Dudley Hypertension Pathway. Presented for discussion, approval and ratification to

e Dudley Hypertension Pathway Document Description Document Type Clinical Pathway Service Application Diagnosis and Management Version 2.0 Ratification date May 2016 Review date May 2018 Lead Author(s) Name Position within the Organisation Shelagh Cleary Vascular Programme Manager, Lead Vascular Nurse, DMBC Clair Huckerby Pharmaceutical Advisor- Medicines Optimisation Lead, Dudley CCG Presented for discussion, approval and ratification to Area Clinical Effectiveness Sub Committee Change History Version Date Comments 1.0 July 2014 Approved 1.1 April 2016 Updated 2.0 May 2016 Approved 1

Background This pathway will cover screening, diagnosis, treatment and referral options for people with, or suspected of having hypertension, the links to other programmes such as the NHS Health Checks programme and to the Quality and Outcomes Framework. The pathway applies directly to all service providers in Dudley who are involved in the management of people with hypertension and is recommended as good practice guidance for each of the independent contractor professions. National and local guidance, policies, reports and/or papers which this particular document should be read in conjunction with are as follows. Local Dudley Guidance: Best Practice Guidelines for Lifestyle Assessment Cardiovascular Risk pathway Hyperlipidaemia Guidelines Diabetes Adult Management Guidelines National Guidance: NICE Guidelines for: Management of Atrial Fibrillation Secondary Prevention of Myocardial Infarction Management of Patients with Heart Failure Management of Hypertension Lipid Modification Management of Obesity 2

Contents: Page No. Pathway Overview 5 Introduction. 6 Signs and Symptoms.. 8 High Risk Groups. 8 Measuring Blood Pressure. 9 Postural Hypotension.. 10 White Coat Hypertension. 11 Diagnosing Hypertension.. 11 Ambulatory/Home Blood Pressure Monitoring.. 11 Urgent Referral Indications... 12 Hypertension Stages.. 12 Investigations on diagnosis 13 Initiating Medication 18 Hypertension Treatment Thresholds... 18 Blood pressure Targets. 19 Key Points in the Management of People with Hypertension... 19 Pharmacological Management of Hypertension 20 Logical Therapeutic Combinations 21 Annual Review 21 Indications for referral 22 References..23 3

Dudley Hypertension Pathway Pathway for the Diagnosis and Management of Hypertension: Including Clinic Reference Guide 4

Hypertension Pathway Overview S c r e e n i n g Introduction Signs / Symptoms High Risk Groups Measuring blood pressure ABPM / HBPM White coat hypertension Hypertension Staging Diagnostic read codes QOF contract indicators D i a g n o s i s I n v e s t i g a t i o n s Investigations on Diagnosis: Cardiovascular o Lipids o CVD Risk assessment o Manual Pulse o ECG Renal o egfr o Proteinuria o Haematuria Diabetes o Fasting glucose Lifestyle Eye Other o Thyroid function o Phaeochromatocytoma o Hyperaldosteronism o Cushing s syndrome o Obstructive sleep apnoea o Coartication of aorta o Acromegaly Initiating Medication: Treatment thresholds Blood pressure targets Key points in the management of hypertension The Pharmacological Management of Hypertension Use of antihypertensive Drugs in Concurrent States When is it Appropriate to use Betablockers? Dudley Drug Formulary: Drugs approved for the Treatment of Hypertension: M e d i c a t i o n M o n i t o r i n g Annual I Review Blood pressure targets Indications for Referral Urgent referral Useful Links Community Cardiology Service 5 R e f e r r a l

Ratio of reported to expected prevalence of hypertension by CCG 2013/14 Introduction Based on QOF returns for year end 2015 in Dudley the hypertension prevalence has increased to 17.7%, compared to Doncaster modeled figures where the expected prevalence for Dudley is 26%. This would amount to approximately 26,000 people who would be expected to have hypertension who remain undiagnosed. Despite this statistic Dudley CCG now has the highest reported to expected hypertension prevalence in England (Atlas of Variation 2013/14). 0.70 Ratio of reported to expected prevalence of hypertension by CCG (QOF 2013/14 hypertension prevalence / Estimated prevalence modelled by the former ERPHO 0.60 0.50 Dudley CCG CCGs 5th (Best) Quintile CCGs 4th Quintile CCGs 3rd Quintile CCGs 2nd Quintile CCGs 1st (Worst) Quintile 0.40 0.30 CCG Collaborative working across the Health Economy over the last decade has seen the Standardised Mortality Rate from hypertension related diseases move from twice the England average to be in line with the England average. 6

