CVD Risk of Hypertension. Regina Giblin CVD Clinical Development Coordinator

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1 CVD Risk of Hypertension Regina Giblin CVD Clinical Development Coordinator

CVD Clinical Development Coordinator In-house education

uk Often interactive with questions and case studies

studies Individual practice (ECG reading) worksheets,

3 CVD Clinical Development Coordinator In-house education for your team: Regina Giblin Often interactive with questions and case studies throughout Facilitated discussions & reflection Case studies Individual practice (ECG reading) worksheets, practice ECG s Quizzes Presentations Group Work Individual work or in pairs

4 2020 VISION Fewer people die early or suffer from cardiovascular disease (CVD) People have lower risk factors, helping prevent CVD Fewer people die of heart attacks, and out of hospital cardiac arrest survival rate increases from below 10% All people with cardiovascular disease and cardiac conditions get the information, guidance and support they need

5 Risk Factors Increase our likelihood of developing Cardiovascular Disease Q: Are you able to identify the CVD Risk Factors?

7 Tackling High Blood Pressure Better prevention Better detection Better management People from the most deprived areas are 30% more likely than the least deprived to have high blood pressure

8 Hypertension Better Prevention Better Detection Better Management

9 What Is Blood Pressure? The pressure of blood in the arteries Systolic pressure Diastolic pressure What is a normal blood pressure?

10 BP High- So What? Major risk factor for strokes, heart attacks, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension can cause vascular and renal damage leading to a treatment-resistant state Each 2 mmhg rise in systolic blood pressure associated with increased risk of mortality: 7% from heart disease 10% from stroke.

11 Hypertension Hypertension is common in the UK population Prevalence influenced by age and lifestyle factors and may increase with ageing population Over one quarter of the adult population in the UK have hypertension ½ are not receiving treatment for their Hypertension Half of those over 60 years have hypertension

12 It s All Atheroma Increased Pressure Turbulent Flow Endothelial Damage Development of Atheroma

13 Tower Hamlets CCG 22,835 Adults with diagnosed HTN 7.8% of the population registered with a GP however expected prevalence of hypertension in TH was 16.9%, meaning that 9.2% or 27,000 adults could have hypertension that has not been diagnosed

14 Causes of Hypertension In 95% of cases there is no identifiable cause of hypertension and it relates to lifestyle and genetic factors

15 Causes Primary Hypertension: no identifiable cause, relates to lifestyle, genetic makeup (95% cases) Secondary Hypertension: underlying cause such as renal disease, endocrine, pregnancy, adrenal gland disease Malignant Hypertension : 1% of essential (primary) and secondary will develop rapidly rising or very high BP that threatens end organ damage requires urgent action.

16 Diagnosis If the clinic blood pressure is 140/90 mmhg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. (HBPM is a suitable alternative to ABPM)

17 Correct Cuff Size? Too small a cuff on a large arm leads to over-reading Too large a cuff on smaller arm underestimation of BP

18 Ambulatory BP Monitoring When using the following to confirm diagnosis, ensure: at least two measurements per hour during the person s usual waking hours between 0800 and 2200hrs Use the average of at least 14 measurements to confirm diagnosis DRIVING and ABPM

19 Applying the monitor for ABPM Manually check the pulse Measure the patients blood pressure in both arms Measure the circumference of the patients upper arm (without clothing) halfway between the tip of the shoulder and the elbow Do 2 BP readings with the ABPM before the patient leaves the clinic

20 Additional benefits of ABPM Assessment of BP variability Diagnosis and on-going assessment of white coat hypertension or effect Evaluation of drug resistant hypertension Determining efficacy of drug treatment over 24 hours Diagnosis and treatment of hypertension in pregnancy Evaluation of symptomatic hypotension

21 Daytime & Night Time Set awake period when initially entering patient details and during the night hourly readings will allow sleep You will need a minimum of 14 daytime BP readings for accurate diagnosis and setting the intervals at every 30 minutes in the day will normally allow this

22 Dipping Status Normal circadian rhythm allows for a nocturnal drop in blood pressure of >10% If a BP does not drop ( non dipper) or the drop is >20% (extreme dipper), there is evidence that there may be increased risk of CVD (European Society of Hypertension,2013)

23 Home BP Monitoring

24 Home BP Monitoring Two consecutive seated measurements, at least 1 minute apart Blood Pressure is recorded twice daily (ideally morning and evening) Record for at least 4 days and preferably for a week Measurements on the first day are discarded and average value of all remaining is used.

25 Applying the Monitor In general use non dominant arm, unless clinical reason not to do so But use arm with higher measurement if there is a difference of >20mmHg for systolic pressure or >10mmHg for diastolic pressure between the 2 arms on 2 measurements A difference in BP of>20/10mmhg may be sign of underlying problem such as main artery stenosis to that arm or dissection of subclavian artery may need specialist investigation

26 Irregular Pulse If pulse is irregular for example in atrial fibrillation, multiple clinic readings are needed using a manual sphygmomanometer to diagnose hypertension

27 Definition of Hypertension Stage 1 Hypertension: Clinic BP is 140/90 mmhg or higher and ABPM or HBPM average is 135/85 mmhg or higher. Stage 2 Hypertension: Clinic BP 160/100 mmhg is or higher and ABPM or HBPM daytime average is 150/95 mmhg or higher. Severe Hypertension: Clinic BP is 180 mmhg or higher or Clinic diastolic BP is 110 mmhg or higher.

