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HYPERTENSION DEFINITION Hypertension (high BP) is a disease of vascular regulation in which the mechanisms that control arterial pressure

within the normal range are altered. Predominant mechanisms of control are the central nervous system (CNS), the renal pressor system (renin-angiotensin-aldosterone system), and extracellular fluid volume. DEFINITION Hypertension, or high blood pressure (BP), is defined as a persistent systolic blood pressure (SBP) greater than or equal to 140 mm Hg, diastolic blood pressure (DBP) greater than or equal to 90 mm Hg, or current use of antihypertensive medication. There is a direct relationship between hypertension and cardiovascular disease (CVD). Contributing factors to the development of hypertension include cardiovascular risk factors combined with socioeconomic conditions and ethnic differences. Hypertension is generally an asymptomatic condition. Individuals who remain undiagnosed and untreated for hypertension present the greatest challenge and opportunity for health care providers. TYPES OF HYPERTENSION PRIMARY HYPERTENSION SECONDARY HYPERTENSION ACCELERATED HYPERTENSION CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS TO PUT IN WORDS Hypertension is classified as follows: Prehypertension: BP 120 to 139 / 80 to 89 mm Hg Hypertension, Stage 1: BP 140 to 159 / 90 to 99 mm Hg Hypertension, Stage 2: systolic BP greater than or equal to 160 or diastolic BP greater than or equal to 100 mm Hg. PRIMARY HYPERTENSION Also called as Essential Hypertension Approx. 95% of patients Diastolic -- 90 mm of Hg Systolic -- 140 mm of Hg or more CAUSES Idiopathic Hyperactivity of sympathetic vasoconstricting nerves Presence of vasoactive substance on smooth muscle Increased cardiac output, followed by arteriole constriction Excessive dietary sodium intake, sodium retention, insulin resistance, and hyperinsulinemia Familial (genetic) tendency PATHOPHYSIOLOGY OF PRIMARY HYPERTENSION The hemodynamic hallmark of hypertension is persistently increased SVR. Water and sodium retention: A high-sodium intake may activate a number of pressor mechanisms and cause water retention. Altered renin-angiotensin mechanism: High plasma renin activity (PRA) results in the increased conversion of angiotensinogen to angiotensin I causing arteriolar constriction, vascular hypertrophy, and aldosterone secretion. Stress and increased SNS activity: Arterial pressure is influenced by factors such as anger, fear, and pain. Physiologic responses to stress, which are normally protective, may persist to a pathologic degree, resulting in prolonged increase in SNS activity. Increased SNS stimulation produces increased vasoconstriction, increased HR, and increased renin release. Insulin resistance and hyperinsulinemia Abnormalities of glucose, insulin, and lipoprotein metabolism are common in primary hypertension. Additional pressor effects of insulin include vascular hypertrophy and increased renal sodium reabsorption.

Endothelial cell dysfunction: Some hypertensive people have a reduced vasodilator response to nitric oxide. Nitric oxide, an endothelium-derived relaxing factor (EDRF), helps maintain low arterial tone at rest, inhibits growth of the smooth muscle layer, and inhibits platelet aggregation. Endothelin produces pronounced and prolonged vasoconstriction. ISOLATED SYSTOLIC HYPERTENSION Systolic BP elevation in the absence of elevated diastolic BP is termed isolated systolic hypertension SECONDARY HYPERTENSION Occurs in approx. 5% of patients with hypertension Renal pathology: Congenital anomalies, pyelonephritis, renal artery obstruction, acute and chronic glomerulonephritis Reduced blood flow to kidney causes release of renin. Renin reacts with serum protein in liver Coarctation of aorta Endocrine disturbances: Pheochromocytoma Adrenal cortex tumors Cushings syndrome Hyperthyroidism Medications such as estrogens, sympathomimetics, antidepressants, NSAIDs, steroids Consequences of Hypertension Prolonged hypertension damages blood vessels in the brain, eyes, heart, and kidneys and increases the risk of stroke, angina, MI, blindness, and heart and kidney failure Blood vessel damage occurs through arteriosclerosis in which smooth muscle cell proliferation, lipid infiltration, and calcium accumulation occur in the vascular epithelium Damage to heart, brain, eyes, and kidneys is termed target organ disease; this is the major object of prevention in patients with high BP Risk Factors Increase in incidence is associated with the following risk factors : Age:- between 30 and 70 Race:- Black Overweight, sleep apnea Family history Smoking Sedentary lifestyle Diabetes mellitus Metabolic syndrome RESEARCH EVIDENCE Prevalence Black -30% Non-hispanic whites-25% Mexicans-Americans-22% Recent data have shown that only 70% of adults with hypertension are aware of it, 59% receive treatment, and only 34% reach BP control (less than 140/90 mm Hg). CLINICAL MANIFESTATIONS Usually asymptomatic May cause headache, dizziness, blurred vision when greatly elevated BP readings more than 140/90 mm of Hg CLINICAL MANIFESTATIONS OF HYPERTENSION Often called the silent killer because it is frequently asymptomatic until it becomes severe and target organ disease occurs. Target organ diseases occur in the heart (hypertensive heart disease), brain (cerebrovascular disease), peripheral vasculature (peripheral vascular disease), kidney (nephrosclerosis), and eyes (retinal damage). Hypertension is a major risk factor for coronary artery disease (CAD). Sustained high BP increases the cardiac workload and

produces left ventricular hypertrophy (LVH). Progressive LVH, especially in association with CAD, is associated with the development of heart failure Hypertension speeds up the process of atherosclerosis in the peripheral blood vessels, leading to the development of peripheral vascular disease, aortic aneurysm, and aortic dissection. Intermittent claudication (ischemic muscle pain precipitated by activity and relieved with rest) is a classic symptom of peripheral vascular disease involving the arteries. Hypertension is one of the leading causes of end-stage renal disease, especially among African Americans. The earliest manifestation of renal dysfunction is usually nocturia. The retina provides important information about the severity and duration of hypertension. Damage to retinal vessels provides an indication of concurrent vessel damage in the heart, brain, and kidney. Manifestations of severe retinal damage include blurring of vision, retinal hemorrhage, and loss of vision. DIAGNOSTIC EVALUATION ECG Chest X-ray Proteinuria, elevated serum blood urea nitrogen (BUN), and creatinine levels Serum potassium Urine (24-hour) for catecholamines Renal scan Renal duplex imaging Outpatient ambulatory BP measurements MANAGEMENT(lifestyle modifications) Lose weight if body mass index is greater than or equal to 25. Limit alcohol Get regular aerobic exercise equivalent to 30 to 45 minutes of brisk walking most days. Cut sodium intake to 2.4 g or less per day Include recommended daily allowances of potassium, calcium, and magnesium in diet. Smoking cessation Reduce dietary saturated fat and cholesterol Consider reducing coffee intake CONTD If, despite lifestyle changes, the BP remains at or above 140/90 mm Hg over 3 to 6 months, drug therapy should be initiated If BP extremely elevated or in presence of cardiovascular risk factors, single drug therapy may be given CONSIDERATIONS IN SELECTING THERAPY Race:- Blacks respond well to diuretic therapy; Whites respond well to ACE inhibitors Age:- some adverse effects may not be tolerated well by elderly people Concomitant diseases and therapies:- some agents also treat migraines, benign prostatic hyperplasia, heart failure Quality of life impact:- tolerance of adverse effects Economic considerations:- newer agents very expensive ANTI-HYPERTENSIVE DRUG GROUPS Diuretics Beta-adrenergic blockers Alpha-receptor blockers Central alpha agonists Peripheral adrenergic agents Combined alpha and beta-adrenergic blockers ACE inhibitors Angiotensin receptor blockers Calcium antagonists Direct vasodilators Drugs currently available for treating hypertension work by 1) decreasing the volume of circulating blood, and/or (2) reducing SVR.

