Hypertension John Kedward

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HypertensionJohn Kedward

• BHS IV, 2004 and Update of the NICE Hypertension
  Guideline, 2006
• Guidelines for management of hypertension report
  of the fourth Working Party of the British
  Hypertension Society, 2004 BHS IV
• B Williams et al J Hum Hyp (2004) 18 139-185.
• www.nice.org.uk/CG034NICEguideline

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Hypertension Management of hypertension in adults
in primary care This is a partial update of
NICE clinical guideline 18
Issue date June 2006
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LEARNING NEEDS

• ITEM YOUR NEED Y/N
• BP MEASUREMENT N N N N N
• DIAGNOSIS GRADES Y N N Y Y
• INVESTIGATIONS N Y N Y N
• WHEN TO TREAT Y Y Y Y N
• RISK ASSESS TOOLS Y Y Y Y Y
• FIRST LINE RX Y Y Y Y Y
• ADD IN TREATMENTS Y Y Y Y Y
• TITRATE TO MAX Y Y Y Y Y
• TREAT TARGETS Y Y Y Y Y
• MONITORING TESTS Y Y Y Y Y

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LEARNING NEEDS

• ITEM YOUR NEED Y/N
• ROLE GP/NURSE in Rx Y Y Y Y Y
• ROLE DR/NURSE ADD IN Y Y Y Y Y
• SIDE EFFECTS Y Y Y Y N
• INTERACTIONS Y Y Y Y N
• CONTRAINDICATIONS Y Y Y Y Y
• PRACTICE PROTOCOLS N Y N N Y
• STATINS/ASPIRIN HIGH RISK Y N Y Y Y

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Diagnosis grades classification

• Define hypertension?
• What are the definitions for the different grades
  of hypertension?
• Mild?
• Moderate?
• Severe?

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BHS classification of blood pressure levels
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Investigations

• What investigations should you do routinely in a
  new hypertensive?
• What investigations would you do in patients with
  other symptoms/ signs?
• Which symptoms/ signs?
• Which investigations?

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Routine investigations

• Urine strip test for protein and blood why?
• Serum creatinine and electrolytes why?
• Blood glucose - ideally fasted why?
• Blood lipid profile (at least total and high
  density lipoprotein (HDL) cholesterol) ideally
  fasted for consideration of triglycerides why?
• Electrocardiogram why?

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Secondary Hypertension think!!

• Drugs (non-steroidal anti-inflammatory drugs,
  oral contraceptives, steroids, liquorice,
  sympathomimetics, some cold cures)
• Renal disease (present, past, or family history,
  proteinuria or haematuria palpable
  kidney(s)polycystic, hydronephrosis, or
  neoplasm)
• Reno-vascular disease (abdominal or loin bruit)
  raised creatinine with ACE inhibitors
• Phaeochromocytoma (paroxysmal symptoms) urinary
  VMAs
• Conns syndrome (tetany, muscle weakness,
  polyuria,
• hypokalaemia)
• Coarctation (radio-femoral delay or weak femoral
  pulses), differences in BPs between different
  arms.
• Cushings (general appearance osteoporosis,
  truncal obesity, moon face, purple straie, muscle
  weakness, easy bruising, hirsutism,
  hyperglycaemia, hypokalemia, hyperlidipaedia )

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Potential indications for the use of ambulatory
blood pressure monitoring 

• Unusual variability
• Possible white coat hypertension
• Informing equivocal treatment decisions
• Evaluation of nocturnal hypertension
• Evaluation of drug-resistant hypertension
• Determining the efficacy of treatment over 24 hrs
  
• Diagnoses and Rx of hypertension in pregnancy
• Evaluation of symptomatic hypotension

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When to treat hypertension?

• What factors help you decide when to treat
  hypertension?
• Name five other factors that influence the
  decision to treat?
• Grade of hypertension based on Number of readings
  and the Average of the readings
• 10 year cardiovascular risk over 20
• Signs of renal disease raised creatinine
• Diabetes
• Left ventricular hypertrophy on an ECG
• Cardiovascular complications

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Cardiovascular risk calculator

• NOT Framingham CHD risk
• Use Framingham based Cardiovascular risk
• Tables in back of BNF
• Electronic CVD calculator
• Or, QRISK Calculator (Nottingham)
• Treat all with CVDgt 20 with aspirin, simvastatin
  40mg and BP to target

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Electronic Cardiovascular Risk Calculator
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What is Left Ventricular Hypertrophy?