28 Day Time Drop If BP drops during the day, consider postural hypotension Patients with hypertension associated with a systolic drop of >20mmHg or diastolic drop of >10mmHg when standing should not be treated with antihypertensives, and may need specialist referral (BJPCN Vol10,Issue 3 Oct-Dec 2013)

29 Treatment Offer Antihypertensive Drug Treatment to people: who have Stage 1 hypertension (CBP140/90) are aged under 80 and have high CV risk, diabetes, target organ damage, renal disease, established CVD. who have Stage 2 hypertension (CBP160>100) at any age HIGH CV risk: 10 year CVD risk over 20% (utilising a tool such as QRISK2)

30 CV Risk &Target Organ Damage Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension. For all people with hypertension offer to: test urine for presence of protein take blood to measure glucose, electrolytes, creatinine, estimated glomerular filtration rate and cholesterol examine fundi for hypertensive retinopathy arrange a 12-lead ECG

31 Treatment If aged under 40 with stage 1 hypertension and without evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider: specialist evaluation of secondary causes of hypertension further assessment of potential target organ damage

32 Specialist Referral Secondary Hypertension suspected Those aged <40 assessment of end organ damage/secondary causes Suspect Phaeochromocytoma Labile BP headache sweating postural hypotension Accelerated Hypertension BP >180/110 papilledema and or retinal haemorrhages

CBPM 140/90 mmhg & ABPM/HBPM 135/85 mmhg Stage 1 hypertension CBPM 160/100 mmhg & ABPM/HBPM 150/95 mmhg Stage 2 hypertension Care Pathway If target organ damage present or 10- year cardiovascular

33 CBPM 140/90 mmhg & ABPM/HBPM 135/85 mmhg Stage 1 hypertension CBPM 160/100 mmhg & ABPM/HBPM 150/95 mmhg Stage 2 hypertension Care Pathway If target organ damage present or 10- year cardiovascular risk > 20% Offer antihypertensive drug treatment If younger than 40 years Consider specialist referral Offer lifestyle interventions Offer patient education and interventions to support adherence to treatment Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

34 Aged under 55 years A Aged over 55 years or black person of African or Caribbean family origin of any age C Step 1 Summary of antihypertensive drug treatment A + C A + C + D Resistant hypertension A + C + D + consider further diuretic3, 4 or alpha- or beta-blocker5 Consider seeking expert advice Step 2 Step 3 Step 4 Key A ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C Calcium-channel blocker (CCB) D Thiazide-like diuretic See slide notes for details of footnotes 1-5

36 Anti-Hypertensives ACE inhibitors Ramipril, Lisinopril, Perindopril Angiotensin receptor blockers Losartan, Candesartan, Valsartan, Irbesartan These drugs block an enzyme called angiotensin which then allows blood vessels to relax and widen, which lowers blood pressure. People on these drugs will need regular blood tests to check their kidney function and potassium levels, as well as regular BP checks.

37 Anti-Hypertensives Calcium Channel blockers Amlodipine. You need a regular flow of calcium into the cells of your heart muscle to contract normally. Calcium channel blockers reduce the amount of calcium entering the muscle cells of the arteries, causing them to relax and widen. As a result, BP falls. Common side effects: swollen ankles, headaches, nausea.

38 Anti-Hypertensives Diuretics (water tablets) Indapamide, bendroflumethiazide, furosemide. Diuretics act on the kidneys to increase the output of water and salt in the urine. They remove excess fluid from the body. They can cause your blood vessels to relax and dilate which can lead to a fall in BP. People on these medications will also need renal function and potassium levels checked regularly.

39 Monitoring Use clinic blood pressure measurements to monitor response to treatment. Aim for target blood pressure below: 140/90 mmhg in people aged under /90 mmhg in people aged 80 and over

40 Hypertension Targets for Diabetics Set a target blood pressure < 130/80 mmhg for people with kidney, eye or cardiovascular damage. For people with diabetes, without target organ damage set a target of <140/80mmHg (NICE 2014: Managing blood pressure in Type 2 diabetes)

41 Indications for Referral Resistant HTN Multiple adverse reactions to HTN meds Persistent non adherence Complex prescribing due to co-morbidities (e.g. CKD and ACE/ARB) Accelerated or malignant HTN Suspected secondary HTN HTN <40yrs

42 Adherence Long term persistence is known to be low. Dutch study found only 39% of patients used their medication continuously during the 10yr follow up. 22% temporarily discontinued and restarted treatment 39% discontinued treatment permanently. Check with patient and prescribing records at all HTN reviews.

