CPT1: Hypertension

Question 1

What is hyper tension and what risks is there?

Answer 1

• High BP
• increased risk of stroke, MI, Heart faliure, Chronic Kidney disease, cognitive decline and premature death
• Untreated hypertension can cause vascular and renal damage leading to a treatment resistant state
• Each 2mmHg rise in systolic BP is associated with increased risk of mortality:
  
  • 7% from Heart disease
  • 10% from stroke

Question 2

Describe epidemiology in the UK

Answer 2

• Hypertension is common in the UK population.
• Prevalence influenced by age and lifestyle factors.
• 25% adult population have hypertension.
• 50% over 60 years have hypertension.
• With an ageing population, the prevalence of hypertension and requirement for treatment will continue to increase.

Question 3

What is hypertension

Answer 3

The blood pressure at which it is beneficial to have treatment as the risk of morbidity and mortality are high

Question 4

1. What is primary hypertension referred to as?
2. What % of cases is the cause of hypertension unknown?
3. What % is caused by secondary hypertension (what does this mean)
4. Give examples of secondary hypertensive causes

Answer 4

1. Essential hypertension
2. 95%
3. 5% - secondary to some identifiable causes
4. Renal artery stenosis, endocrine disease

Question 5

Hypertension is a strong link with morbidities. This increases expotnentiall with what risk factors?

Answer 5

• Diabetes, Renal disease
• Smoking, hyperlipidaemia
• Gender, previous MI or Stroke

Question 6

What are factors causing high blood pressure?

Answer 6

1. Atherosclerosis - Plaque formation in the arteries/ blood vessels occludes blood flow and causes narrowing of the arteries. This results in high BP
2. Sodium homeostasis - reduced ability to excrete Na+ leads to increase retainment of Na+ and therefore water. This results in high BP. Decrease of 3g of Na+ intake (50mmols) = Decrease of 5mmHg in BP
3. Na+ intake - increasing Na+ intake increases Na+ and water retneion
4. Age - decreases vascular compliance
5. Alcohol in take
6. Obesity

Question 7

Describe Obesity in relation to hypertension and innervation

Answer 7

• • Obese patients have higher BP
• •30% hypertension attributable to obesity
• In untreated patients, loss of 9 kg = drop of 19/18 mm Hg
• Treated = 30/21 mm Hg
• Single most effective non-pharm intervention

Question 8

Descrbie the different stages of hypertension

Answer 8

• Stage 1:
  
  • Clinical BP is 140/90 mmHg or higher AND HBPM or ABPM is 135/85 mmHg or highrt
• Stage 2:
  
  • Clinical BP is 160/100 mmHg or higher AND HBPM or ABPM is 150/95 mmHg or higher
• Stage 3:
  
  • Clinical BP is 180mmHg or higher OR Clinical diastolic is 110mmHg or higher

HBPM = home BP monitoring

ABPM = Ambulatory BP monitoring

Question 9

What does diagnosis involve?

Answer 9

• If Clinical BP (CBPM) is 140/90 mmHg or higher then offere to ABPM to confirm diagnosis.

Ensure:

• ABPM:
  
  • Taken at least 2 every 1 hour during their usual waking hours. Average of at least 14 measurements to confirm diganosis
• HBPM
  
  • 2 consecutive seated BP measurements at least a minute apart fo at least 4 days and preferably for a week
  • Discard first day measurements
  • Average rest

Question 10

What are routine investigations which should be carried out?

Answer 10

• Urine strip test for protein and blood (renal)
• Serum creatinine and electrolytes
• Blood glucose - ideally fasted (diabetes?)
• Blood lipid profile (at least total and high density lipoprotein (HDL) cholesterol) – ideally fasted for consideration of triglycerides
• Electrocardiogram

Question 11

Discuss the careplan for Stage 1 and 2

Answer 11

Question 12

Describe Antihypertensive drug treatment plan

Answer 12

Step 1 treatment:

• Offer people aged under 55 years step 1 antihypertensive treatment with an angiotensin-converting enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB). If an ACE inhibitor is prescribed and is not tolerated (for example, because of cough), offer a low-cost ARB. [new 2011] [1.6.6]
• Do not combine an ACE inhibitor with an ARB to treat hypertension. [new 2011] [1.6.7]
• Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged over 55 years and to black people of African or Caribbean family origin of any age. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. [new 2011] [1.6.8]
• If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as 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 or hydrochlorothiazide. [new 2011] [1.6.9]
• For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.10]

Related recommendations:

Recommendations 1.6.11 and 1.6.12 have not been updated and reviewed since ‘Hypertension’ (NICE clinical guideline 34, 2006).