• Thickening of the left ventricular muscle in
  response to hypertension/ other processes
• There are several sets of criteria used to
  diagnose LVH via electrocardiograph
• None of them are perfect
• The Sokolow-Lyon index
• S in V1 R in V5 or V6 (whichever is larger)
  35 mm
• R in aVL 11 mm
• Other criteria are more complicated but more
  accurate

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How to treat?

• What is first line treatment and how does this
  differ between different patient groups?
• What is added in when first line treatment fails
  to bring to target?
• What about 3rd line treatment?
• 4th line?

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Non Drug Treatments

• Maintain normal weight for adults (BMI 20-25
  kg/m2)
• Reduce salt intake to lt100 mmol/day (lt6g NaCl or
  lt2.4 g Na/day)
• Limit alcohol consumption to ?3 units/day for men
  and ?2 units/day for women
• Engage in regular aerobic physical exercise
  (brisk walking rather than weight lifting) for
  ?30 minutes per day, ideally on most of days of
  the week but at least on three days of the week
• Consume at least five portions/day of fresh fruit
  and vegetables
• Reduce the intake of total and saturated fat

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Titrating to Target

• What are BP targets and do these vary between
  different groups?
• Diabetic target?
• CKD target?
• Other targets?
• How do you increase treatment with ACEI and
  Calcium Channel Blockers?

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Hypertension Treatment Targets
Systolic and diastolic blood pressures should
both be attained, e.g. lt140/85 mmHg means less
than 140 mmHg for systolic blood pressure and
less than 85 mmHg for diastolic blood pressure
  Clinic BP (mmHg) No diabetes Diabetes CKD CKD
Protein Optimal BP lt140/85 lt130/80 lt130/80
lt120/75 Audit Standard lt150/90 lt140/80 lt140/85
lt140/85 QOF TARGETS Audit standard reflects the
minimum recommended levels of blood pressure
control. Despite best practice, the Audit
Standard will not be achievable in all treated
hypertensives. For ambulatory (mean daytime) or
home blood pressure monitoring
- reducing these targets by 10/5 is
recommended.
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Titrating Treatments

• ACEI
• increase in doubling steps every two weeks
• Monitor renal function with each increase
• E.g Ramipril starter pack 2.5, 5, 10mg tabs
• Rapidly rising creatinine and/or unwell patient
  may indicate renal artery stenosis stop ACEI
• Stop increasing if patient has side effects
• In elderly hypotension dizziness more likely,
  especially if already taking diuretic
• ACEI cough develops after several weeks in a
  small percentage of patients

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Titrating Treatments

• Calcium Channel blockers
• Start with lower dose and reassess every 2 weeks
  they work quickly on BP
• Increase in small incremental steps
• Side effects very common at higher doses
  (headaches, flushing, ankle swelling)
• Use once daily dose to improve compliance
  (amlodipine, or MR nifedipine commonly used)
• Diuretics dose is not titrated
• Use bendroflumethiazide 2.5mg

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Other medications for hypertensive
patients Primary prevention (1) Aspirin use 75mg
daily if patient is aged ?50 years with blood
pressure controlled to lt150/90 mm Hg and either
target organ damage, diabetes mellitus, or 10
year risk of cardiovascular disease of ?20
(measured by using the new Joint British
Societies cardiovascular disease risk chart) (2)
Statin use sufficient doses to reach targets if
patient is aged up to at least 80 years, with a
10 year risk of cardiovascular disease of ?20
(measured by using the new Joint British
Societies cardiovascular disease risk chart) and
with total cholesterol concentration
?3.5mmol/l (3) Vitaminsno benefit shown, do not
prescribe
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Other medications for hypertensive patients

• Secondary prevention
• (including patients with type 2 diabetes)
• Aspirin use for all patients unless
  contraindicated
• (2) Statin use sufficient doses to reach targets
  if patient is aged up to at least 80 years with a
  total cholesterol concentration ?3.5 mmol/l
• (3) Vitamins no benefit shown, do not prescribe

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Lipid targets
Targets for lipid lowering in secondary
prevention Ideal - TClt4.0mmol/l or LDL
lt2.0mmol/l or 25 ? in TC or 30 ? in
LDL-C whichever is the greater Audit - TC
lt5.0mmol/l or LDL lt3.0mmol/l or 25 ? in
TC or 30 ? in LDL-C whichever is the greater
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Monitoring Hypertension

• At target a least 6 monthly
• Close to target 3-4 monthly
• Above target until max tolerated therapy see
  monthly
• Renal function at least once yearly