2001-2003 2002-2004 2003-2005 2004-2006 2005-2007 2006-2008 2007-2009 2008-2010 2009-2011 2010-2012 Standardised Rate per 100,000 Population Directly Standardised Mortality Rates from Hypertensive Disease by Year 3-Year Rates, Dudley, Both Sexes Aged Under 75, 2012 8 7 6 5 4 3 2 1 0 Continued work to reduce the hypertension prevalence gap is required. It is anticipated that for every additional 1,000 patients Blood Pressure (BP) controlled, there are 469k of savings for the NHS over 5 years, or 469 per patient. This would mean a total potential cost saving of 13m over 5 years for the 27,800 patients missing from hypertension registers in Dudley. In addition to this we know that by reducing BP from 150/90mmHg to 140/90mmHg, the risk of CHD is reduced by 22% and the risk of stroke is reduced by 41%. This pathway will cover screening, diagnosis, treatment and referral options for people with or suspected of having hypertension, the links to other programmes such as the NHS Health Checks programme and to the Quality and Outcomes Framework. Definition of Hypertension When blood pressure remains higher than normal over time (at least several months) it is called variously, high blood pressure, raised blood pressure or hypertension. Hypertension occurs when the heart has to use more energy to pump against the greater resistance of the vascular system Blood Pressure = Cardiac Output x Peripheral Resistance Hypertension screening is included in the NHS Health Checks Programme, which seeks to invite people without a vascular condition or hypertension for a health check. If blood pressure is found to be raised at the time of the check, this is highlighted to GP practices who then follow-up these patients following the hypertension diagnostic pathway. NHS Health Check: Dudley Pathway Vascular Risk Assessment and Management 7

Signs and Symptoms Hypertension is usually asymptomatic, but there are some indicators which should prompt a blood pressure check. These include: Headaches Dizziness Blurred vision Epistaxis Tinnitus Palpitations Nocturia Other symptoms may indicate blood pressure has risen to a dangerously high level. These include: Chest pain Sweating Shortness of breath Wheeze Transient vision loss Loss of consciousness Fits High Risk Groups Some co-morbid conditions are more commonly associated with hypertension, these are: Cardiovascular: o Coronary heart disease o Stroke and TIA Renal o Chronic Kidney disease o Phaeochromatocytoma Endocrine o Diabetes o Hyperaldosteronism o Cushing s syndrome o Hyperthyroidism o Acromegaly Pulmonary o Chronic obstructive pulmonary disease o Obstructive Sleep apnoea Some lifestyle behaviours will increase the risk of developing hypertension. These include: Smoking Hyperlipidaemia Alcohol consumption (where this is over recommended limits) Obesity Physical inactivity High salt intake 8

Certain drugs may also affect blood pressure levels. These include: Combined oral contraceptives Immunosupressants NSAIDS COX 2 Stimulants (including caffeine products such as coffee, cola) Mineralocorticoids Anti-parkinsons drugs Monoamine oxidase inhibitors Anabolic steroids Sympathomimetics Soluble analgesia and indigestion remedies have a high salt content and should also be avoided where possible. For further information see the Dudley guideline, Salt Content of Soluble Analgesics and Indigestions Remedies Other Determinants Hypertension is more common in BME groups. African-Caribbean groups have a higher risk of hypertension and subsequent stroke or renal failure, but not higher levels of coronary heart disease, whilst South Asians also have a higher risk of hypertension, but tend to have higher levels of coronary heart disease. http://qjmed.oxfordjournals.org/content/94/7/391.full.pdf+html Black people (as they are referred to in NICE guidance), i.e. those people of African or African-Caribbean origin have a much higher prevalence of hypertension. For this reason, many studies have been conducted looking at their response to anti-hypertensive medication. Differences were found in response to drug treatment for black people, indicating treatment with specific anti-hypertensive drugs and combinations. http://www.york.ac.uk/inst/crd/ehc/ehc84.pdf People in lower socioeconomic groups also have a higher risk of hypertension and an increased risk of cardiovascular mortality compared to more affluent groups. http://journals.lww.com/jhypertension/abstract/2009/04000/risks_of_socioeconomic_depriva tion_on_mortality_in.11.aspx Measuring Blood Pressure Devices Mercury Sphygmomanometers continue to provide the reference standard for measurement of blood pressure although, due to their bulk and the fact that they contain mercury their use is currently being phased out. If using a mercury device, then a mercury spillage kit should be available at all times and it should not be taken out of the building. Mercury devices are not available to buy. Hybrid devices are available which resemble the mercury sphygmomanometer but use an LED display in place of a mercury column. They are used in the same way as the mercury devices by auscultation of the brachial artery. 9

