NICE BHS Hypertension guidelines 2011 update Review for clinicians Sept 2011 Mark Thomas West Midlands Hypertension Centre Heart of England NHS Trust www.wmhc.co.uk mark.thomas@heartofengland.nhs.uk Full update at: http://www.nice.org.uk/nicemedia/live/13561/56008/56008.pdf Slide set at: http://guidance.nice.org.uk/cg127/slideset/ppt/english Other information including Clinical Case scenarios available via: http://guidance.nice.org.uk/cg127
Questions select your one best answer What is the preferred step 2 Renin-Angiotensin system inhibitor for Afro Caribbean patients? ACE inhibitor ARB Do not use as they respond poorly to these agents If you do use ambulatory BP monitoring, which measurement do you consider? mean daytime BP mean 24hr BP mean early morning BP
Questions select your one best answer What is the preferred method to diagnose HTN? at least three clinic readings on separate days ambulatory BP monitoring home BP monitoring Which of these is a preferred diuretic for initiation in hypertension? Furosemide 20 mg Hydrochlorothiazide 12.5 mg Bendroflumethiazide 2.5 mg Chlortalidone 25 mg
Questions select your one best answer What is the preferred step 2 Renin-Angiotensin system inhibitor for Afro Caribbean patients? ACE inhibitor F ARB T Do not use as they respond poorly to these agents F If you do use ambulatory BP monitoring, which measurement do you consider? mean daytime BP T mean 24hr BP F mean early morning BP F
Questions select your one best answer What is the preferred method to diagnose HTN? at least three clinic readings on separate days F ambulatory BP monitoring T home BP monitoring F Which of these is a preferred diuretic for initiation in hypertension? Furosemide 20 mg F Hydrochlorothiazide 12.5 mg F Bendroflumethiazide 2.5 mg F Chlortalidone 25 mg T
Diagnosis ABPM is the preferred method of diagnosis of primary HTN: if BP in clinic 140 or 90 mm Hg take a second reading if second reading substantially different take a third reading record lower of last two readings if clinic BP 140/90 confirm with ABPM
ABPM Take tworeadings per waking hour Need at least 14 measurements in waking hours Use mean daytime/waking BP value as the measure of choice
Home BP monitoring Not as good as ABPM Use if cannot tolerate ABPM 2 early AM plus 2 early evening readings Readings at least 1 minute apart, seated At least 4 days, ideally 7 days of 4 readings/day Discard first days readings and average the rest
Implementation BMJ comment Median cost of a single ambulatory monitoring device was estimated at 1016 ( 1160; $1638), and 380 was needed each year per device for servicing, calibration, and replacement of parts General practices and emerging consortiums should therefore work closely with secondary care to develop local ambulatory monitoring implementation plans
Diagnostic cutoffs Stage Lower limit Upper limit Comment I Clinic AND 140/90 <160/100 (159/99) I ABPM 135/85 <150/95 (149/94) Daytime mean II Clinic AND 160/100 <180/110 (179/109) II ABPM 150/95 Daytime mean III Clinic 180/110 Start therapy immediately
Thresholds for intervention Stage III: Treat all Stage II: Treat all Stage I: aged 40 79 years Treat if any of TOD, diabetes, renal disease, cardiovascular disease or 10 yr CVD risk 20% aged under 40 years Treat if any of TOD, diabetes, renal disease, cardiovascular disease or 10 yr CVD risk 20% If no risk factors consider specialist evaluation and more detailed assessment of TOD 10 year risk estimation can underestimate lifetime risk in these younger patients
Aged under 55 years A Aged over 55 years or black person of African or Caribbean family origin of any age C 2 Step 1 Summary of antihypertensive drug treatment A + C 2 A + C + D Resistant hypertension A + C + D + consider further diuretic 3, 4 or alpha-or beta-blocker 5 Consider seeking expert advice Step 2 Step 3 Step 4 Key A ACE inhibitor or low-cost angiotensinii receptor blocker (ARB) 1 C Calcium-channel blocker (CCB) D Thiazide-like diuretic See slide notes for details of footnotes 1-5
Followup Method of BP monitoring If no WC effect: followup with clinic measurements If WC effect followup with ABPM or HBPM Target BP Under 80 years aim Clinic BP < 140/90 aim ABP/HBP < 135/85 80 years and over aim Clinic BP <150/90 aim ABP/HBP < 145/85
Changes to regime see NICE slides Diuretics drop out of both step 1 and step 2 However diuretics remain as part of step 1 in AFC or >55 year old patients with: oedema/intolerance with CCBs heart failure high risk of HF Typically step 2 is combination of A + C
Step 2 in Afro Caribbean patients For step 2 a low cost ARB is recommended for combination with a CCB in preference to an ACE inhibitor
Changes to regime see NICE slides Diuretics: Chlortalidone 12.5 25 mg od Indapamide 1.5 mg SR or 2.5 mg Bendroflumethiazide or Hydrochlorothiazide no longer recommended for initiation but should continue if patient stable If BP not controlled on optimal / best tolerated doses of A + C + D = resistant HTN
Step 4 Resistant Hypertension options if K 4.5 mmol/l Spironolactone 25 mg od if K > 4.5 mmol/l Higher dose thiazide like diuretic if above not tolerated, not effective or contraindicated: αor βblocker recommended