BY DR IJAZ HUSSAIN

AIM

• To discuss with colleagues the recent changes in NICE guide lines for management of Hypertension

• To share mutual knowledge and experiences on the subject.

OBJECTIVE

• After this activity the colleagues will be able to register latest changes in guide lines for management of Hypertension and then apply it in their day to day clinical life.

INTRODUCTION

• This guidance is a partial update of NICE clinical guideline

34 (published June 2006) and will replace it. NICE clinical

guideline 34 partially updated and replaced NICE clinical

guideline 18 (published August 2004).

• In this update new recommendations have been added on

blood pressure measurement, the use of ambulatory and

home blood pressure monitoring, blood pressure targets

and antihypertensive drug treatment.

• High blood pressure (hypertension) is one of the most important

preventable causes of premature morbidity and mortality in the UK.

Hypertension is a major risk factor for

– Stroke (ischaemic and haemorrhagic)

– Myocardial infarction

– Heart failure

– Chronic kidney disease

– Cognitive decline

– Premature death

• Untreated hypertension is usually associated with progressive rise in blood

pressure. The vascular and renal damage that may cause treatment-

resistant state.

INTRODUCTION

MOST IMP MODIFIABLE RISK FACTOR

• coronary heart disease (the leading cause of death in North America)

• Stroke (the third leading cause)• Congestive heart failure• End-Stage renal disease• Peripheral vascular disease.

BACKGROUND

• 50 million people are affected in USA alone• 30 % of the adults are still unaware of their

hypertension• 40 % of the diagnosed Pts are not using

adequate treatment• 67 % of those who are being treated, do not

have their hypertension controlled under 140/ 80 mm Hg.

Q: 52 Years old man seen in hypertension clinic. He was diagnosed around three weeks ago and started on Tab Ramipril. This has been titrated up to 10 mg OD. His blood pressure remains around 156/92 mm Hg. What is most appropriate next step in management.

• Add Bendroflumethiazide• Add Bisoprolol• Switch Ramipril to Prindopril• Add Amlodipine• Add Losartan

KEY POINTS

• Treatment and care should take into account

people’s needs and preferences. People with

hypertension should have the opportunity to

make informed decisions about their care and

treatment, in partnership with their healthcare

professionals. If people do not have the capacity

to make decisions.

KEY POINTS

• Good communication between healthcare professionals and

people with hypertension is essential. It should be supported by

evidence-based written information tailored to the person’s needs.

Treatment, care, and the information being given, should be

culturally appropriate. It should also be accessible to people with

additional needs such as physical, sensory or learning disabilities,

and to people who do not speak or read English.

• If the person agrees, families and care givers should have the

opportunity to be involved in decisions about treatment and care.

DIAGNOSING HYPERTENSION

• If the first and second blood pressure

measurements taken during a consultation are

140/90 mmHg or higher, offer 24-hour

ambulatory blood pressure monitoring (ABPM) to

confirm the diagnosis of hypertension.

• If ambulatory blood pressure monitoring (ABPM)

is not acceptable to the patient then home BP

monitoring is advised

AMBULATORY BLOOD PRESSURE MONITORING (ABPM)

• Blood pressure is measured for a total of 24

hours.

• At least two measurements per hour are taken

during the day (08:00 to 22:00).

• At least one measurement per hour is taken

during the night (22:00 to 08:00).

• Use the average daytime blood pressure

measurement, calculated using a minimum of 14

daytime measurements, to confirm a diagnosis

of hypertension.

When using ABPM to confirm a diagnosis of hypertension, ensure that:

HOME BLOOD PRESSURE MONITORING (HBPM)

• When using home blood pressure monitoring (HBPM) to confirm a

diagnosis of hypertension, ensure that:

• For each blood pressure measurement, two consecutive

measurements are taken, at least 1 minute apart and with the

person seated

• Blood pressure measurements are taken twice daily, ideally in the

morning and evening. Blood pressure measurement continues for

at least 4 days, ideally for 7 days.

• Discard the measurements taken on the first day and use the

average value of all the remaining measurements to confirm a

diagnosis of hypertension.