Aneroid Sphygmomanometers measure pressure using a bellows system. They can be less accurate than alternatives, especially over time. For this reason it is recommended that they are calibrated every 6 months. Automated devices are recommended for ease of use in clinic and by patients for HBPM. However, as the devices work on oscillometry which needs to be in a regular flow, any irregular pulse will cause an error message on the machine. If error messages are observed, then a manual pulse should be taken to rule out an irregular pulse before attempting to measure blood pressure with the automated device again or with another device Taking a Blood Pressure Measurement Blood pressure (BP) should be measured by a health care professional who has undergone training, using a machine which is regularly serviced and calibrated. The patient should be seated comfortably and relaxed. Before commencing the blood pressure measurement, manually palpate the radial or brachial artery and note the pulse rhythm. If there is an irregular pulse present, then automated devices will not work (they will display an error message) or if readings are given they will be unreliable. If an irregular pulse is present, blood pressure should be recorded by direct auscultation of the brachial artery. To measure blood pressure the patients arm should be supported at chest level. An appropriate size cuff should be used for which the inner bladder fits to at least 80% of the upper arm circumference but not more than 100%, i.e. there is no overlap. Under cuffing will overestimate blood pressure while over cuffing will underestimate blood pressure. BP should be measured in both arms. If there is a discrepancy of more than 20mmHg, repeat the measurements to confirm. If the discrepancy persists, then the arm with the higher reading should be used. This arm can then be noted and should be used for each subsequent visit. (N.B. the arm with the lower pressure indicates vascular compromise and so examination and appropriate referral is indicated) If the BP is above 140/90, (either systolic, diastolic, or both) check the BP again to confirm. If there is a substantial difference between the first 2 readings take a third measurement at the end of the consultation or after a short interval of 5 10 minutes, where patient remains seated comfortably. The blood pressure should be recorded as the lower of the last 2 readings taken N.B. If the BP is > 180/110, urgent (same day) referral /management is needed to identify other co-morbid conditions and the possibility of accelerated hypertension. Postural Hypotension Where postural hypotension is suspected, i.e. in those with dizziness on standing, falls, people with diabetes or the elderly, according to NICE Clinical Guideline 127: Hypertension: 10

Measure the BP with the person seated or lying. Ask the person to stand and then measure BP after 1 minute. If there is a drop of 20mmHg systolic pressure or more on standing then postural hypertension is present. The recommendations for confirming postural hypotension (Consensus Statement on the Definition of Orthostatic Hypotension, Consensus Committee of the American Autonomic Society) is: To lie the patient flat for 10 minutes Measure BP Stand the patient Measure BP again 1-3 minutes after standing. White Coat Hypertension White coat hypertension is defined as those with persistently elevated clinic BP measurements but normal daytime average BP readings. In patients experiencing white coat hypertension a difference of at least 10/5 mmhg is observed between home and clinic measurements. This can be much greater in those with a higher baseline blood pressure and tends to increase with age. Where white coat hypertension is suspected, a request for Ambulatory Blood Pressure monitoring (ABPM) or Home Blood Pressure monitoring (HBPM) should be made when considering a hypertension diagnosis. White coat effect occurs in someone who has hypertension and is on treatment, but has clinic readings are consistently higher than home readings. This can lead to problems when titrating medication and lead possibly to over medication. It is suggested that where white coat effect is suspected that HBPM is considered. Diagnosing Hypertension 1. If the BP recorded after following the procedure above is 140/90, check this reading on 2 more consultations 2 4 weeks apart. 2. Exclude the possibility of confounding factors such as white coat hypertension following the guidance above. 3. If the BP is found to be consistently 140/90, then a diagnosis of hypertension should be made. NICE Definition of Hypertension: Persistently raised BP 140/90 mmhg Ambulatory BP Monitoring (ABPM) / Home BP Monitoring (HBPM) 11

