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Hypertension

Hypertension. Introduction and care pathways. Hypertension adds to the overall risk of CV disease Jackson R, et al. Lancet 2005; 365: 434-441. 5-year CVD risk (%). Care Pathway. Diagnosing hypertension NICE Guideline CG034 2006 .

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Hypertension

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  1. Hypertension Introduction and care pathways

  2. Hypertension adds to the overall risk of CV diseaseJackson R, et al. Lancet 2005; 365: 434-441 5-year CVD risk (%)

  3. Care Pathway

  4. Diagnosing hypertensionNICE Guideline CG034 2006 • Accurate measurement of BP needs meticulous clinical technique using properly validated and regularly calibrated devices • Several BP measurements are required before hypertension is diagnosed • Ask patients with initial BP >140/90mmHg to return for at least two further visits, normally a month apart • Measure BP twice on each visit under the best possible conditions • Refer patients with signs/symptoms of malignant hypertension immediately (BP>180/110mmHg) • Ambulatory/home monitoring is not currently recommended but may be useful on occasions (e.g. for establishing white-coat hypertension)

  5. Device Bulletin DB2006(03) July 2006 • Ensure that only clinically validated equipment is purchased • Check mercury devices at least annually and aneroid devices at least twice a year • Ensure large and regular cuffs are available • Undercuffing overestimates BP, overcuffing underestimates BP • Don’t discount hypertension because of suspected anxiety • Consider ABPM if >10mmHg discrepancy (systolic) • Measure BP in both arms initially and use arm with higher values for subsequent readings • Consider referral if >20mmHg (systolic) or >10mmHg (diastolic) difference between arms

  6. Device Bulletin DB2006(03) July 2006 • Ensure arm is supported, with cuff at the level of the heart • Measure BP at the same time of day if practically possible • Remember average daytime ABPM are approx 10/5mmHg less than surgery measurements • Remember the “white coat effect” • Remember BP variability is large • It can vary from the mean by a standard deviation of 12/8mmHg in the same patient on different days • Measurement of BP by any method is less reliable in the presence of arrhythmias such as atrial fibrillation

  7. Hypertension guidelines: thresholds NICE and JBS-2NICE Guidelines 2002, 2004 and 2006; JBS-2 2005

  8. Hypertension guidelines: targets NICE and BHS-IVNICE Guidelines 2002, 2004 and 2006; JBS-2 2005

  9. The HOT studyHansson L, et al. Lancet 1998; 351: 1755-1762 Major CV events All MIs “The principal results of the HOT Study demonstrate the benefits of lowering blood pressure in patients with hypertension to 140mmHg systolic and 85mmHg diastolic, or lower. Efforts to lower blood pressure further, down to 120mmHg systolic and 70mmHg diastolic, appear to give little further benefit, but do not cause any significant additional risk.” All stroke CV mortality

  10. Diet and lifestyle

  11. Effect for lifestyle interventions

  12. The three steps to hypertension heaven™ • Does the patient really need to use drug therapy? • check the sphyg and your technique • do several readings on different occasions • review all potential drug causes and try non-drug therapies first (unless the BP is really high) • attend to other risk factors e.g. smoking, lipids, etc. • If you do need to treat, getting the pressure down is more important than worrying too much about which drugs to use • thiazides are still first choice for most people, CCBs and Ace-Is are first choice for some people, ß-blockers should not routinely be used first-line, doxazosin is first choice for almost no-one • choose agent(s) according to the individual (e.g. ACEI in heart failure) • think about switching drug classes if you don’t get a response • Treat the patient, not the blood pressure • compliance is important – a drug that is not taken will not work • remember the U-shaped curves in HOT: the potential benefits to be gained from decreasing BP ever further must be weighed against the acceptability to the patient of aggressive therapy with multiple drugs

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