Pete and Mihir

   Why they’re important Which risk factors?

Risk assessment

 ◦ ◦ Curriculum statements 5 Healthy people, promoting health and preventing disease 15.1 Cardiovascular problems

   QOF In those patients with a new diagnosis of hypertension (excluding those with pre existing CHD, diabetes, stroke and/or TIA) recorded between the preceding 1 April to 31 March: the percentage of patients aged 30 to 74 years who have had a face-to-face cardiovascular risk assessment at the outset of diagnosis (within 3 months of the initial diagnosis) using an agreed risk assessment tool 8 Points Disease Prevalence

 That warm fuzzy feeling that comes in the knowledge you are saving people’s lives (by reducing 10 year cardiovascular end point incidence)

 45,000

   Lifestyle factors you can change Factors you can’t change Factors that can be treated

 Family History

 Male

 Age

 Extreme baldness

 Early menopause

 Age

 Ethnic group

 Smoking

 Sedentary lifestyle

 Obesity

 Salt/diet

 Alcohol

 Hypertension

 Cholesterol

 triglycerides

 diabetes

 Chronic kidney disease

  Anyone age 40-74 who is likely to be at high risk – calculate risk with data already available (NICE) Anyone over 40 (JBS2)

 ◦ ◦ ◦ ◦ ◦ ◦ The following patients should not have their risk calculated, as they are considered already to be at high enough risk to justify lifestyle and other interventions Patients with atherosclerotic CVD.

Hypertension (≥160/100 mm Hg) with target organ damage.

Patients with type 1 or type 2 diabetes mellitus.

Renal dysfunction (including diabetic nephropathy).

Familial hypercholesterolaemia, familial combined hyperlipidaemia People aged 75 or older should also be considered at increased risk of CVD, particularly if hypertensive or smokers.

   Use a validated tool to calculate estimated 10 year risk.

Discuss lifestyle modification Start/change treatment

  Framingham with JBS2 adjustments QRisk2  ◦ Type 2 diabetes (early on) UKPDS

       Tends to overestimate UK population risk Underestimates risk of socially deprived/south asian/female populations Age (30-74) Smoking Status Sex Glucose LVH         BP Central Obesity Total Cholesterol South Asian Origin HDL Cholesterol Family History of CVD (Men <55 and women <65 years) Total /HDL Ratio Serum TG mmol/L

       Patient age (30-84).

Patient gender.

Current smoker (yes/no).

Diabetic.

Family history of heart disease aged <60 (yes/no).

Treatment with blood pressure agent .

Postcode (Townsend score)        Body mass index (height and weight).

Systolic blood pressure (use current not pre-treatment value).

Total and HDL cholesterol.

Ethnicity.

Rheumatoid arthritis.

Chronic kidney disease.

Atrial fibrillation.

 http://www.patient.co.uk/doctor/Primary Cardiovascular-Risk-Calculator.htm

 www.qrisk.org

 www.dtu.ox.ac.uk

Is it a disease? Is it an illness?

Is it a condition?

Is it a syndrome?

What is it?

Hypertension is the one of the most important preventable causes of morbidity and mortality in the UK It is a major risk factor for cardiovascular disease At least one quarter of adults (and more than half of those are above 60) in the UK have high blood pressure 2mmHg rise in systolic BP causes 7% increased risk of mortality in IHD and 10% increased risk of mortality from stroke The NHS spent £1 billion on drug costs alone on blood pressure management in 2006

140/90?

135/85?

160/100?

180/110???

Stage 1 Hypertension: Clinic blood pressure is 140/90mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure of135/85mmHg or higher Stage 2 Hypertension: Clinic blood pressure is 160/100mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure of 150/95mmHg or higher Severe Hypertension: Clinic systolic BP is 180mmHg or higher, or clinic diastolic BP is 110mmHg or higher

Adequate initial training and periodic review Automated devices regularly recalibrated. Do not use automated devices if there is pulse irregularity Standardize environment. Patient should be quiet and seated, with an outstretched and supported arm For postural hypotension patient should be stood for at least 1 minute before BP measurement (If SBP falls by ≥20mmHg – Review medication/Specialist referral)

If clinic BP is ≥140/90, offer ABPM to confirm diagnosis of HTN Clinic BP Measure BP in both arms (Use arm with higher reading), if BP ≥140/90mmHg repeat BP. If substantially different repeat a third time. Record the lower of the last 2 measurements as clinic BP ABPM At least 2 measurements per hour during waking hours Use the average value of at least 14 measurements taken during usual waking hours HBPM For each BP reading, two consecutive measurements are taken, at least 1 minute apart and with the person seated Record twice daily, ideally morning and evening Record for at least 4 days, ideally 7 days (Discard first day’s readings)

Use formal calculator Test for proteinuria and haematuria Estimation of the albumin:creatinine ratio Bloods for plasma glucose, U&E, eGFR and lipids Fundus examination 12 lead ECG

Clinic blood pressure

Normotensive

Clinic blood pressure ≥ 140/90 mmHg Clinic blood pressure ≥180/110 mmHg If accelerated hypertension 8 or suspected phaeochromocytoma 9 Refer same day for specialist care Consider starting antiHTN drug treatment immediately Offer ABPM 10 (or HBPM 11 if ABPM is declined or not tolerated) ABPM/HBPM < 135/85 mmHg

Normotensive

If evidence of target organ damage Offer to assess cardiovascular risk and target organ damage Consider alternative causes for target organ damage ABPM/HBPM ≥ 135/85 mmHg

Stage 1 hypertension

If target organ damage present

or

10-year cardiovascular risk > 20% If younger than 40 years ABPM/HBPM ≥ 150/95 mmHg

Stage 2 hypertension

Offer antihypertensive drug treatment Consider specialist referral Offer to check blood pressure at least every 5 years, more often if blood pressure is close to140/90 mmHg 8 haemorrhage. 9 Signs of papilloedema or retinal Labile or postural hypotension, headache, palpitations, pallor and diaphoresis. 10 Ambulatory blood pressure monitoring. 11 Home blood pressure monitoring. 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

Lifestyle – Who? When? How?