For all patients with a BP of 140/90 or more, confirmed on a further 2 occasions, offer ambulatory BP monitoring to confirm the diagnosis of hypertension. If ABPM is not tolerated then HBPM can be offered as a suitable alternative. Access to ABPM ABPM can be accessed by: GP practice if equipment and appropriate clinical expertise is available to interpret results Referral to Community Cardiology service Referral to Cardiology Dept ABPM the test 2 measurements must be taken per hour during waking hours (08:00 22:00) Calculate the average value of at least 14 measurements. Hypertension is diagnosed if the average BP is 135/85 HBPM Suitable equipment must be provided and checked by the issuer. Training must be given to the patient to ensure correct measurements are taken Measurements must be taken twice a day, morning and evening if possible Each reading must be taken with the patient seated and relaxed 2 readings must be taken at each occasion with at least a minute apart and the lower of the 2 recorded. Continue recording BP for 7 days (or at least 4 days if this is not possible) When analysing results discard the results taken on the first day and calculate the average of the remaining results. Hypertension is diagnosed if the average BP is 135/85 If a diagnosis of hypertension is confirmed, then the level of hypertension should be staged as follows: Hypertension Stage Criteria Normotensive < 135/85 1 140/90 or 135/85 ABPM or HBPM average result 2 160/100 or 150/95 ABPM or HBPM average result Severe 180/110 If hypertension is not diagnosed, BP should be checked every 5 years. Where BP is borderline, follow-up should be arranged more frequently. Urgent Referral indications Arrange urgent referral for: Accelerated hypertension -BP 180/110 and papilloedema/retinal haemorrhage present, arrange urgent referral to cardiology. Phaeochromatocytoma - BP 180/110,postural hypertension, headache, palpitation, sweating. 12

Investigations on Diagnosis A diagnosis of hypertension should prompt investigation of possible target organ damage, vascular assessment and investigation of conditions which may cause or contribute to the progression of the condition. The following investigations should be undertaken. N.B. For people aged under 40 with stage 1 hypertension and no evidence of target organ damage, consider specialist referral for more detailed assessment. CVD risk calculators may underestimate the lifetime risk of CVD events in these people. Cardiovascular (CVD) Lipid profile Fasting blood samples should be sent requesting a full lipid profile, i.e. total cholesterol (TC), high density lipoprotein (HDL), low density lipoprotein (LDL) and triglycerides (TG). Target values for primary prevention are given below: Lipid Total Cholesterol HDL Ratio (TC/HDL) LDL Triglycerides Target value / mmol/l 4.0-5.0 or less 1.0 or more ( 1.2 in women and people with diabetes) 4.0 5.0 or less 2.0-3.0 or less 1.7 or less If the lipid values are out of normal range, advise a low cholesterol diet and modification of lifestyle behaviours for at least 3 months and re-check. If lipids remain out of range, consider further lifestyle modification and initiation of lipid lowering medication according to Dudley Hyperlipidaemia Guidelines Familial Hyperlipidaemia (FH) Familial Hyperlipidaemia should be considered in any patient with: TC - 7.5 mmol/l or more, and/or LDL 4.9 mmol/l or more In the presence of tendon xanthoma and/or o Premature CVD (CVD diagnosis in males aged <55, females aged <65) o Premature familial CVD (1 st degree relative with CVD diagnosis in male aged <55 or female <65) Follow Dudley Hyperlipidaemia Guidelines where FH is suspected. CVD Risk Assessment An estimation of CVD risk should be calculated using QRISK2 http://qrisk.org/ The lipid value used to calculate CVD risk is TC:HDL ratio, i.e. TC /HDL If the risk score is calculated as high risk, i.e. 20% risk of CVD in the next 10 years or more then the patient should be added to the practice high risk of CVD register. To do this, add the read code: 14O70 High risk of heart disease. Lipid lowering medication should be considered for all those at high risk following local Dudley Hyperlipidaemia Guidelines. 13