JNC - VII CLASSIFICATION

• Normal – Systolic lower than 120, diastolic lower than 80

• Pre-hypertension– Systolic 120-139, diastolic 80-90

• Stage 1– Systolic 140-159, diastolic 90-99

• Stage 2– Systolic equal to or more than 160, diastolic equal to or

more than 100

CLASSIFICATION

• Stage 1 hypertension:

Initial clinic blood pressure 140/90 mmHg or higher and

subsequent ambulatory blood pressure monitoring (ABPM)

daytime average or home blood pressure monitoring (HBPM)

average blood pressure 135/85 mmHg or higher.

• Stage 2 hypertension:

Initial clinic blood pressure 160/100 mmHg or higher and

subsequent ABPM daytime average or HBPM average blood

pressure 150/95 mmHg or higher.

• Severe hypertension:

Clinic blood pressure 180/110 mmHg or higher.

DIAGNOSIS PROTOCOL

Clinic BP Reading– If a BP reading is >= 140 / 90 mmHg patients should be

offered ABPM to confirm the diagnosis.

– Patients with a BP reading of >= 180/110 mmHg should be considered for immediate treatment.

Ambulatory blood pressure monitoring (ABPM)– At least 2 measurements per hour during the person’s

usual waking hours (for example, between 08:00 and 22:00)

– Use the average value of at least 14 measurements

DIAGNOSIS PROTOCOL

If ABPM is not tolerated or declined HBPM should be offered.

• For each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated

• BP should be recorded twice daily, ideally in the morning and in the evening

• BP should be recorded for at least 4 days, ideally for 7 days

• Discard the measurements taken on the first day and use the average value of all the remaining measurements

MANAGEMENT PROTOCOLABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)

• Treat if < 80 years of age and any of the following apply; – Target organ damage – Established cardiovascular disease – Renal disease, – Diabetes Mellitus– 10-year cardiovascular risk equivalent to 20% or greater

ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension)

• Offer drug treatment regardless of age

• For patients < 40 years consider specialist referral to exclude secondary causes.

MANAGEMENT PROTOCOL Step 1 treatment

• Patients < 55-years-old: ACE inhibitor (A)• Patients > 55-years-old or of Afro-Caribbean origin: calcium channel blocker

Step 2 treatment

• ACE inhibitor + calcium channel blocker (A + C)

Step 3 treatment

• Add a Thiazide Diuretic (D, i.e. A + C + D)

Note:NICE now advocate using either Chlortalidone (12.5–25.0 mg once daily) or Indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional Thiazide diuretic such as Bendroflumethiazide

MANAGEMENT PROTOCOL NICE define a clinic BP >= 140/90 mmHg after step 3 treatment with

optimal or best tolerated doses as Resistant Hypertension. They suggest step 4 treatment or seeking expert advice

Step 4 treatment

• consider further diuretic treatment, – If potassium < 4.5 mmol/l add Spironolactone 25mg od– If potassium > 4.5 mmol/l add higher-dose Thiazide-like diuretic

treatment• If further diuretic therapy is not tolerated, or is

contraindicated or ineffective, consider an alpha- or beta-blocker

• If BP still not controlled seek specialist advice.

BLOOD PRESSURE TARGET

Clinic BP/ ABPM / HBPM• Age < 80 years140/90 mmHg135/85

mmHg• Age > 80 years150/90 mmHg145/85

mmHg Age < 80 Yrs 140/90 mm Hg

135/85 mm HgAge > 80 Yrs 150/90 mm Hg 145/85 mm Hg

NEW DRUG

• Direct Renin inhibitors e.g. Aliskiren (branded as Rasilez)• by inhibiting renin blocks the conversion of angiotensinogen to

angiotensin I• no trials have looked at mortality data yet. Trials have only investigated

fall in blood pressure. Initial trials suggest aliskiren reduces blood pressure to a similar extent as angiotensin converting enzyme (ACE) inhibitors or angiotensin-II receptor antagonists

• Adverse effects were uncommon in trials although diarrhoea was occasionally seen

Only current role would seem to be in patients who are intolerant of more established antihypertensive drugs