Diuretics promote sodium and water excretion, reduce plasma volume, decrease sodium in the arteriolar walls, and reduce the vascular response to catecholamines. Adrenergic-inhibiting agents act by diminishing the SNS effects that increase BP. Adrenergic inhibitors include drugs that act centrally on the vasomotor center and peripherally to inhibit norepinephrine release or to block the adrenergic receptors on blood vessels. Direct vasodilators decrease the BP by relaxing vascular smooth muscle and reducing SVR. Calcium channel blockers increase sodium excretion and cause arteriolar vasodilation by preventing the movement of extracellular calcium into cells. Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II and reduce angiotensin II (A-II)mediated vasoconstriction and sodium and water retention. A-II receptor blockers (ARBs) prevent angiotensin II from binding to its receptors in the walls of the blood vessels. Thiazide-type diuretics are used as initial therapy for most patients with hypertension, either alone or in combination with one of the other classes. When BP is more than 20/10 mm Hg above SBP and DBP goals, a second drug should be considered. Most patients who are hypertensive will require two or more antihypertensive medications to achieve their BP goals. Side effects and adverse effects of antihypertensive drugs may be so severe or undesirable that the patient does not comply with therapy. Hyperuricemia, hyperglycemia, and hypokalemia are common side effects with both thiazide and loop diuretics. ACE inhibitors lead to high levels of bradykinin, which can cause coughing. An individual who develops a cough with the use of ACE inhibitors may be switched to an ARB. Hyperkalemia can be a serious side effect of the potassium-sparing diuretics and ACE inhibitors. Sexual dysfunction may occur with some of the diuretics. Orthostatic hypotension and sexual dysfunction are two undesirable effects of adrenergicinhibiting agents. Tachycardia and orthostatic hypotension are potential adverse effects of both vasodilators and angiotensin inhibitors. Patient and family teaching related to drug therapy is needed to identify and minimize side effects and to cope with therapeutic effects. Side effects may be an initial response to a drug and may decrease with continued use of the drug. BEST MANAGEMENT OF HYPERTENSION To use the fewest drugs at the lowest doses while encouraging the patient to maintain lifestyle changes. After BP has been under control for at least 1 year, a slow, progressive decline in drug therapy can be attempted. However, most patients need to resume medication within 1 year. PATIENT EDUCATION GUIDELINES Following the DASH eating plan DASH Dietary Approaches to Stop Hypertension Based on 2,000 calories per day diet Depending on patients caloric needs, the number of daily servings may vary For more information, log on to http://www.nhlbi.nih.gov/health/public/heart/hbp/dash. DASH WEIGHT REDUCTION Weight reduction. A weight loss of 10 kg (22 lb) may decrease SBP by approximately 5 to 20 mm Hg. Dietary Approaches to Stop Hypertension (DASH) eating plan. Involves eating several servings of fish each week, eating plenty of fruits and vegetables, increasing fiber intake, and drinking a lot of water. The DASH diet significantly lowers BP. Restriction of dietary sodium to less than 6 g of salt (NaCl) or less than 2.4 g of sodium per day. This involves avoiding foods known to be high in sodium (e.g., canned soups)

and not adding salt in the preparation of foods or at meals. Restriction of alcohol HYPERTENSIVE CRISIS Hypertensive crisis is a severe and abrupt elevation in BP, arbitrarily defined as a DBP more than 140 mm Hg. Hypertensive crisis occurs most often in patients with a history of hypertension who have failed to comply with their prescribed medications or who have been undermedicated. Hypertensive crisis related to cocaine or crack use is becoming a more frequent problem. Other drugs such as amphetamines, phencyclidine (PCP), and lysergic acid diethylamide (LSD) may also precipitate hypertensive crisis that may be complicated by drug-induced seizures, stroke, MI, or encephalopathy. Hypertensive emergency develops over hours to days and is defined as BP that is severely elevated (more than 180/120 mm Hg) with evidence of acute target FM organ damage. Hypertensive emergencies can precipitate encephalopathy, intracranial or subarachnoid hemorrhage, acute left ventricular failure with pulmonary edema, MI, renal failure, dissecting aortic aneurysm, and retinopathy. Hypertensive emergencies require hospitalization, intravenous (IV) administration of antihypertensive drugs, and `intensive care monitoring. COMPLICATIONS CONTD CONTD NURSING ASSESSMENT Nursing History Family history of high BP Previous episodes of high BP Dietary habits and salt intake Cigarette smoking Episodes of headache, weakness, muscle cramp, tingling, palpitations, sweating, vision disturbances Medication that could elevate BP Hormonal contraceptives, steroids NSAIDs, Nasal decongestants, appetite suppressants NURSING ALERT The finding of an isolated elevated BP does not necessarily indicate hypertension. However, the patient should be regarded as at risk for high BP until further assessment through history taking, repeat BP measurements, and diagnostic testing either confirms or denies the diagnosis NURSING DIAGNOSES Deficient Knowledge regarding the relationship between the treatment regimen and control of the disease process Ineffective Therapeutic Regimen Management related to medication adverse effects and difficult lifestyle adjustments NURSING INTERVENTIONS Provide basic education Explain the meaning of high BP, risk factors Stress that there can never be total cure, only control can be done Stress the fact that there may be no correlation between high BP and symptoms Have the patient recognize that hypertension is chronic and requires persistent therapy and periodic evaluation.Effective treatment improves life expectancy CONTD Explain the pharmacologic control of hypertension:Explain that the drugs used for effective control of elevated BP will likely produce adverse effects. Warn the patient of the possibility that orthostatic hypotension may occur initially with some drug therapy Instruct the patient to get up slowly to offset the feeling of dizziness

Encourage the patient to sit or lie down immediately if he feels faint Alert the patient to expect initial effects, such as anorexia, lightheadedness, and fatigue, with many medications GERONTOLOGIC ALERT Polypharmacy, cognitive changes, and sensory deficits in the elderly may make dosage adjustment and control of BP difficult. Work with the patient, family, and home care nurse to devise a simple method for the patient to take the proper medications. Elderly patients are also more sensitive to therapeutic levels of drugs and may demonstrate adverse effects while on an otherwise average dosage.They may be more sensitive to postural hypotension and should be cautioned to change positions with great care. ACCELERATED HYPERTENSION DEFINITION Also called as Malignant Hypertension Occurs when B.P. elevates extremely rapidly Threatens one or more target organs like brain, heart & kidney. PATHOPHYSIOLOGY CLINICAL MANIFESTATIONS Brain effects: Encephalopathy Stroke Progressive headache, stupor, seizures Kidney effects: Decreased blood flow, vasoconstriction BUN elevated Plasma renin activity increased Urine specific gravity lowered Proteinuria Renal failure Cardiac effects: Left-sided heart failure Acute MI Right-sided heart failure MANAGEMENT Immediate hospitalization and treatment if the following are present Seizures Abnormal neurologic signs Severe occipital headache Pulmonary edema The patient is hemodynamically monitored in the ICU Antihypertensive agents are administered parenterally. Agents include: Vasodilators Adrenergic inhibitors short-acting calcium antagonist Diuretics NURSING ALERT BP should be reduced gradually and wide pressure variations avoided because lowered BP may not be adequate to perfuse vital organs NURSING INTERVENTIONS Record BP frequently Monitor for adverse effects of medications: headache, tachycardia, orthostatic hypotension Measure urine output accurately Observe for hypokalemia, especially if patient is placed on diuretic therapy. Monitor for ventricular dysrhythmias HYPERTENSION DEFINITION ACCORDING TO NICE as of August 2011 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. Diagnosing hypertension If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the persons usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the persons usual waking hours to confirm a diagnosis of hypertension. Cont diagnosing hypertension When using home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension, ensure that: for each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated and blood pressure is recorded twice daily, ideally in the morning and evening and blood pressure recording 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. Initiating and monitoring antihypertensive drug treatment, including blood pressure targets Initiating treatment 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 Continitiating treatment Offer antihypertensive drug treatment to people of any age with stage 2 hypertension. For people aged under 40 years 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. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people. Monitoring treatment and blood pressure targets For people identified as having a white-coat effect1, consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor the response to antihypertensive treatment with lifestyle modification or drugs. Continued Key priorities for implementation

