug treatment Assist in evaluation of Nocturnal hypertension - BP should go down at night, if it remains high day and night the patient is more at risk of target organ damage efficacy of treatment-ensuring that the drugs are keeping the BP low over the full 24 hrs 24 hour observation of blood pressure for patients with symptomatic hypotension assessment of patients whose BP that has a large variability In the Diagnosis & treatment of hypertension in pregnancy It can help in the evaluation of drug resistant hypertension This additional 24 hour BP information can help the patient see that drug treatment is a sensible optionSlide 64 indications for ABPM- when is it a sensible idea? The BHS also recognises that Ambulatory blood pressure monitoring can help in treatment decisions and have suggested when it maybe useful If you suspect someone has �white coat� hypertension - that is, there BP goes up when they see a Dr or nurse In Treatment decisions- When your trying to make a decision on whether to start stop or increase drug treatment Assist in evaluation of Nocturnal hypertension - BP should go down at night, if it remains high day and night the patient is more at risk of target organ damage efficacy of treatment-ensuring that the drugs are keeping the BP low over the full 24 hrs 24 hour observation of blood pressure for patients with symptomatic hypotension assessment of patients whose BP that has a large variability In the Diagnosis & treatment of hypertension in pregnancy It can help in the evaluation of drug resistant hypertension This additional 24 hour BP information can help the patient see that drug treatment is a sensible option

37. 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. Slide 65 Interpreting results NICE don�t recommend ABPM for primary care. Both the BHS and NICE agree that ABPM and home readings need to be adjusted to represent clinic readings. All research morbidity and mortality have been based on clinic readings which is why they need to be adjusted as follows: They recommend adding 10/5 mmHg to average daytime pressure. e.g. day-time average pressure = 158/89 add 10/5 adjusted reading = 168/94 They say that Home readings of less than 130/85 can probably be considered normal.Slide 65 Interpreting results NICE don�t recommend ABPM for primary care. Both the BHS and NICE agree that ABPM and home readings need to be adjusted to represent clinic readings. All research morbidity and mortality have been based on clinic readings which is why they need to be adjusted as follows: They recommend adding 10/5 mmHg to average daytime pressure. e.g. day-time average pressure = 158/89 add 10/5 adjusted reading = 168/94 They say that Home readings of less than 130/85 can probably be considered normal.

38. 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 Slide 67 Closure�.blah Thank you for listening�Slide 67 Closure�.blah Thank you for listening