Hypertension Martine Butters Clinical Trainer martine buttersnottinghamcitycare nhs

Hypertension Martine Butters Clinical Trainer martine. butters@nottinghamcitycare. nhs. uk

Outcomes n To understand the significance of hypertension and the importance of NICE Guidelines Hypertension: an interactive workshop for HCAs

Blood Pressure (BP) n n n Blood pressure is the pressure against the walls of the arteries as blood is pumped around your body by your heart. As the heart pumps the blood out, the pressure is highest and when the heart is filling up again ready for the next pump, the blood pressure is lowest It is measured in millimetres of mercury (mm. Hg) and recorded as Systolic / Diastolic Hypertension: an interactive workshop for HCAs

Blood Pressure n n n Ideally we should have a BP of 120/80 or below Most UK adults have readings in the range of 120/80 to 140/90 According to NHS CHOICES, normal BP is between 90/60 and 140/90 Hypertension: an interactive workshop for HCAs

Blood Pressure n n n NICE (2011) recommend a target of 140/90 or less in uncomplicated adults If BP is 140/90 or more, it requires assessment The 2005 Joint British Societies’ Guidelines on prevention of CVD recommend a BP target of 130/80 or less for people with diabetes, established CVD or chronic renal disease (Diabetes UK 2008) Hypertension: an interactive workshop for HCAs

Hypertension n n n A BP that is persistently higher than normal levels Common condition affecting around a quarter of the UK adult population (H&SCIC 2012/13) A sub group particularly affected is Western Af. Cs’ (PHE 2014) Associated with increased risk of developing disorders including CVD, renal disease & strokes 1 in 3 deaths are from CVD each year Monitoring and patient support is crucial Hypertension: an interactive workshop for HCAs

Hypertension Guidelines Nice guideline 34, August 2011 http: //www. nice. org. uk Ø Adults (aged 18 and over) X People with diabetes X Children and young people X Pregnant women Hypertension: an interactive workshop for HCAs

NICE Guidelines (2011) NICE outline key responsibilities: n Measure blood pressure n Offer lifestyle intervention n Patient education n Pharmacological intervention n Assess CVD risk Hypertension: an interactive workshop for HCAs

Types of hypertension n Primary: most common type, no obvious cause Secondary: underlying causative disorder for example renal disease Malignant Hypertension: an interactive workshop for HCAs

Hypertension q q q Stage 1: Clinic BP is 140/90 or higher and subsequent ABPM or HBPM daytime average BP is 135/85 or higher Stage 2: Clinic BP is 160/100 or higher and subsequent ABPM or HBPM daytime average is 150/95 or higher Severe Hypertension: Clinic systolic BP is 180 or higher or clinic diastolic BP is 110 or higher Hypertension: an interactive workshop for HCAs

Risk factors for Hypertension n n Sometimes doesn’t have a clear cause Age Lifestyle Family History/Genetics Ethnic Group Adrenal problems Thyroid problems Diabetes CKD (Secondary Hypertension) Medications: OCP, Mental Health Drugs, Recreational Drugs Hypertension: an interactive workshop for HCAs

Symptoms n n n Is very often a silent condition that shows no symptoms Usually only get symptoms when the strain on the arteries leads to more serious problems such as angina, MI, CVA If very high may get: severe headache, confusion, vision problems, chest pain, blood in urine, pounding in chest & neck Hypertension: an interactive workshop for HCAs

Diagnosis If clinic BP is 140/90 or higher, take a second measurement during the consultation n If the second measurement is substantially different from the first, take a third n Record the lower of the last two measurements as the clinic BP (NICE 2011) n Aim is for clinic BP to below 140/90 (under 80) 150/90 (80 or over) n Hypertension: an interactive workshop for HCAs

Diagnosis n n n If BP 140/90 or higher offer ABPM to confirm the diagnosis of hypertension Ensure that at least 2 measurements per hour are taken during the person’s usual waking hours Use the average value of at least 14 measurements to confirm the diagnosis Hypertension: an interactive workshop for HCAs

Intervention: measure BP by HBPM n n If unable to tolerate ABPM offer HBPM For each BP recording, 2 consecutive measurements are taken at least 1 minute apart & with the person seated n Recorded twice daily, ideally morning & evening n n Recording continues for at least 4 days, ideally 7 Discard measurements taken on 1 st day & use the average value of all the remaining measurements to confirm diagnosis NICE clinical guideline 127, August 2011 Hypertension: an interactive workshop for HCAs

NICE CG 127 Aug 2011 Hypertension: an interactive workshop for HCAs

Health Check If confirmed hypertension offer; q Urine test for protein, send a sample for albumin: creatinine ratio q Reagent strip for haematuria q A 12 -lead ECG q Blood Test; Glucose, U/ES, e. GFR, Lipids, FBC q Examine fundi for hypertensive retinopathy q People aged under 40 with Stage 1 Hpt consider seeking specialist referral (causes & target organ damage) Hypertension: an interactive workshop for HCAs

Severe Hypertension n Consider starting antihypertensive therapy without waiting for ABPM/HBPM results May need immediate Specialist referral Whilst waiting for a diagnosis, carry out investigations for target organ damage and formal CVD risk Hypertension: an interactive workshop for HCAs

Afro-Caribbeans’ q q q Hpt is the leading cause of death & disability in Western Af. Cs’ Genetic link Sensitivity of BP to salt intake is often increased and as the inability to excrete ingested salt is impaired, leads to an expansion of intravascular volume Also tend to show low plasma renin levels, reason uncertain but maybe related to renal/sodium handling and reduced sympathetic nervous activity Dietary salt restriction Hypertension: an interactive workshop for HCAs