Manual Pulse Palpation A manual pulse should be palpated each time blood pressure is measured, especially in any patient over 50 years of age or experiencing symptoms of atrial fibrillation. If an irregular pulse is detected, then an ECG should be performed to detect abnormality. See NICE guidance Electrocardiogram (ECG) A 12-lead ECG should be performed on diagnosis of hypertension to detect any undiagnosed conditions, such as left ventricular hypertrophy and also to provide a baseline. Renal Chronic Kidney Disease (CKD) is the most common identifiable cause of hypertension. Also see Phaeochromatocytoma and primary aldosteronism Estimated Glomerular Filtration Rate Blood specimens should also include a request for estimated glomerular filtration rate (egfr), serum creatinine and urea. Any egfr result of <90 mls/min should be followed up appropriately using the NICE CG73 Proteinuria Proteinuria should be measured by sending early morning urine samples to the biochemistry laboratory requesting the albumin/creatinine ratio (ACR). Positive proteinuria is defined by ACR of 30mmol/l or more. Haematuria A dipstick test should be performed for the presence of blood in the urine. The presence of blood may indicate a urological or a renal origin and should prompt further investigation. For all positive haematuria and proteinuria tests follow the NICE CG73 Type 2 Diabetes Fasting Serum Glucose Blood specimens should include a request for fasting serum glucose or HbA1C. o A fasting serum glucose of 6.1mmol/l to 6.9mmol/l or an HbA1C of 42 to 47 may indicate a diagnosis of non-diabetic hyperglycaemia NDH. o A fasting serum glucose result of 7.0mmol/l or an HbA1C of 48 or more may indicate a diagnosis of type 2 diabetes, especially where osmotic symptoms and /or ketonuria is present. See Dudley Diabetes Guidelines Lifestyle Smoking Smoking status should be recorded. This should be repeated annually except for those who have never smoked. 14

For smokers and those who have quit within the last 5 years, calculate lifetime tobacco exposure as pack years, http://smokingpackyears.com or use the link on the LTC template in Emis. Assess motivation to quit smoking and offer referral to stop smoking clinic, either in practice or to Dudley Stop Smoking Service. For information on assessing motivation and referral see Best Practice Guidelines for Lifestyle Assessment Healthy Diet Assess diet objectively using the Dudley Assessment Questionnaire in Best Practice Guidelines for Lifestyle Assessment. This will indicate a dietary assessment of good, average or poor diet. Record the result in the patient medical record. Give healthy diet advice for all those with an average or poor score Further assessment for progress to improve diet can be made by repeating the score after a period of time when changes have been made successfully. In particular, in addition to healthy diet advice: o Salt consumption this should be no more than 6g a day (1 level teaspoon). If expressed as sodium to maximum daily consumption should be 2.5g. Do not advise the use of branded salt substitute products as these contain potassium chloride) o Caffeine limit consumption to 5 teacups (200mls each) a day. Advise particular caution with energy drinks and fizzy drinks containing caffeine. Weight/Body Mass Index (BMI) Measure height and weight and calculate BMI. BMI classification below: BMI (kg/m 2 ) BMI Classification < 18.5 Underweight 18.5 24.9 (south Asian 18.5 23) Healthy weight 25 29.9 (south Asian 23 27.5) Overweight 30 (south Asian 27.5) Obese For those who are overweight or obese give advice on a reducing diet and consider referral. See Best Practice Guidelines for Lifestyle Assessment Waist Measurement Body shape and fat distribution gives an indication of CVD risk. A large waist, especially where the waist measurement is larger than the hip measurement is associated with increased risk of CVD. It is also associated with the development of metabolic syndrome and diabetes. Waist measurements associated with increased risk are given below: Gender/Ethnicity Men Women Asian men Asian women Increased Risk 40 inches (102cm) 35 inches (88cm) 90cm 80cm All those with large waist i.e. central visceral fat distribution, should be advised to reduce weight and increase physical activity if they are inactive. 15

