Problem 1: Management of Hypertension Flashcards
Discuss if Anna’s treatment for hypertension is appropriate? NICE guidelines on hypertension
Step 1: angiotensin converting enzyme (ACE) inhibitor or low cost angiotensin II receptor blocker (ARB). (ACEi can cause cough) Do NOT combine ACEi and ARB to treat hypertension.
Offer step 1 with a calcium channel blocker to people aged over 55 years old and to black African or Caribbean family origin of any age. If not appropriate i.e. oedema or intolerance (or evidence of heart failure) then a thiazide-like diuretic.
Recommend chlortalidone or indapamide over bendroflumethiazide or hydrochlorothiazide.
Beta blockers not recommended unless in younger people particularly with an intolerance or contraindication to ACEi or ARB.
Step 2: CCB in combination with ACEi or ARB if step 1 not adequate control. ARB in preference to ACEi in combo with CCB in Caribbean or African patients.
Step 3: before step 3, review medication use in step 2 ensuring it is optimal and at best tolerated doses. Thiazide-like diuretic added if required.
Step 4: Resistant hypertension if above 140/90 mmHg and consider a 4th medication and/or seeking expert advice.
Consider further diuretic therapy with low-dose spironolactone. Consider higher dose thiazide-like diuretics if blood potassium is high. Monitor blood for sodium and potassium and renal function within 1 month.
What is Anna’s target clinical blood pressure?
Aim for a target clinic blood pressure below 140/90 mmHg in people aged under 80 years with treated hypertension
When using ABPM or HBPM to monitor response to treatment (for example, in people identified as having a ‘white coat effect’[5] and people who choose to monitor their blood pressure at home), aim for a target average blood pressure during the person’s usual waking hours of:
below 135/85 mmHg for people aged under 80 years
below 145/85 mmHg for people aged 80 years and over.
Describe why Anna’s ethnicity is so important, when considering treatment for hypertension
Black people tend to develop hypertension at an earlier age, and target organ damage differs from that in white people. The first study to compare the renin-angiotensin system in black and white hypertensive people was done in 1964 and reported that 30% of black people with hypertension had no detectable plasma renin activity. Most but not all subsequent studies have confirmed that renin activity is lower than in white people in both hypertensive and normotensive black people.
Affects treatment used to control blood pressure.
Explain how Anna’s overall cardiovascular risk is calculated
Full formal risk assessment uses QRISK: Use the QRISK2 risk assessment tool to assess cardiovascular disease risk for the primary prevention of cardiovascular disease in people up to and including age 84 years.
Use the QRISK2 risk assessment tool to assess cardiovascular disease risk in people with type 2 diabetes.
Age, sex, ethnicity, smoking status, diabetes, angina heart attack in relatives of 1st degree, AF, CKD, AF, BP treatment, RA, cholesterol measurements, systolic BP, BMI
Explain the lifestyle advice you could offer to Anna to help reduce her blood pressure. Consider how you can tailor your advice to her Carribean diet
Cardioprotective diet: total fat intake is 30% or less of total energy intake, saturated fats 7% or less of total intake and dietary cholesterol intake is less than 300mg/day.
Olive oil, rapeseed oil or spreads based on these oils to use in food preparation.
Wholegrain varieties of starch, intake or sugar reduced, 5 portions of fruits and vegetables, 2 portions of oily fish per week, 4-5 portions of unsalted nuts , seeds, legumes.
Carribean diet: cooking with less saturated fat: better to steam boil poach grill or bake jerk chicken or beef jerky.
Leanest cuts of meat should be used, high fat cuts such as wings, spare ribs etc avoided.
skimmed milk not full fat, low fat yoghurt for cream.
Physical activity: 150 minutes of moderate intensity aerobic activity each week. Muscle strengthening activity on 2 or more day per week.
Lipid measurement and referral
14 units of alcohol in a week; spread rather than binged.
Are there any issues when prescribing amlodipine with her other medications?
Simvastatin 20mg max a day when taken with amlodopine
Discuss whether Anna needs to be on a statin
The decision whether to start statin therapy should be made after an informed discussion between the clinician and the person about the risks and benefits of statin treatment, taking into account additional factors such as potential benefits from lifestyle modifications, informed patient preference, comorbidities, polypharmacy, general frailty and life expectancy.
Include all of the following in the assessment: smoking status, alcohol consumption, blood pressure, body mass index or other measure of obesity, total cholesterol, non‑HDL cholesterol, HDL cholesterol and triglycerides, HbA1c, renal function and eGFR, transaminase level (alanine aminotransferase or aspartate aminotransferase), thyroid‑stimulating hormone
How is hypertension diagnosed in clinic?
If blood pressure measured in the clinic is 140/90 mmHg or higher:
Take a second measurement during the consultation.
If the second measurement is substantially different from the first, take a third measurement.
Record the lower of the last two measurements as the clinic blood pressure.
If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension
What are the stages of hypertension?
Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.
Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.
How should treatment be initiated based on stages of hypertension?
Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following:
target organ damage, established cardiovascular disease, renal disease, diabetes, a 10-year cardiovascular risk equivalent to 20% or greater
Offer antihypertensive drug treatment to people of any age with stage 2 hypertension
For people < 40 y/o with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage.
What are the general guidelines in hypertensive medication prescribing?
Where possible, recommend treatment with drugs taken once a day.
Prescribe non-proprietary drugs to minimise cost.
Offer people aged 80 years and over the same antihypertensives as 55-80 year olds.
Offer antihypertensive drug treatment to women of child-bearing age in line with separate guidelines.
How are people identified for full formal cardiovascular risk assessment?
Prioritize people based on informal estimate of risk, people over 40 years old should have their estimated risk reviewed on a ongoing basis. Prioritze people for a full risk assessment if their 10 year risk of cardiovascular disease is 10% or more.
Full formal risk assessment uses QRISK2