1 A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis Key priorities for implementation continued Choosing antihypertensive drug treatment Offer people aged 80 years and over the same antihypertensive drug treatment as people aged 5580 years, taking into account any comorbidities. Step 1 treatment 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. Cont If a diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.525.0 mg once daily) or indapamide (1.5 mg modified-release or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. 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 cont Step 4 treatment For treatment of resistant hypertension at step 4: Consider further diuretic therapy with low-dose spironolactone (25 mg once daily)2 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. Measuring blood pressure Healthcare professionals taking blood pressure measurements need adequate initial training and should have their performance reviewed periodically7. Devices for measuring blood pressure must be properly validated, maintained and regularly recalibrated according to manufacturers instructions7. If using an automated blood pressure monitoring device, ensure that the device is validated8 and an appropriate cuff size for the persons arm is used. Measuring blood pressure When measuring blood pressure in the clinic or in the home, standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. Palpate the radial or brachial pulse before measuring blood pressure, since automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation). If pulse irregularity is present, measure blood pressure manually, using direct auscultation over the brachial artery. Postural hypotension

In people with symptoms of postural hypotension (falls or postural dizziness): measure blood pressure with the person either supine or seated measure blood pressure again with the person standing for at least 1 minute prior to measurement. If the systolic blood pressure falls by 20 mmHg or more when the person is standing: review medication measure subsequent blood pressures with the person standing consider referral to specialist care if symptoms of postural hypotension persist. Diagnosing hypertension Measure blood pressure in both arms. If the difference in readings between arms is more than 20 mmHg, repeat the measurements. If the difference in readings between arms remains more than 20 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading. 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. Confirming the diagnosis If the clinic blood pressure is 140/90 mmHg or higher, offer ABPM to confirm the diagnosis of hypertension. If a person is unable to tolerate ABPM, HBPM is a suitable alternative to confirm the diagnosis of hypertension. While waiting to confirm the diagnosis, carry out investigations for target organ damage and a formal assessment of cardiovascular risk Severe hypertension Consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM, for people with severe hypertension. Specialist investigations Refer people to specialist care the same day if they have: accelerated hypertension (blood pressure usually higher than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage) or suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor and diaphoresis). Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. Using ambulatory or home blood pressure monitoring Ambulatory blood pressure monitoring Ensure that at least two measurements per hour are taken during the persons usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person's usual waking hours to confirm the diagnosis. Home blood pressure monitoring Home blood pressure monitoring Ensure that: for each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated

blood pressure is recorded twice daily, ideally in the morning and evening blood pressure recording 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 the diagnosis. If hypertension is not diagnosed Offer to measure the persons blood pressure at least every 5 years. Consider measuring it more often than every 5 years if the persons clinic blood pressure is close to 140/90 mmHg. If there is evidence of target organ damage such as left ventricular hypertrophy, albuminuria or proteinuria, consider carrying out investigations for alternative causes of the target organ damage. Assessing cardiovascular risk and target organ damage Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension, both for raised blood pressure and other modifiable risk factors9,10. Estimate cardiovascular risk in line with the recommendations on Identification and assessment of CVD risk in Lipid modification11. Cont Assess target organ damage12: Test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip. Take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate (eGFR), serum total cholesterol and HDL cholesterol. Examine the fundi for the presence of hypertensive retinopathy. Arrange for a 12-lead electrocardiograph to be performed. For people aged under 40 with stage 1 hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people. Lifestyle interventions Lifestyle advice should be offered initially and then periodically to people undergoing assessment or treatment for hypertension9,13. Ask people about their diet and exercise patterns, and offer guidance and written or audiovisual materials to promote lifestyle changes9. Ask people about their alcohol consumption and encourage them to cut down if they drink excessively9. Discourage excessive consumption of coffee and other caffeinerich products9. Encourage people to keep their salt intake low or substitute sodium salt9. Offer people who smoke advice and help to stop smoking9. Tell people about local initiatives (for example, run by healthcare teams or patient organisations) that provide support and promote lifestyle change9. Cont Do not offer calcium, magnesium or potassium supplements as a method of reducing blood pressure9. Relaxation therapies can reduce blood pressure and people may wish to try them. However, it is not recommended that primary care teams provide them routinely9

9 This recommendation was developed for the original 2004 guideline. 10 Clinic blood pressure measurements must be used in the calculation of cardiovascular risk. 11 NICE clinical guideline 67 (2008), available from www.nice.org.uk/guidance/CG67 12 For NICE guidance on the early identification and management of chronic kidney disease see Chronic kidney disease (NICE clinical guideline 73, 2008), available from www.nice.org.uk/guidance/CG73 13 For NICE guidance on the prevention of obesity and cardiovascular disease see Obesity (NICE clinical guideline 43, 2006), available from www.nice.org.uk/guidance/CG43, and Prevention of cardiovascular disease at population level (NICE public health guidance 25, 2010), available from www.nice.org.uk/guidance/PH25 Antihypertensive drug treatment If possible, offer drugs taken only once a day14. Prescribe non-proprietary drugs if these are appropriate and minimise cost14. Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or higher) the same treatment as people with both raised systolic and diastolic blood pressure14. Offer people aged over 80 years the same antihypertensive drug treatment as people aged 5580 years, taking into account any comorbidities. Do not combine an angiotensin-converting enzyme (ACE) inhibitor with an angiotensin II receptor blocker (ARB). Offer antihypertensive drug treatment to women of childbearing potential in line with the recommendations on Management of pregnancy with chronic hypertension and Breastfeeding in Hypertension in pregnancy15. Initiating and titrating antihypertensive drug treatment Step 1 treatment Offer step 1 treatment to people aged under 80 with stage 1 hypertension and one or more of: target organ damage established cardiovascular disease renal disease diabetes 10-year cardiovascular risk equivalent to 20% or more. Offer step 1 treatment to people of any age with stage 2 hypertension Cont Offer people aged under 55 years an ACE inhibitor or a low-cost ARB. If an ACE inhibitor is prescribed and is not tolerated (for example, because of cough), offer a low-cost ARB. Offer people aged over 55 years and black people of African or Caribbean family origin of any age a calcium-channel blocker (CCB). 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. If treatment with a diuretic is being started, or changed, offer a thiazide-like diuretic, such as chlortalidone (12.525.0 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.