For guidance on measuring waist circumference see Best Practice Guidelines for Lifestyle Assessment Physical Activity The recommendation for physical activity is either: 75 minutes of vigorous exercise a week 30 minutes of moderate intensity activity on at least 5 days of the week 150 minutes of moderate exercise per week Or a combination of all of the above To assess physical activity status use an objective measurement, which reproducible and can be used to track progress when repeated after changes are made. Use either: The Physical Activity Self Assessment graph o Anyone with a sedentary or not enough score should receive advice and brief intervention The GP Physical Activity Questionnaire GPPAQ o Anyone with an inactive or moderately inactive score should be offered physical activity advice and brief intervention See Best Practice Guidelines for Lifestyle Assessment Alcohol Consumption Assess alcohol consumption and record as number of units consumed per week. The recommended limits are: 14 units/week - males and females Alcohol should also be assessed as to daily consumption. For those with a diagnosis of hypertension the daily limit is: 1-2 units/day To include at least 2 alcohol free days a week The AUDIT questionnaire should be completed using the Emis template http://www.alcohollearningcentre.org.uk For further information see Best Practice Guidelines for Lifestyle Assessment Eyes The fundi should be examined for the presence of hypertensive retinopathy. Other Causes Thyroid Function Initial blood samples should also include a request for thyroid function. 16

The presence of an overactive thyroid hyperthyroidism, is associated with hypertension. Treatment should include regulation of the thyroid gland in conjunction with hypertension therapy. Consideration of referral to specialist management is indicated. The presence of an underactive thyroid hypothyroidism, is associated with levels of hyperlipidaemia. The thyroid condition should be treated and fasting lipids repeated during a state of euthyroid. Phaeochromatocytoma A phaeochromatocytoma is a tumour which releases large amounts of adrenaline and noradrenaline. Patients with signs and symptoms suggestive of a phaeochromatocytoma should be referred for immediate specialist treatment due to the seriousness of the condition and the risk it carries. Signs and symptoms include: Raised blood pressure 180/110mmHg Postural hypotension Palpitation and tachycardia Headache Raised glucose levels Facial flushing Nervousness Sweating Decreased gastrointestinal movement Oedema Hyperaldosteronism (primary aldosteronism) Aldosterone is a hormone which controls sodium and water balance. Typical signs and symptoms as well as hypertension include: Sodium retention Low serum potassium Possible irregular pulse Muscle weakness Where Hyperaldosteronism is suspected plasma aldosterone: renin ratio should be requested and referral to specialist considered. Cushing s Syndrome Cushing s syndrome is caused by excess production of glucocorticoids. Signs and symptoms including hypertension are: Sudden weight gain Central obesity Striae, thinning and darkening of the skin Moon face Weakness, muscle atrophy and fatigue Osteoporosis Backache Headache Glucose intolerance Oligomenorrhoea/amenorrhoea Thirst Polyuria Impotence 17

Depression and insomnia Where Cushing s syndrome is suspected, referral for specialist treatment should be considered. Obstructive Sleep Apnoea (OSA) Obstructive sleep apnoea is caused by the upper airway becoming obstructed during sleep. It is more common in men, especially those with a large collar size (17+) or who are obese. Signs and symptoms including hypertension are: Daytime drowsiness Snoring Oedema to the lower extremities Nocturia Morning headache Where OSA is suspected an OSA assessment should be requested and referral to respiratory specialist considered. For more information on OSA refer to NICE TA 139 Coartication of Aorta Coartication of the aorta is a congenital condition where a segment of the aorta is narrowed, reducing oxygenated blood flow around the body. Signs and symptoms in addition to hypertension are decreased or delayed femoral pulse and abnormal chest X-ray. Where coartication of the aorta is suspected, refer to cardiology for Doppler or CT imaging. Acromegaly Acromegaly is caused by excess production of growth hormone. Signs and symptoms in addition to hypertension are: Cardiomegaly Enlarged facial features Enlarged jaw Headache Joint pain Excessive hair growth Sweating Drowsiness, tiredness and weakness Impaired glucose tolerance Initiating Medication: Hypertension Treatment Thresholds 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 QRISK2 score of 20% or greater 18

