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Primary care team meeting

Primary care team meeting . Hypertension Dr Som Desilva. What do we need to discuss?. Managing hypertension in surgery New guidance on diagnosis Home BP vs ABP When and what investigations are needed What drug treatments and who should titrate. Also.

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Primary care team meeting

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  1. Primary care team meeting Hypertension Dr Som Desilva

  2. What do we need to discuss? • Managing hypertension in surgery • New guidance on diagnosis • Home BP vs ABP • When and what investigations are needed • What drug treatments and who should titrate

  3. Also • What is best way for titration to take place • If any problems who should Nurse or HCA go to • Monitoring of hypertension • Long term care planning - update

  4. New changes from NICE • Ambulatory blood pressure is suggested as the investigation of choice for all with suspected hypertension. • Home readings are an alternative, if ambulatory cannot be used. • Clinic BP readings are no longer recommended for the diagnosis of hypertension, however they can (and should) be used to monitor responses to treatment.

  5. Hypertension is now defined as This affects who we treat. stage 1 and 2 • Stage 1 hypertension - Think of it as borderline hypertension on ABPM – BP 135-149/85-94 treat only if 10y CVD risk >20% or end organ damage (fundoscopy/ecg/renal) • Stage 2 hypertension - >150/95 – Offer treatment straight away.

  6. What BP should we worry about? 140 -170 90-109 IN CLINIC • IF BP • Repeat during consultation. • If 2nd reading substantially different from 1st, take a 3rd reading. • Record the lower of the last 2 readings. IF still high then arrange 24h BP or home BP monitor

  7. What if BP very high? • When lower of 3 readings of BP >> • ?accelerated hypertension – should consider immediate drug treatment with out waiting for results of home bp/24h bp • Should speak to on-call GP 180/110

  8. What’s treatment? • Lifestyle advice to all – DIET, SMOKING, ALCOHOL & CAFFEINE, EXERCISE • DRUG TREATMENT

  9. WHAT INVESTIGATIONS? • Oncediagnosis has been established • ECG • Bloods –Nice recommends FBC U+E RBS eGFR Total cholesterol&HDL • ACR • Dipstick urine for haematuria • Fundoscopy

  10. I would recommend • TFT - thyroxicosis rare but can cause elevated bp – esp if there is little variation in day and night time blood pressure – (bp is being driven along by secondary cause) • In younger pts -> ie less than 50 consider: Renal U/S with renal artery calibre (NOT BEST FOR RAS BT EASIER THAN RENAL MRA) 24h Urine for catecholamines

  11. 10Y of CARDIOLOGY • NEVER FOUND A PHEO – but still looking!!!! • 2 THYROTOXIC PATIENTS • 2 LUNG CANCERS • 3 RENAL TUMOURS • 1 HYDRONEPHROSIS • 1 SECONDARY ADRENAL TUMOUR

  12. How to do ABPM • Ambulatory BP readings (ABPM) • Use a device that measures at least 2 measurements/hour during waking hours. • You need to have at least 14 readings to average. • In the past we added 10/5 to ABPM before making decisions – there is no need to do this now, since the decision flow charts are based on ABPM not clinic readings.

  13. How to do Home BP monitor • Home BP monitoring (HBPM) • Take readings morning & evening for at least 4d, preferably 7d. • On each occasion take 2 readings ≥1min apart, whilst seated. • Discard the first day’s readings, and average the remaining readings.

  14. What drugs • Depends on age and ethnicity • Ace-I >> CCB >> ACE+CCB >>diuretic >> Alpha blocker >> beta blocker >>ARB if not already on >> Methyl dopa

  15. DRUG TREATMENTS Age >55 OR BLACK PERSON Age <55 ACE-I (OR ARB IF ACE NOT TOLERATED) CCB (CALCIUM CHANNEL BLOCKER) ACE-I + CCB Diuretics : Indapamide or chlortalidone NOT bendroflumethiazide ACE-I + CCB + THIAZIDE LIKE DIURETICS ACE-I + CCB + DIURETIC + SPIRONALACOTONE /HIGHER DOSE DIURETIC OR ALPHA BLOCKER OR BETA BLOCKER

  16. When should we titrate up drugs? • Use clinic BP readings to monitor response to treatment. • Ambulatory/home readings can be used in those with known ‘white coat’ hypertension (defined as a discrepancy of >20/10 between clinic and average ambulatory or home readings at time of diagnosis). • Increase drug therapy if these targets are not achieved. • Aim for: • Clinic BP readings of: Ambulatory/home average readings of: • <80y <140/90 <80y <135/85 • >80y <150/90 >80y <145/85

  17. So who and what do we organise? GP s ? Arrange home/abpm Results –who looks at them Suspected bp HCA nurse Investigations – ecg and bloods etc Confirms diag ? Start treatment Monitor bp When stable- 9m fu in bp clinic Up titrate bp

  18. management • What we don’t want is hypertensive patients taking up gp appts for confirmation of diagnosis and titration! • Or do we want pts coming to gp at diagnosis to confirm/agree a management plan – monitored by HCA or nurse over next 6m??

  19. Discuss?? • What about the other clinics – CD clinics now filled up with mixture of diseaseS on different days • DIAB – BE /DJ - try and find Som during week • What about COPD/ASTHMA/IHD/STROKE • HOW ABOUT A GP OF THE WEEK?? • QUERY GOES TO ON CALL GP • GOOD TO SORT OUT WHILE PT IN BUILDING

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