Cont 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. Beta-blockers are not preferred in step 1. However, they may be considered for younger people if ACE inhibitors and ARBs are contraindicated or not tolerated or there is evidence of increased sympathetic drive, and for women of child-bearing potential. If blood pressure is not controlled by step 1 treatment, offer step 2 treatment. Cont Step 2 treatment Offer a CCB in combination with either an ACE inhibitor or an ARB16. 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. For black people of African or Caribbean family origin, consider an ARB16 in preference to an ACE inhibitor, in combination with a CCB. If a beta-blocker was used in step 1, add a CCB rather than a thiazide-type diuretic, to reduce the persons risk of developing diabetes. Before considering step 3 treatment, review medication to ensure step 2 treatment is at optimal or best tolerated doses. Cont Step 3 treatment Offer an ACE inhibitor or an ARB16 in combination with a CCB and a thiazide-like diuretic. Regard clinic blood pressure that remains 140/90 mmHg or higher after step 3 treatment with optimal or best tolerated doses as resistant hypertension. Consider step 4 treatment or seeking expert advice. Cont Step 4 treatment Consider further diuretic therapy with low-dose (25 mg once daily) spironolactone17 if blood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a reduced eGFR, because they have an increased risk of hyperkalaemia. Consider further diuretic therapy with a higher-dose thiazidelike diuretic if blood potassium level is higher than 4.5 mmol/l. When using further diuretic therapy, monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter. If further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker. If blood pressure remains uncontrolled with optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained.16 Monitoring treatment Use clinic blood pressure measurement to monitor the response to treatment. For people identified as having a white-coat effect23, consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor the response to treatment. Blood pressure targets Clinic blood pressure People aged under 80 years: lower than 140/90 mmHg

People aged over 80 years: lower than 150/90 mmHg Daytime average ABPM or average HBPM blood pressure during the persons usual waking hours People aged under 80 years: lower than 135/85 mmHg People aged over 80 years: lower than 145/85 mmHg Patient education and adherence to treatment Help people to make informed choices by providing guidance and materials about the benefits of drugs and the unwanted side effects sometimes experienced24. Tell people about patient organisations that have forums for sharing views and information24. Offer an annual review of care to monitor blood pressure, provide people with support and discuss their lifestyle, symptoms and medication24. Interventions to support adherence to treatment Only use interventions to overcome practical problems associated with non-adherence if a specific need is identified25. Target the intervention to the need. Interventions might include: suggesting that people record their medicine-taking encouraging people to monitor their condition simplifying the dosing regimen using alternative packaging for the medicine using a multi-compartment medicines system25. 23 Measuring blood pressure Mercury sphygmomanometers give the most accurate non-invasive BP readings. Accuracy varies widely between other available devices. If a non-mercury (e.g. digital) sphygmomanometer is used, it should be checked and validated every 6 months to maintain accuracy. Where possible, validation against a mercury sphygmomanometer should be conducted by measuring BP simultaneously with both devices on a single arm using a simple Y-piece connection How to measure BP accurately in the clinic The patient should be seated and relaxed, preferably after several minutes of sitting in a quiet room prior to the measurement. The selected arm should be free of constricting clothing so that the cuff can be wrapped around the upper arm without impediment. Select the appropriate cuff size. The bladder length should be at least 80% and width at least 40% of the circumference of the mid-upper arm. The use of standard-sized cuffs in people with large arms can result in artificially high BP readings. If an oversized cuff cannot be satisfactorily fitted on a large arm, consider using an appropriately sized cuff on the forearm and auscultating the radial artery instead. Wrap the cuff snugly around the upper arm, with the centre of the cuff bladder positioned over the brachial artery and the lower border of the cuff about 2 cm above the bend of the elbow. Ensure that the cuff is at heart level by supporting the arm. Palpate the radial pulse while inflating the cuff and note the pressure at which the radial pulse ceases to be palpable. Continue to inflate the cuff a further 30 mmHg above this pressure. Deflate the cuff at a rate of 23 mmHg/beat or less while palpating and note the pressure at which the radial pulse reappears. Fully deflate the cuff, wait approximately 30 seconds,

then inflate the cuff to at least 30 mmHg above that at which the radial pulse reappeared. While deflating the cuff at a rate of 23 mmHg/beat or less, auscultate over the brachial artery in the antecubital fossa. Record the result for systolic and diastolic BP to the nearest 2 mmHg. For the systolic reading, record the level at which the beats (at least two consecutive beats) are heard, even if they then disappear transiently with progressive deflation (the auscultatory gap). For the diastolic reading, use disappearance of sound (phase V Korotkoff ). Use muffling of sound (phase IV Korotkoff ) only if sound continues to zero. Wait 30 seconds before repeating the procedure in the same arm. Average the readings. If the first two readings differ by more than 10 mmHg systolic or 6 mmHg diastolic, or if initial readings are high, have the patient rest quietly for 5 minutes then take several readings until consecutive readings do not vary by greater than these amounts. Common errors in BP measurement The following errors can contribute to undertreatment of hypertension: cuff placed over clothing incorrect cuff size worn cuff inaccurate sphygmomanometer (e.g. not serviced regularly, not validated correctly) arm elevated above heart failure to check that both arms give comparable readings (e.g. at initial visit) patient not rested before measurement BP measurements outside the clinic Additional readings may be obtained by 24-hour ambulatory BP monitoring or by self-measurement of BP. It is useful to obtain BP readings outside the clinic, because approximately 15% of the general population show elevated BP when measured in the clinic but not in other settings (isolated clinic or white coat hypertension).3 In a similar proportion of people, ambulatory BP may be high while clinic BP is normal (isolated ambulatory, masked or reverse white-coat hypertension. Compare the recorded profile with standard ambulatory BP values (Table 1). Note that normal values for ambulatory BP differ from clinic-measured BP normal values. Take into account any patient diary information and time of drug treatment, where relevant. The diagnosis of hypertension is supported if the patients average ambulatory BP reading exceeds standard values for daytime BP or night-time BP or if ambulatory BP load (area under the BPtime curve) is reported and exceeds the reference range by more than 20%. Mean night-time ambulatory BP level should be at least 10% lower than the daytime level.17 Patients who do not show a night-time lowering of BP (non-dippers) are at increased cardiovascular risk.18 Standard ambulatory BP values Measuring BP Recommendations Use the recommended technique at every BP reading to ensure accurate measurements and avoid common errors. Pay particular attention to the following:

Measure BP with a regularly serviced mercury sphygmomanometer, or regularly validate your instrument against a mercury sphygmomanometer. At the patients first BP assessment, measure BP on both arms. Thereafter, use the arm with the higher reading. In patients who may have orthostatic hypotension (e.g. the elderly, those with diabetes), measure BP in sitting position, and repeat after the patient has been standing for at least 2 minutes. Cont If possible, obtain BP measurements outside the clinic (by ambulatory BP monitoring or self-measurement), particularly for patients with any of the following: unusual variation between BP readings in the clinic suspected white coat hypertension (e.g. clinic hypertension in a person without known cardiovascular risk factors) hypertension that is resistant to drug treatment suspected hypotensive episodes (e.g. in those who are elderly or have diabetes). Interpret ambulatory BP profiles using standard reference values for daytime (awake), night-time (asleep) and 24-hour means. Diagnosis and classification of hypertension The diagnosis of hypertension should be based on multiple BP measurements taken on several separate occasions, e.g. at least twice, one or more weeks apart (sooner if hypertension is severe). International definitions of hypertension vary. The suggested classification system used in this guideline was developed following an assessment of the systems used in the United States and in Europe. Although the term hypertension is potentially misleading because BP-related risk is a continuum with no defined lower cut-point, it has been retained in this guideline for practical reasons, on the understanding that individual cardiovascular risk assessment determines appropriate management in each patient. Evaluation in patients with confirmed hypertension History Take a full history with particular attention to the following: known duration of raised BP and previous levels ambulatory or self-measured BP levels (if known) previous antihypertensive therapy, efficacy and adverse effects past history or current symptoms of ischaemic heart disease, heart failure, cerebrovascular disease or peripheral arterial disease past history or current symptoms that suggest CKD, e.g. nocturia, dark urine (suggesting haematuria) symptoms suggestive of a condition that may cause secondary hypertension, e.g. phaeochromocytoma (paroxysmal headache, sweating, palpitations), sleep apnoea (obesity, snoring) the presence of asthma, chronic obstructive pulmonary disease, diabetes, dyslipidaemia, gout, erectile dysfunction, sleep apnoea or other significant illnesses family history of hypertension, diabetes, dyslipidaemia, stroke, CKD or premature (before age 60 years) coronary heart disease modifiable lifestyle risk factors: obesity, physical inactivity, smoking, excessive intake of alcohol,