Blood Pressure Targets Long-term Evidence Based Target Condition Primary 140/90 ( 135/85 HBPM) Hypertension 150/90 If aged over 80 years CVD 140/90 Diabetes 140/80 130/80 If eye, kidney or cerebrovascular complications: CKD 120 139/ 90 120 129/80 If ACR 70: Treatment to these targets is essential for reducing the risk of complications and the development of other co-morbid conditions Key Points in the Management of Hypertensive Patients For blood pressure measurement guidance referring to treatment thresholds and target ranges it is recommended that NICE guidance is followed. This is available locally in the Clinical Pathway for the Management of Cardiovascular Risk. Where Chronic Kidney Disease is present follow the NICE guidance. When titrating patients it is imperative that BP readings are taken regularly and treatment is reviewed at each consultation. Where possible take blood pressure readings at the same time of day. Robust recall systems need to be in place along with a medication review programme in order to improve compliance and concordance. Patients who do not attend for blood pressure monitoring on 3 separate occasions, or make a decision that they do not wish to receive blood pressure monitoring, need to fully understand the decision they are making about their treatment and their health. Once they understand their decision they can then be recorded as giving informed dissent using the Read code 8I3Y. They will then be removed from the denominator population for this indicator in the LTC framework. Prior to initiating antihypertensive treatment ensure that non-pharmacological options are considered and used first, refer to the Clinical Pathway for the Management of Cardiovascular Risk which includes lifestyle guidance. Guidance on the management and limitation of the salt content of medicines is available following the link. Hypertensive patients prescribed drugs with a high content of salt should have their treatment reviewed as this could limit the effectiveness of the antihypertensive. Within Dudley Health Economy Practice Based Pharmacists (PBPs) are widely involved in the management of patients with long term conditions in particular those with hypertension. A protocol for the management of hypertensive patients as part of a PBP clinic is available from the Prescribing Team. Allow at least 4 weeks at a dose for a full response. Treatment should be reviewed if BP falls below the optimal level. Refer to the Clinical Pathway for the Management of Cardiovascular Risk for practical issues and those not covered by this guideline when managing hypertensive patients. 19

The Pharmacological Management of Hypertension Patient aged <55 years Patient aged 55 years or black patients of any age STEP 1 ACE-inhibitor or Low cost ARB (A)* E.g. Ramipril, Lisinopril or Perindopril Low cost ARB = Losartan Check renal function 7-10 days post initiation and each dose up-titration. CCB contraindicated or not tolerated First line, always consider: Calcium Channel Blocker (C) E.g. Amlodipine Unless contraindicated, not tolerated or person has evidence of oedema, heart failure or at high risk of heart failure Thiazide type or like diuretic (D) E.g. Bendroflumethiazide 2.5mg daily or Indapamide 2.5mg daily Check plasma K+ 3-4 weeks after start of treatment. Consider social circumstances. STEP 2 A + C STEP 3 A + C + D STEP 4 Resistant Hypertension Consider either: Spironolactone** 25mg od if K+ 4.5mmol/l. Exercise caution in low egfr as greater risk of hyperkalaemia. Monitor K+ 3-4 weeks after treatment initiation. Other high dose thiazide diuretics (stop present D) Beta Blocker e.g. Bisoprolol, Atenolol or Labetalol (in pregnancy or child bearing women) Alpha Blocker e.g. Doxazosin immediate release (avoid in heart failure) Aliskiren (secondary care nephrology/cardiology initiation only) Consider seeking specialist advice or opinion A = ACE I or low cost ARB C = Calcium Channel Blocker D = Diuretic (thiazide type or like) *ARBs (Irbesartan & Candesartan) are appropriate as an alternative to an ACE-I when an ACE is not tolerated or contra-indicated. Losartan has been approved for hypertension with diabetic / nephropathy and Valsartan has been approved for hypertension post MI. **Spironolactone not licensed for hypertension so obtain informed consent and document. 20

