MPharm Programme Hypertension PDF

WEEK 13 MPharm Programme Hypertension Slide 1 of 30 MPHM13 Hypertension  Overview WEEK 13 Definition Prevalence Type Causes Diagnosis Management...

WEEK 13 MPharm Programme Hypertension Slide 1 of 30 MPHM13 Hypertension  Overview WEEK 13 Definition Prevalence Type Causes Diagnosis Management Patients perspective Slide 2 of 30 MPHM13 Hypertension  Definition WEEK 13 It is not a disease! So what is it? Cardiac Output x Peripheral resistance = blood pressure What is a normal, high or low BP? Slide 3 of 30 MPHM13 Hypertension  What is it a risk factor for? WEEK 13 MI, HF, Stroke, CKD, PVD If hypertension is identified then a full assessment of cardiovascular risk should be undertaken not just managing the BP Remember, if a patient has hypertension but no established CVD they are treated as primary prevention rather than secondary prevention. Slide 4 of 30 MPHM13 Hypertension  Risk WEEK 13 Effective management of hypertension – 35-40% reduction in stroke incidence – 20-25% reduction in myocardial infarction – >50% reduction in heart failure SBP rise of 20 mmHg led to a doubling of age- specific mortality rates for stroke, IHD, and other vascular disease 5 mmHg reduction can reduce risk of renal failure by 25% HTN leads to increased morbidity and mortality Slide 5 of 30 MPHM13 Hypertension  Jackson WEEK 13 et al Lancet 2005 HTN & CV RISK Slide 6 of 30 MPHM13 Hypertension WEEK 12 Hypertension and cardiovascular risk Jackson et al Lancet 2005 Absolute cardiovascular disease risk (ie the probability that a patient will have a cardiovascular event in a defined period) is determined by the synergistic effect of cardiovascular risk factors present. The most powerful risk predictors are age, previous symptomatic cardiovascular disease and pathophysiological changes, such as left ventricular hypertrophy and renal impairment but many factors including increasing blood pressure and lipids, smoking, and male sex interact to determine absolute risk. Single risk factors such as blood pressure or cholesterol have a minor effect on a patients absolute risk in the absence of other risk factors, but they can have a major effect in the presence of several risk factors Slide 7 of 31 MPHM13 Cardiovascular - Hypertension WEEK 12 Slide 8 of 31 MPHM13 Cardiovascular - Hypertension  Type WEEK 13 Primary (essential) HTN – In this lecture we will focus on primary hypertension but there are situations where hypertension is secondary to an underlying cause. Slide 9 of 30 MPHM13 Hypertension WEEK 12 Slide 10 of 31 MPHM13 Cardiovascular - Hypertension  Diagnosis WEEK 13 How do patients present? Taking a BP – Manual or Machine? How and When? Slide 11 of 30 MPHM13 Hypertension WEEK 13 Measuring Blood Pressure Important points Check for pulse irregularity and if present measure manually Standardise the environment Use appropriate cuff size for patient’s arm In people with symptoms of postural hypotension: – measure blood pressure with the person either supine or seated – measure blood pressure again with the person standing for at least 1 minute before measurement Slide 12 of 30 MPHM13 Hypertension WEEK 13 Diagnosing hypertension 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 2 measurements as the clinic blood pressure. If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension Slide 13 of 30 MPHM13 Hypertension WEEK 13 Diagnosing hypertension Confirm diagnosis of hypertension in people with a: – clinic blood pressure of 140/90 mmHg or higher and – ABPM daytime average or HBPM average of 135/85 mmHg or higher. If hypertension is not diagnosed, measure the person's clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person's clinic blood pressure is close to 140/90 mmHg Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice Slide 14 of 30 MPHM13 Hypertension WEEK 12 Slide 15 of 31 MPHM13 Cardiovascular - Hypertension  Assessing CVD risk and target WEEK 13 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 factors. For all people with hypertension offer to: 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 glycated haemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol examine the fundi for the presence of hypertensive retinopathy arrange for a 12-lead electrocardiograph to be performed Slide 16 of 30 MPHM13 Hypertension WEEK 13 Lifestyle advice Offer lifestyle advice to people with suspected or diagnosed hypertension, and continue to offer it periodically Ask about people's diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure Ask about people's alcohol consumption and encourage a reduced intake if they drink excessively Discourage excessive consumption of coffee and other caffeine- rich products Encourage people to keep their dietary sodium intake low Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. Offer advice and help to smokers to stop smoking Slide 17 of 30 MPHM13 Hypertension  Urgent cases WEEK 13 If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral carry out investigations for target organ damage as soon as possible: – If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM. – If no target organ damage is identified, repeat clinic blood pressure measurement within 7 days. Slide 18 of 30 MPHM13 Hypertension WEEK 13 Urgent cases Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with: – signs of retinal haemorrhage or papilloedema or – life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). Slide 19 of 30 MPHM13 Hypertension WEEK 13 Definitions Established cardiovascular disease Past medical history of stroke or transient ischemic attack, heart attack, angina, narrowed peripheral arteries Slide 20 of 30 MPHM13 Hypertension WEEK 13 Treatment of hypertension Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following: – target organ damage – established cardiovascular disease – renal disease – diabetes – an estimated 10-year risk of cardiovascular disease of 10% or more – Use clinical judgement for people with frailty or multimorbidity Slide 21 of 30 MPHM13 Hypertension WEEK 13 Treatment of hypertension Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with a clinic blood pressure of over 150/90 mmHg. Use clinical judgement for people with frailty or multimorbidity For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks. Slide 22 of 30 MPHM13 Hypertension WEEK 12 Blood pressure targets Reduce and maintain BP to the Postural hypotension: following targets: Base target on standing Age