salt or saturated fats, recreational drug use (amphetamines, cocaine) medications (including complementary medicines) that raise BP Cont personal, psychosocial and environmental factors that could influence the course and outcome of antihypertensive care e.g. educational background, family situation, work environment and associated psychological stress (assess for depression, social isolation and quality of social support). history of hypokalaemia or suggestive symptoms (e.g. muscle weakness, hypotonia, muscle tetany, cramps, cardiac arrhythmias). Medications that may increase BP Clozapine Corticosteroids Haemopoietic agents (darbepoetin, epoetin) Immunomodifiers (cyclosporin, tacrolimus) Leflunomide Monoamine oxidase inhibitors: reversible (moclobemide), irreversible (phenelzine, tranylcypromine)* Non-steroidal anti-inflammatory drugs (conventional and cyclooxygenase-2 selective) Oral contraceptives Oral decongestants (e.g. pseudoephedrine Sibutramine Stimulants (dexamphetamine sulfate, methylphenidate hydrochloride) Sympathomimetic agents Venlafaxine (dose-related) Rebound hypertension may occur following abrupt withdrawal of the following: bromocriptine clonidine. *The use of monoamine oxidase inhibitors in combination with tyramine-rich foods (e.g. matured or out-of-date cheese, fermented or matured meats, yeast and soy bean extracts, and others) can lead to hypertensive crisis. Complementary medicines that may increase BP American mistletoe Angels trumpet Butchers broom Caffeine-containing products (e.g. guarana, black tea, cola nut, green tea, mate) Ephedra (ma huang) Gentian Ginger preparations Ginseng preparations Liquorice Melatonin Peyote Phenylalanine Sage St Johns wort Adapted with Physical examination Perform a physical examination with particular attention to the cardiovascular system, including the following: pulse rate, rhythm and character jugular venous pulse and pressure evidence of cardiac enlargement (displaced apex, extra heart sounds), or evidence of decompensation

(basal crackles or wheeze on lung auscultation, peripheral oedema, abdominal signs, e.g. pulsatile liver) evidence of arterial disease (e.g. carotid, renal or abdominal bruits, abdominal aortic aneurysm, absent femoral pulses, radiofemoral delay) Cont abnormalities of the optic fundi (e.g. tortuosity, thickening or arteriovenous nipping of retinal arteries, retinal haemorrhages, exudates, diabetic retinopathy, papilloedema) evidence of CKD (e.g. palpable kidneys) focal neurological signs evidence of abnormalities of the endocrine system (e.g. Cushings syndrome, thyroid disease) waist circumference (cm) and/or body mass index (BMI): weight (kg) in light clothing, divided by the square of height (m) without shoes. Initial investigations Undertake the following investigations to assess for end-organ disease or associated clinical conditions: Dip stick testing of urine for blood and protein If abnormal, proceed to urine microscopy. If proteinuria detected ( 1+ on dip stick), measure 24-hour urinary protein excretion. Assessment of microalbuminuria (highly recommended for all patients and mandatory for those with diabetes). Microalbuminuria status correlates with cardiovascular risk and its presence indicates end-organ damage. Cont The most accurate screening test is urinary albumin/creatinine ratio on a spot urine sample. Use this method where available. If albumin/creatinine ratio 2.0 mg/mmol (males) or 2.5 mg/mmol (females) is detected, repeat the test to confirm. If confirmed, obtain a 24-hour urine collection for accurate measurement. Cont Blood analysis (sodium, potassium, chloride, bicarbonate, urea, creatinine, uric acid, haemoglobin, fasting glucose, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, liver function tests). Electrocardiogram (ECG) to detect conduction disturbances, arrhythmias, coronary heart disease or left ventricular hypertrophy. The presence of strain pattern (ST depression and T-wave inversion) is associated with increased cardiovascular risk in patients with hypertension. Further investigations Further investigations should be undertaken as indicated on the basis of clinical suspicion following the history, physical examination and routine investigations. These may include the following: Echocardiogram (if available), where the result will affect treatment decisions. Echocardiography is the most accurate widely available method of detecting left ventricular hypertrophy. Cont Ankle-brachial index (ABI) in those with risk factors for peripheral arterial disease (e.g. smoking, diabetes, vascular bruits, older age). A finding of < 0.9 is diagnostic for peripheral arterial disease. For more information on ABI, see the position statement by Society of Interventional Radiology.20

Carotid Doppler as indicated (e.g. if bruits detected Plasma aldosterone/renin ratio. Primary aldosteronism occurs in 510% of patients with hypertension and is not excluded by normal serum potassium.21 It should be considered in all patients with hypertension, especially those with moderate-to-severe or treatment-resistant hypertension and those with hypokalaemia. For information on testing procedure, including medications that affect the result, see www. heartfoundation.org.au/Professional_Information/ Clinical_Practice/Hypertension. Referral to a specialist for investigation is recommended when primary aldosteronism is suspected. Cont 24-hour urinary catecholamine, metanephrine and normetanephrine excretion (with creatinine) and/or plasma catecholamine, metanephrine* and normetanephrine* concentration. These tests are indicated by symptoms of episodic catecholamine excess and/or episodic hypertension (suggestive of phaeochromocytoma). Renal artery duplex ultrasound, renal nuclear medicine imaging, and/or CT angiographyindicated in young females with hypertension, older patients who might have atherosclerotic renal artery disease, and patients with a renal bruit. Absolute cardiovascular risk The management plan for a person with hypertension should take into consideration the individuals absolute risk of cardiovascular disease (see When to intervene, page 12). Absolute cardiovascular risk is the probability (expressed as a percentage) of an individual experiencing a cardiovascular event (e.g. myocardial infarction or stroke) during a predefined period of time (e.g. the next 5 years). Blood pressure is a major determinant of absolute cardiovascular risk. Patients at highest absolute risk include those with existing cardiovascular disease or those with multiple risk factors (e.g. diabetes, older age, overweight/obesity and dyslipidaemia). Cont The purposes of assessing absolute cardiovascular risk are: to identify other modifiable risk factors that require management to predict who will benefit most from intervention and determine the appropriate management plan to reduce BP to enable the patient to understand the degree of urgency for reducing BP and correcting other risk factors. When to intervene in patients with confirmed hypertension Recommendations The decision to intervene and the development of a comprehensive management plan (including lifestyle advice and drug treatment) should be based on a thorough clinical investigation to identify associated clinical conditions and/or end-organ damage and assessment of absolute cardiovascular risk. Initiate antihypertensive drug treatment immediately in hypertensive patients with any of the following: grade 3 hypertension or isolated systolic hypertension with widened pulse pressure (SBP 160 mmHg and DBP 70 mmHg) associated conditions or evidence of end-organ damage (regardless of BP) high absolute risk of cardiovascular disease, based