Step 2 treatment

• If blood pressure is not controlled by step 1 treatment, offer step 2 treatment with a CCB in combination with either an ACE inhibitor or an *ARB. [new 2011] [1.6.13]
• If a CCB is not suitable for step 2 treatment, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. [new 2011] [1.6.14]
• For black people of African or Caribbean family origin, consider an ARB* in preference to an ACE inhibitor, in combination with a CCB. [new 2011] [1.6.15]

*Choose a low-cost ARB

Additional information: the pathway above focuses on stage 1 and 2 hypertension. For the full care pathway see page 35 of the NICE guideline.

NOTES FOR PRESENTERS. Key priority recommendations are identified with [KPI] in these notes.

Step 3 treatment

• Before considering step 3 treatment, review medication to ensure step 2 treatment is at optimal or best tolerated doses. [new 2011] [1.6.16]
• If treatment with three drugs is required, the combination of ACE inhibitor (or angiotensin-II receptor blocker), calcium-channel blocker and thiazide-like diuretic should be used. [2006] [1.6.17]

Step 4 treatment

• Regard clinic blood pressure that remains higher than 140/90 mmHg after treatment with the optimal or best tolerated doses of an ACE inhibitor or an ARB plus a CCB plus a diuretic as resistant hypertension, and consider adding a fourth antihypertensive drug and/or seeking expert advice. [new 2011] [1.6.18]
• For treatment of resistant hypertension at step 4:
• Consider further diuretic therapy with low-dose spironolactone4 (25 mg once daily) if the blood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia.
• Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5 mmol/l. [new 2011] [1.6.19] [KPI]
• When using further diuretic therapy for resistant hypertension at step 4, monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter. [new 2011] [1.6.20]
• If further diuretic therapy for resistant hypertension at step 4 is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker. [new 2011] [1.6.21]
• If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained. [new 2011] [1.6.22]

Footnotes

(1) Choose a low-cost ARB. (2) A CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has oedema, evidence of heart failure or a high risk of heart failure. (3) Consider a low dose of spironolactone4 or higher doses of a thiazide-like diuretic. (4) At the time of publication (August 2011), spironolactone did not have a UK marketing authorisation for this indication. Informed consent should be obtained and documented. (5) Consider an alpha- or beta-blocker if further diuretic therapy is not tolerated, or is contraindicated or ineffective.

Question 13

What are other medication used for hypertensive patients?

Answer 13

Secondary prevention (including patients with type 2 diabetes)

1. Aspirin: use for all patients unless contraindicated
2. Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years with a total cholesterol concentration _>3.5 mmol/l
3. Vitamins— no benefit shown, do not prescribe

Question 14

What monitoring should be done?

What are the targets?

Answer 14

Clinic blood pressure measurements to monitor response to treatment. Target blood pressures should be below:

• 140/90 mmHg in people aged under 80
• 150/90 mmHg in people aged 80 and over

For people identified as having a ‘white-coat effect’ ABPM or HBPM used as an adjunct to clinic blood pressure measurements.

Aim for ABPM/HBPM target average of:

• Below 135/85 mmHg in people aged under 80
• below 145/85 mmHg in people aged 80 and over.

Question 15

What are Additional reccomendations?

Answer 15

Lifestyle interventions

Offer guidance and advice about:

• diet (including sodium and caffeine intake) and exercise
• alcohol consumption
• smoking.

Patient education and adherence

Provide:

• information about benefits of drugs and side effects
• details of patient organisations
• an annual review of care.