SHAHKUR SHABIR GP REGISTRAR DR ELLA RUSSELL -GP TRAINER SUNNYBANK MEDICAL CENTRE OCT 2011

 This is the pressure in the arteries when the heart contracts and rests between beats.

 How many people in the UK have high Blood pressure.  8 Million  12 Million  16 Million

 How many people in the UK have high Blood pressure.  8 Million  12 Million  16 Million

 What percentage of hypertensives are younger than age 65?  50%

 What percentage of patients with High BP on treatment are not controlled under BP 140/90?  50%  75%  90%

 What percentage of patients with High BP on treatment are not controlled under BP 140/90?  50%  75%  90%

 How many deaths occur per year in the UK from stroke and heart attacks due to poor blood pressure control? 

 How many deaths occur per year in the UK from stroke and heart attacks due to poor blood pressure control? 

 Primary Cause is UNKNOWN-  ESSENTIAL HYPERTENSION  Secondary Hypertension  Causes include-  RENAL DISEASE: e.g Glomerulonephritis, Polycystic Kidneys, chronic pyelonephritis.

 ENDOCRINE DISEASE: Cushing syndrome Conns syndrome Phaeochromocytoma Acromegaly

 Coarctation of Aorta  Pre Eclampsia and Hypertension in Pregnancy  Drugs: Alcohol, Cocaine  Other factors: Excess alcohol Excess Salt No exercise Stress Smoking

 Usually patients are asymptomatic.  Occasionally patients may experience headaches or visual disturbances.  Patients may have End organ damage: -Left ventricular hypertrophy -TIA/CVA -Myocardial infarction -Renal impairment -PVD

 MALIGNANT HYPERTENTION  Symptoms:  Headache and BP Diastolic >140, renal failure, fits, coma, severe retinopathy.  If suspected admit as Medical Emergency.

Key changes: 1. Classifying Hypertension into stages 2. Recommending the use of Ambulatory Blood pressure monitoring (ABPM) & Home blood pressure monitoring (HBPM) 3. Calcium Channel Blockers are now considered to be superior to Thiazides 4. Bendroflumethizide is no longer the thiazide of choice For NON hypertensive patients BP should be checked every 5 years- aim is <130/85.

IN THE CLINIC If the BP is higher than 140/90, repeat BP twice in the same consult and take the lower reading. IfBP <140/90NO ACTION IfBP >140/9024 hour ABPM or HBPM

NORMOTENSIVEABPM/HBPM <135/85 STAGE 1 Hypertension-Clinic BP >= 140/90 & subsequent ABPM daytime average or HBPM >=135/85 STAGE 2 Hypertension-Clinic BP >= 160/100 & subsequent ABPM daytime average or HBPM >=150/95 SEVERE Hypertension-Clinic Systolic Bp >= 180 or Clinic diastolic BP >= 100- Refer immediately May need treatment same day! In AF patients may not be suitable for ABPM OR HBPM- so use serial Clinic BP readings

If the BP reading is >= 140/90 patients should be offered ABPM to Confirm diagnosis.  2 measurements per hour during waking hours  Use the average of minimum 14 measurements

If ABPM is declined or not tolerated of HBPM -BP should be recorded twice daily, ideally morning and evening. -BP should be recorded minimum 4 days, ideally 7 days. -Discard the first day measurements and use the average value of the remaining.

ALWAYS ADVISE ON LIFESTYLE MODIFICATION Give Explanation of HTN and CVD risk.  Stop Smoking  Limit Alcohol consumption to recommended values  Regular physical exercise  Diet- Reduce salt intake, increase fruit/vegetable, Reduce intake of saturated fat.  Eat oily fish If Cardiovascular 10 year risk is >20% then a statin is recommended.

Stage 1: ABPM/HBPM >= 135/85  Treat if <80 years and following apply-  Cardiovascular disease  Diabetes  Renal disease  10 year cardiovascular risk equivalent to 20% or greater.

Stage 2: ABPM/HBPM >= 150/95  Offer drug treatment regardless of age.  For patient <40 age consider specialist referral to exclude secondary causes.

 Patients <55 years: Use ACE INHIBITOR (Enalapril/lisinopril)  Patients>55 years or African/caribbean origin any age: Use CALCIUM CHANNEL BLOCKER (Amlodipine)

(A + C) ACE INHIBITOR & CALCIUM CHANNEL BLOCKER (if failure/high risk of failure- NO CCB, use Thiazide like diuretic)

( A + C + D) ACE + CCB + THIAZIDE-LIKE DIURETIC (not bendroflumethiazide) Remember old guidelines recommended Bendroflumethiazide. Now NICE recommend using: -Indapamide- 1.5mg m/r or 2.5mg once daily -Chlortalidone mg once daily

<80 years aim for <140/90 >80 years aim for 150/90  After STEP 3 IF Blood Pressure is >140/90 with optimal doses best tolerated.  Go to Step 4 or seek expert advice.

Consider further diuretic treatment If potassium <4.5- add spironolactone If potassium >4.5 add higher dose thiazide like diuretic treatment Consider alpha or beta blocker. SPECIALIST REFERRAL

 Cost of ABPM machine?  Average price is £  How many machines does the practice need?  Practice has 3 machines Servicing / Calibration is annual and is £8 per machine Replacement Cuffs are £46 each (factor in replacement every 3 years) No grants currently available for 24 hr BP  HCA will place Machines on patients

AUDIT FOR LAST 20 PATIENTS WHERE 24 HR BP MONITORING REQUESTED

Were all these referrals needed?? REASONS FOR 24 HR BLOOD PRESSURE MONITORING IN THE LAST 20 REFERRALS

THANK YOU! ANY QUESTIONS