on the presence of markers of high risk or as estimated using a risk calculator. Advise lifestyle risk reduction for all patients, especially those with high-normal BP or hypertension (see Lifestyle modification, page 13). Also consider drug therapy for: patients with moderate risk of a cardiovascular event (1015% probability within the next 5 years) as estimated using a risk calculator Aboriginal and Torres Strait Islander adults. Explain the health implications of current risk and the potential benefits of the recommended treatment Lifestyle modification Lifestyle modification is indicated for all patients with hypertension, regardless of drug therapy. It may reduce, or even abolish, the need for antihypertensive drugs. REGULAR ACTIVITY There is strong evidence that regular physical activity has an independent cardioprotective effect.24 Regular aerobic exercise can lower systolic BP by an average of 4 mmHg and diastolic BP by an average of 2.5 mmHg.25 People with any the following should defer physical activity until medical review: grade 3 hypertension (systolic BP 180 mmHg or diastolic BP 110 mmHg) unstable angina, uncontrolled heart failure, severe aortic stenosis, resting tachycardia or arrhythmias symptoms (e.g. chest discomfort, shortness of breath) on low activity diabetes with poor glycaemic control other acute illness. Smoking cessation Smoking cessation may not directly reduce BP, but markedly reduces overall cardiovascular risk. The risk of myocardial infarction is 26 times higher 27,28 and the risk of stroke is 3 times higher in people who smoke than in non-smokers.29,30 Advice from health professionals is effective in increasing quit rates. Even 35 minutes taken to encourage smokers to attempt to quit can increase success rates.31 CONT Pharmacotherapy (nicotine replacement therapy, bupropion, varenicline) is effective. The risk of adverse effects is small and is generally outweighed by the significant risk of continuing to smoke. Dietary modification There is strong evidence that salt restriction can reduce systolic BP by approximately 45 mmHg in hypertensive individuals and 2 mmHg in normotensive individuals.32 Responses vary between individualsgenerally greatest among the elderly and those with severe hypertension. (Suitable for patients with normal renal function only): Increasing dietary potassium can reduce systolic BP by 48 mmHg in hypertensive individuals and 2 mmHg in normotensive individuals.32 CONT A healthy eating pattern includes mainly plant-based foods e.g. fruits, vegetables, pulses and a wide selection of wholegrain foods, moderate amounts of low-fat or reduced-fat dairy products, moderate amounts of lean unprocessed meats, poultry and fish, moderate amounts of polyunsaturated and monounsaturated fats (e.g. olive oil, canola oil,

reduced-salt margarines). Limit salt intake to 4 g/day (65 mmol/day sodium) by: choosing foods processed without salt, foods labelled no added salt or low salt (or reduced salt products when other options are unavailable) avoiding high-salt processed foods, salty snacks, takeaway foods high in salt, salt added during cooking or at the table. Patients with normal renal function only: increase potassium intake by eating a wide variety of fruits and vegetables, plain unsalted nuts (limit quantity and frequency to avoid excess kilojoules), and legumes (e.g. beans, lentils, dried peas). Patients taking potassium-sparing diuretics must limit potassium intake to avoid severe hyperkalaemia Weight reduction Every 1% reduction in body weight lowers systolic BP by an average of 1 mmHg.33,34 Weight reduction by as little as 4.5 kg reduces BP and/or prevents hypertension in a large proportion of overweight people.1 Weight loss of 10 kg can reduce systolic BP by 610 mmHg Sibutramine may increase BP in some patients, particularly those who are both obese and hypertensive monitor BP regularly. Assess waist circumference (preferable) and BMI. Targets are: waist circumference < 94 cm (males); < 80 cm (females) BMI < 25 kg/m2 (see notes below). Set achievable intermediate goals in consultation with patients and assess progress regularly. Advise patients on how to reduce kilojoule intake as well as increase physical activity. Explain that energy input (kilojoules) from food and drinks must be less than the kilojoules expended in daily activities and planned regular physical activity in order to lose weight. To lose weight, most people will need to do more physical activity than the 30 minutes of moderate-intensity physical activity per day recommended for general health benefits. Emphasise that there is no quick solution; lifestyle changes must be practical and able to be maintained for a lifetime. Limiting alcohol Moderate drinking may increase BP3840 and binge drinking may increase the risk of hypertension.38,41 Reducing alcohol consumption can substantially lower BP in some patients.42 Advise patients with hypertension to limit their intake to: a maximum of two standard drinks per day for men a maximum of one standard drink per day for women. Advise at least two alcohol-free days per week. Supporting long-term lifestyle changes Tailor advice to individual patients needs and set realistic goals. Give regular encouragement. Respond positively to any incremental success, even if targets have not been achieved (e.g. reduction in smoking or weight). Provide specific written instructions. Review progress regularly. Refer to other health professionals (e.g. accredited practising dietitians or exercise professionals) for ongoing support and follow-up where appropriate. Lifestyle Recommendations Manage identified lifestyle risk factors in all patients, whether or not BP is elevated.

Advise patients to aim for healthy targets: At least 30 minutes of moderate-intensity physical activity on most, if not all, days of the week (daily total can be accumulated e.g. three 10-minute sessions). Advise patients of all ages to become more active. Smoking cessation. Refer patients to Quitline. Consider recommending nicotine replacement therapy and/or prescribing oral therapy (bupropion or varenicline) in patients who smoke more than 10 cigarettes per day and have no contraindications. CONT. Waist measurement < 94 cm for men and < 80 cm for women, body mass index (BMI) < 25 kg/m2. When recommending weight loss, advise patients on reducing kilojoule intake as well as increasing physical activity. Dietary salt restriction: 4 g/day (65 mmol/day sodium). Recommend low-salt and reduced-salt foods as part of a healthy eating pattern. Limited alcohol intake: maximum of two standard drinks per day for men or one standard drink per day for women. What this presentation covers Definitions Case scenario 1 : Mary Case scenario 1 : Mary Answer 1.1 You would take Marys blood pressure a third time during the consultation. Question 1.2 The third reading is 149/93 mmHg. You suspect hypertension what would you do next? Case scenario 1 : Mary Answer 1.2 Organise for Mary to receive ABPM through your GP practice. If you are responsible for setting up the monitoring device, you ensure that at least two measurements per hour are taken during Marys usual waking hours (for example, between 8 am and 10 pm). You would use the average value of at least 14 measurements taken during Marys usual waking hours to confirm a diagnosis of hypertension. At the same time you would also carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy). Move to the next slide for a lists of tests and further investigations Case scenario 1 : Mary Answer 1.2 (continued) test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol examine the fundi for the presence of hypertensive retinopathy arrange for a 12-lead electrocardiograph to be performed. You would also carry out a formal assessment of cardiovascular risk (Marys clinic blood pressure must be used in the calculation of cardiovascular risk) using a cardiovascular risk assessment tool, in line with Identification and assessment of CVD risk in Lipid modification