Medication – Who? When? How? What?

Refer – Who? Where? When?

Lifestyle advice should be offered initially then periodically Diet patterns:       Limit salt to 6g/day – Current UK average is 9g (Na content X 2.5 = Salt Content) If you ‘have’ to fry, choose a vegetable oil

 Exercise patterns:  30 minutes in a day is probably minimum to gain health benefits Moderate physical activity means you get warm, mildly out of breath and mildly sweaty  On most days – You cannot ‘store up’ the benefits of physical activity Alcohol:   Men 21 units/week – No more than 4 units/day Women 14 units/week – No more than 3 units/day

Relaxation therapies Excessive consumption of caffeinated products Do not offer magnesium, calcium and potassium supplements Stop smoking Local initiatives

Step 1 Step 2 Step 3 Step 4

Aged under 55 years



A



Aged over 55 years/ black person of African/Caribbean family origin of any age



C



A + C



A + C + D



Resistant hypertension A + C + D + consider further diuretic or alpha- or beta-blocker Consider seeking expert advice

Choose a low-cost ARB.

A CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has oedema, evidence of heart failure or a high risk of heart failure.

Consider a low dose of spironolactone or higher doses of a thiazide-like diuretic.

At the time of publication (August 2011), spironolactone did not have a UK marketing authorisation for this indication. Informed consent should be obtained and documented.

Consider an alpha- or beta-blocker if further diuretic therapy is not tolerated, or is contraindicated or ineffective.

Offer step 1 treatment to people under 80 with stage 1 hypertension and one or more of:     Target organ damage Established cardiovascular disease Diabetes Renal disease  10 year cardiovascular risk higher than 20% Offer step 1 treatment to people at any age with stage 2 hypertension ACEi (Low cost ARB) for people under 55 years CCB for over 55 years/Afro-Caribbean origin – If unsuitable/intolerant to CCB then start with thiazide like diuretic (Indapamide/Chlortalidone) Use beta-blockers in younger patients only if ACEi/ARBs are contraindicated, or there is evidence of increased sympathetic drive, and for women with child-bearing potential

Offer CCB in combo with ACEi/ARB Thiazide like diuretic if CCB unsuitable If beta-blocker was used in step 1 add CCB rather than thiazide like diuretic Optimise doses

Offer ACEi/ARB in combo with a CCB and thiazide-like diuretic If clinic BP ≥140/90mmHg regard as resistant hypertension

Consider low dose (25mg) spironolactone if serum potassium level ≤ 4.5mmol/L – Monitor renal function If serum potassium level ≥ 4.5mmol consider higher dose of thiazide like diuretic If further diuretic therapy is contraindicated/ineffective, consider alpha- or beta-blockers If BP remains uncontrolled maximum tolerated doses, seek expert advice

Under 80s:  Clinic BP – 140/90mmHg  ABPM/HBPM – 135/95mmHg Over 80s:   Clinic BP – 150/90mmHg ABPM/HBPM – 145/95mmHg

    A few key points Optimise everything else before giving a statin Add TFTs to hypertension/CV risk assessment bloods if dyslipidaemia present Offer a statin to those with a 20% or greater 10 year risk of CVD

       A few key points Support, advice, “stop date” “blips vs “failure” Intensive support service Pharmacotherapy NRT vs NNRT (varenicline, bupropion – MHRA warning) 1 go every 6 months How much to prescribe

      Patches 5, 10, 15 mg/16 hr (Nicorette®); 7, 14, 21 mg/24 hr (NiQuitin®) Gum (2 mg, 4 mg) Nasal spray (0.5 mg per puff) Inhalation cartridge (10 mg cartridge plus mouthpiece) Lozenges (1 mg, 2 mg, 4 mg) Sublingual tablets (2 mg)

   Decide on a quit date - the date you intend to stop smoking.

Start taking the tablets one week before the quit date. Start on 0.5 mg daily for three days. Then 0.5 mg twice daily on days four to seven. Then, 1 mg twice daily for 11 weeks.

Take each dose with a full glass of water, preferably after eating.

   One tablet (150 mg) each day for six days. Then increase to one tablet twice a day Aim to stop smoking completely on day eight of treatment.

Continue the tablets for a further seven weeks

    A, 48 year old male Clinic reading 142/92 Home readings 136/86 CV risk 6%

   B, 52 year old white female Home readings 136/86 LVH

    C, 48 year old white male, Clinic reading 162/106 ABPM 136/86 CV risk 25%

    D, 48 year old black male, Clinic reading 162/106 ABPM 136/86 CV risk 25 %

   E 50 year old black male Home readings 155/98 On amlodipine

   F, 65 year old Asian female Home readings 152/96 On ramipril and felodipine

      G, 55 year old black female New patient taking diclofenac for knees for the last year. Feels well BP 184/114 ECG LVH + blood on urine dip Fundoscopy normal/abnormal