43 Patient Education Provide: information about benefits of drugs and side effects details of patient organisations an annual review of care

44 Lifestyle Recommendations Offer guidance and advice about: Diet (including sodium and caffeine intake) Exercise Alcohol consumption Smoking

45 Lifestyle Modifications- Effects on Blood Pressure Modifications* Recommendation Approximate SBP Reduction Reduce weight Maintain normal body weight (BMI of kg/m 2 ) 3-20 mm Hg Adopt DASH diet Reduce dietary sodium Rich in fruit, vegetables and lowfat dairy; reduced saturated and total fat content 8-14 mm Hg <100 mmol (2.4g)/day 2-8 mm Hg Increase physical activity Aerobic activity >30 min/day most days of the week 4-9 mmhg Moderate alcohol consumption Men: < 2 drinks/day Women: < 1 drink/day 2-4 mm Hg Chobanian AV et al., JAMA 2003; 289: Blumenthal JA et al., Arch Intern Med. 2000; 160:

46 Question What is the maximum recommended daily intake of salt? 6 grams

47 Salt High salt intake linked with hypertension Do not use Reduced Sodium Supplements as they have an elevated potassium Common high salt foods include:- Cereals Bread Processed meats/foods Soups and sauces (tinned and packet) Crisps and snacks

48 Summary Blood pressure control key element of CVD risk management Good technique essential Likely to need combination therapy Lifestyle important Education Supported self-management

49 Case Scenario 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.

50 Case Scenario Danny On examination You conclude that Danny s 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 1: What would you do next?

51 Case Scenario Danny Answer 1: You would record Danny s clinic blood pressure as 149/91 mmhg. In order to diagnose hypertension, you organise ambulatory blood pressure monitoring (ABPM) to confirm a diagnosis of hypertension. When organising this you ensure that at least two measurements per hour are taken during Danny s usual waking hours. You would use the average value of at least 14 measurements taken during Danny s 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).

52 Case Scenario Danny 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 arrange for a 12-lead electrocardiograph to be performed.

53 Answer 1 (continued) Case Scenario Danny You would also carry out and a formal assessment of cardiovascular risk (Danny s 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). Additionally, you would ascertain information about lifestyle in areas such as diet, exercise, alcohol, smoking and caffeine consumption and dietary sodium intake and offer appropriate lifestyle advice. Given the history provided you ensure that you include lifestyle advice about smoking, alcohol consumption and diet and exercise Record the results of the investigations and assessments in Danny s notes.

54 Case Scenario Danny Question 2: ABPM indicates that Danny s 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 under 20%. With this information, what is your diagnosis and what would you do next?

55 Answer 2: Case Scenario Danny 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 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.

56 Case Scenario Danny Question 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. What would you consider next in order to help you decide on the best management strategy for Danny?

57 Case Scenario Danny Answer 3 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. Additionally, people under 40 years with stage 1 hypertension are less likely to have overt evidence of target organ damage or vascular disease. You decide to refer Danny for the specialist assessment.

58 Case Scenario Danny Question 3 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?

59 Case Scenario Danny Answer 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, which included the cholesterol levels to discuss prognosis and healthcare options with Danny

60 Case Scenario Danny As appropriate, you would repeat the lifestyle advice that was given in answers 1 and 2 in accordance with the guideline on areas such as diet (including sodium and caffeine intake), exercise, alcohol consumption and smoking. As Danny s 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

61 Case Scenario Danny Question 4 You have previously concluded that Danny s 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 calcium-channel blocker His clinic blood pressure is 135/86 mmhg Would you consider that his blood pressure has been controlled? What would you do next?

62 Case Scenario Danny Answer 4 Danny s 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.

63 Resources for You and Your Patient BHF Resources:- Blood pressure. 10 minutes to change your life high blood pressure How to control it (South Asians) Factfile for GP s on home monitoring Risking it DVD on CHD risk factors other Resources:- British Hypertensive Society up to date information, including guidance on ABPM, patient information, therapeutics and nutritional advice. Blood Pressure UK

64 How to Order All our resources are free to order, although we do ask for a donation if you can afford one Web: bhf.org.uk/publications Call: orderline@bhf.org.uk

65 Heart Helpline We're here to help you, whether you're calling about yourself or someone you care about. Our cardiac nurses and heart health advisors are on hand to help you answer any questions or concerns you have about heart health and heart conditions.

Join the BHF Alliance Benefits for members A valued connection with the BHF Annual learning and development allowance Access to learning and development information Access to a bespoke online

66 Join the BHF Alliance Benefits for members A valued connection with the BHF Annual learning and development allowance Access to learning and development information Access to a bespoke online discussion forum Access to Alliance regional and national events Access to BHF resources Your BHF e-newsletters Free subscription to the Heart Matters Membership and magazine Visit bhf.org.uk/alliance and complete the online application form today

67 Heart Matters Our free service offers support and information for people looking to improve their heart health. As a member you'll benefit from: a welcome pack access to our online community regular issues of Heart Matters magazine free support a dedicated Helpline access to a members' area

69 Questions?

Hypertension Clinical case scenarios for primary care

Hypertension Clinical case scenarios for primary care Implementing NICE guidance August 2011 NICE clinical guideline 127 What this presentation covers Five clinical case scenarios, including: presentation