(NICE clinical guideline 67).Records the results of all investigations and assessment in Marys notes. Case scenario 1 : Mary Question 1.3 The result of Marys ABPM shows daytime average blood pressure of 145/92 mmHg. What would your diagnosis and your next steps be? Case scenario 1 : Mary Answer 1.3 This result shows that Mary has stage 1 hypertension. If you had not already done so (answer 1.2), you would estimate cardiovascular risk and offer tests for target organ damage. You would use the results of the cardiovascular risk assessment to discuss prognosis and healthcare options with Mary. You would also provide lifestyle advice in accordance with the guideline on areas such as diet (including sodium and caffeine intake) and exercise and alcohol consumption. See the definitions slide for ABPM diagnosis criteria Case scenario 1 : Mary Question 1.4 The results of the investigations for target organ damage and formal assessment of cardiovascular risk are: no evidence of target organ damage 10-year cardiovascular risk less than 20%. Nothing abnormal was detected in the other investigations you organised. What is your next step and what treatment would you offer? Case scenario 1 : Mary Answer 1.4 Further assessment You would consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people Treatment Mary does not have target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater, therefore you would not offer antihypertensive drug treatment. You would provide further lifestyle advice in accordance with the NICE clinical guideline. Case scenario 1 : Mary Question 1.5 The results of the specialist assessment identifies that there is no target organ damage and cardiovascular risk remains less than 20%. You would therefore continue not to offer Mary antihypertensive drug treatment and continue to provide advice in line with the lifestyle intervention recommendations 1.4.11.4.9 If Mary had been eligible to receive antihypertensive drug treatment, what should you consider when prescribing antihypertensive drugs for a woman of child-bearing potential? Case scenario 1 : Mary Answer 1.5 There is an increased risk of congenital abnormalities if women take angiotensin-converting enzyme (ACE) inhibitors or angiotensin III receptor blockers (ARBs) during pregnancy, and it is important that women of child-bearing age know this. If the woman is planning a pregnancy she should discuss this with you. If a woman taking ACE inhibitors or ARBs becomes pregnant, these antihypertensive drugs should be stopped and alternatives offered. Link to related recommendations from the Hypertension in Pregnancy (NICE clinical guideline 107):

Question 1.6 What are the key points to remember when measuring blood pressure to ensure that the reading is as accurate as possible? Case scenario 1 : Mary Answer 1.6 Ensure that staff measuring blood pressure are trained. Ensure the person having their blood pressure measured has a regular pulse before using an automated blood pressure monitoring device. Ensure automated devices are validated, maintained and regularly recalibrated. Although not a NICE recommendation, expert opinion would suggest that devices should be maintained annually and there should be a person accountable for recalibrating the devices in order to ensure consistency. Provide a relaxed environment for the person whose blood pressure is being measured. Ensure the use of an appropriate cuff size. Link to British Hypertension Societies list of validated blood pressure monitoring devices Case scenario 2 : Danny Presentation Danny is a 39-year-old black male of Caribbean family origin. He presents to you with a sore ankle after going over on it. Medical history Danny has no significant past medical history. Previous presentations have been related to coughs and colds. He smokes 25 cigarettes a day, alcohol consumption around 20 units/week and has done for 18 years. He works shifts and says that he considers his diet to be unhealthy as a result. On examination You conclude that Dannys ankle is sprained. As part of your routine examination you measure his blood pressure. The first measurement in his left arm is 150/92 mmHg, the second measurement in his right arm is 149/91 mmHg and the third measurement in his left arm is 151/92 mmHg. Question 2.1 What would you do next? Case scenario 2 : Danny Answer 2.1 You would record Dannys clinic blood pressure as 149/91 mmHg. In order to diagnose hypertension, you organise ABPM to confirm a diagnosis of hypertension. When organising this you ensure that at least two measurements per hour are taken during Dannys usual waking hours. You would use the average value of at least 14 measurements taken during Dannys usual waking hours to confirm a diagnosis of hypertension. At the same time you would also carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy). Case scenario 2 : Danny Answer 2.1 (continued) You would: test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol examine the fundi for the presence of hypertensive retinopathy

Management of pregnancy with chronic hypertension Breastfeeding

arrange for a 12-lead electrocardiograph to be performed. You would also carry out and a formal assessment of cardiovascular risk (Dannys clinic blood pressure must be used in the calculation of cardiovascular risk) using a cardiovascular risk assessment tool, in line with the recommendations on Identification and assessment of CVD risk in Lipid modification (NICE clinical guideline 67). Record the results of the investigations and assessments in Dannys notes. Case scenario 2 : Danny Question 2.2 ABPM indicates that Dannys daytime average blood pressure is 147/89 mmHg. There is no evidence of target organ damage, cardiovascular disease, renal disease or diabetes. You identify a 10-year cardiovascular risk equivalent to 12%. With this information, what is your diagnosis and what would you do next? Case scenario 2 : Danny Answer 2.2 You would diagnose stage 1 hypertension and consider referring Danny for a specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. If you had not already done so (answer 2.1) you would also assess cardiovascular risk and offer to test for target organ damage You would use the results of the initial cardiovascular risk assessment to discuss prognosis and healthcare options with Danny. You would also offer Danny lifestyle advice in accordance with the guideline on areas such as diet (including sodium and caffeine intake), exercise, alcohol consumption and smoking. See the definition slide for ABPM diagnosis criteria See section 1.4 of the NICE guideline for recommendations about lifestyle interventions Case scenario 2 : Danny Question 2.3 The results of the tests you arranged (presence of protein in the urine, estimation of the albumin:creatinine ratio, haematuria, plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, cholesterol, hypertensive retinopathy, 12-lead electrocardiograph) have been returned. All are normal with the exception of cholesterol which was total cholesterol = 5.6mmol/L, HDL cholesterol 1.1mmol/L. You decided to refer Danny for the specialist assessment. The results of the specialist assessment are returned. There are no secondary causes of hypertension; however, he was noted to have left ventricular hypertrophy and early evidence of impaired diastolic relaxation on his echocardiogram. The report suggests that these changes are most likely related to hypertension. Thus, Danny has evidence of target organ damage. What would you do next? Case scenario 2 : Danny Answer 2.3 You would offer Danny treatment with a calcium-channel blocker, for example amlodipine. You would also offer him appropriate information about the drug and unwanted side effects. You would see the results of the more detailed cardiovascular risk assessment to discuss prognosis and healthcare options with Danny (detailed in answer 2.2). As appropriate, you would repeat the lifestyle advice that was given in answer 2.2 in accordance with the guideline on areas such as diet (including sodium and caffeine intake), exercise, alcohol consumption and smoking. As Dannys cholesterol level is

marginally elevated, you would also enquire about the fat content of his diet and recommend that he reduces his fat intake. You would note that his cholesterol needs rechecking. You would ask Danny to return to your practice in 4 weeks for a review of his blood pressure and for the results of the tests you have arranged. Case scenario 2 : Danny Question 2.4 You have previously concluded that Dannys sprained ankle has healed and all swelling had cleared. Danny returns to the clinic and you notice both ankles are very swollen, which are new to him. This is likely to indicate that he is not tolerating his calciumchannel blocker. His clinic blood pressure is 135/86 mmHg. Would you consider that his blood pressure has been controlled? What would you do next? Case scenario 2 : Danny Answer 2.4 Dannys blood pressure has been controlled as his clinic blood pressure is now below 140/90 mmHg which is what you were aiming for. However, he was not tolerating the calcium channel blocker. You would change the calcium-channel blocker to a thiazide like diuretic such as indapamide 2.5 mg once daily. You would arrange for him to return to clinic to check his blood pressure again in 4 weeks. Case scenario 3 : Doris Presentation Doris is an 81-year-old female non-smoker. She was diagnosed with stage 2 hypertension, by a practice colleague 1 month ago. It is thought the cause is probably arterial stiffening. Her clinic blood pressure was 174/52 mmHg and her ABPM average was 170/50 mmHg She was not identified as having white-coat hypertension. She has now returned to the practice after your colleague requested she return for a follow up appointment. Medical history Doris has no significant medical history. Question 3.1 What would you have expected your colleague to have initiated with Doris? Case scenario 3 : Doris Answer 3.1 You would have expected your colleague to have: Arranged and reviewed the results of all appropriate tests for target organ damage and cardiovascular risk assessment in line with the NICE guideline. Started treatment with a calcium-channel blocker. Offered Doris information and guidance about her diagnosis and treatment options. Asked Doris to return to your practice clinic in 1 month to check her blood pressure (this is the purpose of her current visit to you). Please note some cardiovascular risk assessments have a maximum age and may not be applicable for use with Doris. Additionally, given her age, Doris will score very highly in all cardiovascular risk assessments. Case scenario 3 : Doris Question 3.2 Doriss total cholesterol is 4.8mmol/L and her HDL is 1.6mmol/L. Glucose is normal. There is no left ventricular hypertrophy or atrial fibrillation on ECG. Her 10-year cardiovascular risk is 27% (using QRISK2). You measure her clinic blood pressure and it is 165/100 mmHg. What would you do next? Case scenario 3 : Doris Answer 3.2 Doriss blood pressure is not controlled.