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Role of The Nurse/ Doctor
ITEM NURSE?
Screening, diagnosis, Read code, initial Invest. YES
Interpreting results/ ECG YES WITH TRAINING
Initiating treatment, titrating treatment ONLY WITH CLEAR PROTOCOL
Adding in treatment, monitoring uptitration in ACEI ONLY WITH CLEAR PROTOCOL
Six monthly reviews YES
Primary Prevention Risk Assessment YES
Initiating aspirin/ statin ONLY WITH CLEAR PROTOCOL
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Practice Protocols

• Practices need to develop their own
• Extensive guidance available from Nurse
  Hypertension Association
• http//www.nha.uk.net/

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CKD Chronic Kidney Disease
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100
gt90 abnormality CKD 1
90
80
60-90 abnormality CKD 2
70
60
30-59 CKD 3
50
40
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15-29 CKD 4
20
lt15 or RRT CKD 5
10
eGFR CKD
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How measure (e)GFR

• Clever lab things etc
• Formula MDRD
• creatinine, age, sex, race (black or other)

tables
Online calc
From lab
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3.3
100
gt90 abnormality CKD 1
90
3.0
80
60-90 abnormality CKD 2
70
60
4.3
30-59 CKD 3
50
40
0.2
30
15-29 CKD 4
20
0.2
lt15 or RRT CKD 5
10
prevalence
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Prevalence 2006/7
CKD National prev 2.24 Local prev 1.51
Highest in Bedford 4.75
Eg list size 6000 285 CKD pts
x67
lowest in Bedford 0.07
Work v. points!
Eg list size 6000 4 CKD pts
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Why bother?

• x30 60 higher all cause mortality
• x20 more likely to die from CVD than progress to
  ESRF

90 have BP
10,000 pts 500 have CKD 3-5 (20 stage 4 10
stage 5)
30 have DM
40 have Vasc dis
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Step 1. Find them
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Screen..contd
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Step 2. Make the diagnosis

• 2 readings three months apart
• Use the right READ Codes

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Step 3. sort them out!

• Who do I need to refer?
• Need to know at least
• Blood tests
• Urine examination
• BP

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Referal on basis eGFR
4, 5 ref
5
4
3 /-ref
3
1, 2
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Referal for other reasons
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Urine examination
ve for blood or protein
MSU Exclude infection
ve for protein (more than a trace)
Do PCR
gt100
ve for blood
45-100
mAcro
mIcro
mIcro protein
mIcro NO protein
Ref Renal clinic
Urology 2WR
gt50
lt50
if egfrlt60
Neg?
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Step 4. review medication
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Step 5. sort out BP

• Targets
• With protein 120/75
• (threshold to start Rx is 130/80 if PCR gt100,
  140/90 otherwise)
• Without protein 130/80
• QOF 140/85 !
• Refer if gt150/90 and on 3 antiBP rx

Remember 90 will have hypertension
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Step 6. should they be on ACEi ?

• Yes if proteinuria
• Yes if no protein, as part combination Rx to
  get to target
• Yes if DM and microalbuminura
• No if no protein and already have good BP
  control
• in which case remember Read codes
• 8I64 ACE not indicated
• 8I6C - A2RB not indicated
• BUT dont exempt them from whole CKD domain!!

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Monitoring ACEi

• Check creatinine (eGFR) and K
• Before start medcn
• 2 weeks after starting
• 2 weeks after any dose change
• Watch for creatinine increase gt20,
• eGFR decrease gt15
• If so repeat creatinine, check K, and refer
  for specialist opinion on whether to stop rx or
  to investigate for renal artery stenosis.

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Step 7. minimize cardiovascular risk

• Lifestyle smoke, wt, excse, alc, salt
• BP etc
• If 10 yr CVD risk gt20 consider
• Aspirin if BP lt 150/90
• Lipid lowering drug therapy

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Step 8. follow-up

• Rem. flu pneumo jabs
• Stage 3 chronic disease model
• Check eGFR 6mthly
• (12mthly if stable, ie lt 2ml/min change over 6m)
• Annual check Hb, K, Ca, phosp
• BP
• Stage 4,5 ?shared care
• Check eGFR 3mthly
• (6mthly if stable CKD4)
• ? 3mthly bloods,

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QOF issues

• Prevalence!
• Role of ACEi
• Appropriate use exemption codes
• unsuitable/dissent , max tol, drugs
• Prevalence of co-existing hypertension
• ?likely changes next year

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Resources

• everything you need to know about CKD, eGFR ,
  treatment and referral pathways can be found
  online
• www.renal.org

There is a very good recent update (April 2007)
about CKD and QOF from NHS Employers and the BMA
FAQs for Chronic Kidney Disease (CKD). This
document can be accessed at -
www.pcc.nhs.uk/77.php  
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