Hypertension?

An evidence based approach to diagnosis and treatment of hypertension

Linda Nazarko Nurse Consultant

North West Healthcare NHS Trust

12th March 2015 LSBU, London

Aims and objectives

To be aware of:

How to define and classify hypertension

How treatment differs in younger and older

adults

How to treat

When to treat

Evidence based guidance

Considerations when managing co-

morbidities

Managing medication

Prevalence hypertension

A quarter middle aged

Half those ages 65 and over

Diabetes doubles risk

Afro-Caribbean and Indian heritage increases risk

Consequences hypertension

2mmhg rise BP = 7 percent rise CHD risk and 10 percent stoke mortality

Managing = 58,000 major CVEs avoided

Lives saved, QOL improved and £97.2 million PA saved

2mmg Hg rise

7 percent rise CHD

risk

10 percent stroke

mortality

What is hypertension?

“A sustained rise in BP above 140/90 mmHg” (NICE, 2011)

Generally three or more readings required to diagnose hypertension

(NICE, 2011: NICE, 2013)

How to diagnose

Classification of hypertension

Stage one is, a clinic measurement of 140/90 mmHg or higher, along with a subsequent ABPM daytime average or HBPM at 135/85 mmHg or higher)

Stage 2 hypertension is, a clinic measurement at 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM of 150/95 mmHg) at any age

Lifestyle interventions

Maintain healthy weight

Exercise & be active

Don’t smoke

Alcohol in moderation

Reduce salt intake

Eat well, limit caffeine

Manage stress

Treatment recommendations

People under 40 stage one hypertension and no target organ damage, cardiovascular disease, diabetes, or renal disease should be evaluated for other secondary causes of hypertension by a specialist.

People under 80 with stage one hypertension and low cardiovascular risk – life style changes and monitor

Treat people under 80 with stage one hypertension and one of the following: target organ damage, cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk equivalent to 20% or more and low cardiovascular risk

Treat people of any age with stage two hypertension -a clinic measurement at 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM of 150/95 mmHg) at any age including over the age of 80.

Key points

Increased focus calcium channel blockers over 55’s, because reduced adverse events and cost-effectiveness.

Thiazide-like diuretics an alternative for those with heart failure, or over 80s who cannot tolerate calcium channel blockers.

When choosing a thiazide-like diuretic, chlorthalidone or indapamide may be more effective than bendro-flumethiazide.

Guide to diagnosis and treatment Aged over 55 years or black person of African or

Caribbean family origin of any age

Step one

Calcium channel blocker (CCB)

(Amlodipine)

Step two

Add ACE inhibitor (ACEiAged over 55 years or black person of African or Caribbean family origin of any age)

(Ramipril, enalapril or lisinipril)

Step three

Add Thiazide type diuretic

(Indapamide)

Step four resistant hypertension

Add further diuretic therapy

Spironolactone 25mg once daily

If not tolerated, C/I or ineffective, consider an alpha blocker (doxazosin) or a beta-blocker (atenolol or bisoprolol).

Consider seeking specialist advice

Diabetes

ACE inhibitors first line

Slow progression of renal complications

Reduce development microalbuminuria DMT2

Reduce insulin resistance

S/E cough- 20 percent affected

Monitor U&Es

Co-morbid conditions

Heart failure – diuretics – BP

Prostatic hypertrophy – tamsulosin

Parkinson’s – BP

Hypotension/overtreatment

Growing recognition dangers over treatment

Postural hypotension – falls, dizziness, reluctance to walk around

Cerebral hypoperfusion

Non compliance leading to overtreatment

Reviewing anti-hypertensives

Golden rule – make one change at a time and weight to see results

But its not always possible to follow this one

Go down steps as you went up

Simplify regimes, maximise each step before going up

Take home messages

Check patient is actually taking medicine

Check taking them as prescribed

Ask about side effects

Remember the Goldilocks rule

Remember that its about the person’s quality

of life not just about blood pressure

Review

Thank you for listening

Any questions?