Malignant Hypertension

Malignant Hypertension n n n Very high BP Comes on suddenly Diastolic is often above 120 mm. Hg Commoner in young black males Collagen Vascular problems Kidney problems Toxaemia of pregnancy Hypertension: an interactive workshop for HCAs

Symptoms n n n Blurred Vision Confusion Chest pain Headache Reduced Urine output Epistaxis TREAT IMMEDIATELY Hypertension: an interactive workshop for HCAs

Lifestyle

Intervention: lifestyle change n n n Diet Exercise Alcohol Smoking Local initiatives Relaxation Hypertension: an interactive workshop for HCAs

Hypertensive Medication

NICE CG 127 Aug 2011 Hypertension: an interactive workshop for HCAs

Afro-Caribbean's & Medication q q q ACE inhibitors act in part via the renin-angiotensin system by decreasing renin release from the kidney. As Af. Cs tend to have low renin, volume expansion hypertension, this type of drug less effective, particularly as monotherapy CCBs recommended as first line treatment. CCBs tend to provide more protection against stroke Hypertension: an interactive workshop for HCAs

Medications n n The use of monotherapy is not always effective Add in a different class of drug rather than increasing initial drug dose Hypertension: an interactive workshop for HCAs

ACE inhibitors How do they work? Possible side effects Other information Lower BP by relaxing blood vessels help to improve blood flow to the heart Fall in BP Skin rash Persistent dry cough Effect on kidneys Major allergic reaction On starting, BP will be checked regularly. U&E checked regularly Eg. Ramipril , Enalapril, Perindopril, Lisinopril Hypertension: an interactive workshop for HCAs

Angiotensin II Antagonists How do they work? Possible side effects Other information In a similar way to ACE inhibitors Dizziness U&E checked regularly Eg. Losartan, Valstartan, Candesartan, Irbesartan Hypertension: an interactive workshop for HCAs

Beta-Blockers, Alpha-Blockers How do they work? Prevent the heart from beating as quickly & forcefully as usual Possible side effects Tiredness Cold hand & feet Vivid dreams Nausea, diarrhoea Skin rash Impotence Dizziness Eg. Atenolol, Metoprolol, Bisoprolol Doxazosin, Prazosin Hypertension: an interactive workshop for HCAs Other information Do not stop taking suddenly without medical advice Titrate to max dose tolerated Care with patients with asthma or wheezing

Calcium Channel Blockers How do they work? Help to relax and widen the arteries Possible side effects Flushing Headache Tiredness Swelling of the ankles Indigestion Constipation Eg. Amlodipine, Felodipine, Diltiazem, Nifedipine Hypertension: an interactive workshop for HCAs Other information Should not be routinely used for secondary prevention

Diuretics How do they work? Possible side effects Other information Lower BP by increasing the output of salt and water in the urine Gout may be made worse Patients with diabetes may find medication increases blood sugar Avoid salty foods and don’t add salt to food. Regular U&E May need potassium supplements Eg. Bendroflumethiazide, Chlortalidone Hypertension: an interactive workshop for HCAs

Medication Compliance

Poor Compliance n n n Insufficient pt education about the illness & low motivation to receive any treatment Complexity of treatment Adverse effects Often an asymptomatic condition Prescription costs Personal health beliefs Hypertension: an interactive workshop for HCAs

Action n n n Communication is paramount Refer to local Pharmacist Refer to Medicines Management Team Offer blister packs/dossette box Check meds i. e. packaging Suggest patients record their medication taking Simplifying the dosing regime Hypertension: an interactive workshop for HCAs

Patient Education

Patient Education n n Good communication skills Assess literacy skills ‘Tailor made’ for the patient Literature review Support Groups Hypertension: an interactive workshop for HCAs

Cardiovascular Disease

Detecting risk factors: CVD n n n Cardiovascular risk important in relation to Hpt More than 1 in 3 deaths from CVD every year Majority are potentially preventable Can affect heart, brain, lower limbs Focus on patients with established disease Find others who are ‘at risk’ Hypertension: an interactive workshop for HCAs

Risk Factors for Coronary Heart Disease Non-modifiable q Hypertension n Family history (males <55 females <60) immediate family n Gender – more common in men (women catch up after menopause) n n n Age Ethnicity High cholesterol levels Diabetes Hypothyroidism Hypertension: an interactive workshop for HCAs Modifiable q n n n Hypertension Smoking Low physical activity Obesity Diet High blood pressure Stress

Intervention: assess CVD risk n n n n Medical history Physical examination Family history Urine test for blood, sample for albumin: creatinine ratio Blood tests: Lipids, Plasma glucose, U&E, FBC, TFTs , Creatinine, e. GFR 12 – lead ECG Formally assess CVD risk using a formal risk prediction tool Hypertension: an interactive workshop for HCAs

Intervention: assess CVD risk Hypertension: an interactive workshop for HCAs

Intervention: assess risk n n n ü o o Framingham Heart Study: 5000 men and women aged 30– 62 followed up from 1971 Limitations – no account of family history / ethnicity Visual aid may be helpful to some patients QRISK, has the advantages of including ethnicity & family history Only provide an approximate risk None should replace clinical judgement Hypertension: an interactive workshop for HCAs n

White Coat Syndrome

§ § § Cause not fully known Sweating, Tachycardia, Palpitations More common in pregnancy & increasing age Consider ABPM or HBPM in conjunction with clinic monitoring Therapeutic patient relationship Good communication skills Hypertension: an interactive workshop for HCAs

Summary n n n Any questions? Evaluations Thank you for listening Hypertension: an interactive workshop for HCAs

Inspection - Hands n Sweating n Cyanosis (blue tinge to nail bed – peripheral cyanosis) n Pallor (white or pale nail bed) n Clubbing (loss of nail bed angle) Hypertension: an interactive workshop for HCAs 49