Logical Therapeutic Combinations All combinations of drugs work except: Verapamil + BB use is contraindicated (depress cardiac rate and function). Diltiazem + BB should be used only under specialist supervision. ACE-I + B have opposing modes of action and should be used in patients with IHD only. Do not use BB and D in combination in those at risk of diabetes. When is it Appropriate to Use Beta-blockers in the Management of Hypertension? For new prescriptions beta blockers are not a preferred initial choice of therapy but may be considered in younger people, particularly: Those with an intolerance or contraindication to ACE-I / ARB Women of child bearing potential or in pregnancy (Labetalol) Patients with evidence of increased sympathetic drive Here, D is best avoided (not absolutely contraindicated) to reduce the risk of new onset diabetes Mellitus. When reviewing those on existing beta blocker therapy, if: BP is not well controlled ( 140/90mmHg) treatment should be revised according to the algorithm. BP is well controlled ( 140/90mmHg) long-term management should be considered as part of the routine review, there is no absolute need to replace the beta-blocker with an alternative agent. Dudley Drug Formulary: Drugs approved for the Treatment of Hypertension (Refer to current BNF for latest prescribing information) Please refer to the local Dudley Drug Formulary Annual Review Annual review should be carried out for all those with hypertension, GP contract indicators stipulate at least 6 monthly monitoring of blood pressure. The annual review should include: Measurement of blood pressure and review of home monitoring Medication review and treatment to target (see blood pressure targets) Bloods: o Urea and electrolytes, egfr 21

o Lipid profile o Fasting serum glucose o Liver function (if taking lipid lowering medication or other indication) Review of symptoms, including identification of new onset suggestive of CVD event or diagnosis: o Chest pain o Shortness of breath o Fatigue o Oedema o Manual pulse o Headache o TIA Review and revision of lifestyle goals, assessment of motivation Blood Pressure Targets (mmhg) Primary 140/90 ( 135/85 HBPM) Hypertension If aged over 80 years: 150/90 CVD 140/90 Diabetes 140/80 If eye, kidney or cerebrovascular complications: 130/80 CKD 120 139/ 90 If ACR 70: 120 129/80 Indications for Referral See urgent referral General Referral Indications Poor response to treatment. Where Blood pressure remains uncontrolled despite 3 antihypertensive agents: o Check patient concordance with treatment o Where possible use once daily preparations o Allow at least 4 weeks for therapeutic effect N.B. It is extremely rare for intolerance to all major drug classes. Discuss hypertension risks and agree a management plan. Seek advice from practice based pharmacist before considering referral. Suspected renal artery stenosis: o A rise of >30% in creatinine or fall of >25% egfr from baseline o BP >150/90 mmhg despite 3 antihypertensives o Unexplained hypokalaemia o Flash pulmonary oedema Investigate and treat secondary causes. refer following indications Dudley pathway guidance (see useful links) 22

References National Clinical Guideline Centre (2011) Clinical Guideline 127. Hypertension: The Clinical Management of Primary Hypertension in Adults. http://guidance.nice.org.uk/cg127 British Hypertension Society http://www.bhsoc.org/ National Institute for Clinical Excellence (2006). Hypertension: Management of Hypertension in Adults in Primary Care. London Dudley Formulary www.dudleyformulary.nhs.uk 23

Abbreviations (main pathway and clinic guide) A ABPM ACE ACEI ACR ARB B BB BMI BP C CCB CHD CKD Angiotensin Converting Enzyme Inhibitor Ambulatory Blood Pressure Monitoring Angiotensin Converting Enzyme Angiotensin Converting Enzyme Inhibitor Albumin:Creatinine Ratio Angiotensin Receptor Blocker Beta Blocker Beta Blocker Body Mass Index Blood Pressure Calcium Channel Blocker Calcium Channel Blocker Coronary Heart Disease Chronic Kidney Disease COX2 Cyclooxygenase 2 CVD COPD CT D DAQ DES ECG Echo egfr GP GPPAQ HBPM HDL ISH Cardiovascular Disease Chronic Obstructive Pulmonary Disease Computerised Tomography Diuretic Dudley Assessment Questionnaire Designated Enhanced Service Electrocardiogram Echocardiogram Estimated Glomerular Filtration Rate General Practitioner General Practice Physical Activity Questionnaire Home Blood Pressure Monitoring High Density Lipoprotein Isolated Systolic Hypotension JBS2 Joint British Societies 2 K+ Potassium 24

LDL LV MI mmhg mmol/l NHS NICE NSAIDs QOF QRISK2 TC TG TIA UE Low Density Lipoprotein Left Ventricular Myocardial Infarction Mini-moles of Mercury Mini-moles per Litre National Health Service National Institute for Clinical Excellence Non-Steroidal Anti-Inflammatory Drugs Quality and Outcomes Framework QResearch CVD Risk Calculator Total Cholesterol Triglycerides Transient Ischaemic Attack Urea and Electrolytes 25