You would check adherence with step 1 treatment. Identify if there is anything you can do (modify dosing regimen, provide a record for her to monitor her medicine taking) to help enhance adherence. You would offer step 2 hypertensive treatment with the addition of an ACE inhibitor. Link to Medicines adherence (NICE clinical guideline 76) Question 3.3 Doris returns to the clinic after a further month. Her clinic blood pressure is 154/90 mmHg. What would you do next? Case scenario 3 : Doris Answer 3.3 You would review Doriss antihypertensive medication and ensure that it is at the optimal or best tolerated dose. You would also consider her adherence to the drug regimen and ensure that any factors that may reduce her adherence are managed. You would arrange for a blood test to check her electrolytes around 2 weeks after starting the ACE inhibitor and ask her to return to the practice in 1 month for the results of the electrolyte test and a further review of her blood pressure. At her next clinic appointment Doriss blood pressure is 145/85 mmHg.. This is an acceptable blood pressure for a person over 80. Doris can stay on current treatment. Case scenario 4 : Derek Presentation Derek is a 53-year-old male who has been diagnosed with stage 2 hypertension. You confirmed diagnosis one month ago. On examination During Dereks diagnosis and assessment his clinic blood pressures was 176/108 mmHg. Additionally, you identified left ventricular hypertrophy on ECG. You were unable to confirm the diagnosis with ABPM because Derek refused it because he is a bus driver and it would interfere with his driving. Question 4.1 What alternative test could you have used to diagnose hypertension? Case scenario 4 : Derek Answer 4.1 You could offer Derek home blood pressure monitoring (HBPM). Question 4.2 When instructing Derek in how to use HBPM, what instructions did you have to give him and what measurements would you base your diagnosis on? Case scenario 4 : Derek Answer 4.2 You would have ensured that each blood pressure recording was based on two consecutive measurements taken at least one minute apart with Derek seated. You would have asked Derek to record his blood pressure twice daily for at least four days and ideally for seven days. To diagnose hypertension based on HBPM, you discard the measurements taken on the first day and take an average of all of the remaining measurements. Question 4.3 The average home blood pressure result was 155/97 mmHg. With this result you noted that Derek had a white-coat effect. However despite this, his HBPM measurements indicated a diagnosis of stage 2 hypertension and he had target organ damage. You made this diagnosis one month ago. You offered lifestyle interventions in line with recommendations 1.4.1 to 1.4.9 in the guideline nd started Derek on step 1 treatment. What drug regimen would you

have offered Derek and how would you monitor his response to treatment? Case scenario 4 : Derek Answer 4.3 You would have offered offer Derek treatment with an ACE inhibitor and HBPM to monitor his response to treatment. Question 4.4 Derek has returned to you with the results of his monitoring HBPM. During the past week, his average blood pressure was 150/94 mmHg. What is the target blood pressure for HBPM when monitoring response to treatment and what would you do about this result? Case scenario 4 : Derek Answer 4.4 For people aged under 80 the target HBPM blood pressure is below 135/85 mmHg. Dereks blood pressure is not controlled so you would offer him step 2 treatment with a calcium-channel blocker in addition to his current ACE inhibitor. Question 4.5 When he returns to you 1 month later, Dereks HBPM result is still above 135/85 mmHg. What would you do next? Case scenario 4 : Derek Answer 4.5 You would check Dereks adherence to treatment in line with recommendations 1.7.1 to 1.7.4 of the guideline. You would review his medication to ensure that step 2 treatment is optimal. Question 4.6 Dereks medication adherence is good and step 2 treatment is optimal. What would you do next? Case scenario 4 : Derek Answer 4.6 You would offer Derek a thiazide-like diuretic in addition to his ACE inhibitor and calcium-channel blocker. Question 4.7 Derek returns to your clinic and his blood pressure is still not controlled. What would you do next? Case scenario 4 : Derek Answer 4.7 Check that Derek has received optimal medication at step 3 and reassess his adherence to his antihypertensive medication. Ensure that Derek has been involved in treatment decisions throughout his care and that you have adapted your consultation style in order to facilitate this involvement. Review Dereks knowledge, understanding and concerns about his antihypertensive medication and .explore whether or not Derek believes that he needs the medication. Link to Medicines adherence (NICE clinical guideline 76) Case scenario 4 : Derek Answer 4.7 (continued) If you identify practical problems, consider interventions such as suggesting Derek records his medicine-taking and monitors his condition, simplifying the dosing regimen, using alternative packaging for the medicine or using a multicompartment medicines system. Ensure that Derek has received appropriate guidance and materials about the benefits of the drugs and unwanted side effects.

Repeat all of these actions on a regular basis when reviewing or prescribing antihypertensive drug treatment for Derek. Question 4.8 You conclude that Derek is adherent to his medication regime and that he is on the optimal doses of the ACE inhibitor, calcium channel blocker and thiazide-like diuretic. What would you do next? Case scenario 4 : Derek Answer 4.8 You seek a specialist opinion for Derek. You anticipate he will be started on step 4 treatment. Case scenario 5 : Philip Presentation Philip is a 56-year-old male who presents to you with feelings of dizziness every time he stands up. Medical history Philip has migraines and takes propranolol modified-release 160 mg daily, which has reduced the frequency. He attends the GP surgerys weight loss clinic. He has lost five stones in 12 months and his BMI is now 29. On examination Philips ECG is normal and his blood pressure is 126/82 mmHg. Question 5.1 What would you do next to investigate the cause of Philips dizziness? Case scenario 5 : Philip Answer 5.1 As he was seated for the first readings, you would ask Philip to stand up for one minute and then measure his blood pressure again. Question 5.2 Philips standing blood pressure is 90/50 mmHg. What would you do next? Case scenario 5 : Philip Answer 5.2 You would review Philips medication. His recent weight loss may mean that the dose of beta-blocker needs to be reduced You would note the postural hypertension in Dereks records so that colleagues measuring his blood pressure in the future are aware that they should measure his standing blood pressure, as well If changes to the migraine prophylaxis do not relieve Dereks dizziness you would consider referral to a specialist. Find out more Visit www.nice.org.uk/guidance/CG127 for: the guideline the quick reference guide Understanding NICE guidance costing report and statement audit support and electronic audit tool baseline assessment tool Implementation advice podcast awareness raising slide set THANKS