What is Blood Pressure? Hypertension. High Blood Pressure. Untreated Hypertension. How Does It Effect the Body? The Brain.

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1 What is Blood Pressure? Hypertension Dr Youssef Beaini Clinical Lead in Cardiovascular Disease in Bradford, Airedale, Wharfedale and Craven GPwSI Cardiology The Ridge Practice, Bradford The force of blood against the wall of the arteries. Systolic means the pressure while the heart beats. Diastolic pressure is measured as the heart relaxes. Normal Blood pressure is less than 120 mm Hg systolic and less than 80 mm Hg diastolic. (We can have a debate about what s normal!) High Blood Pressure Untreated Hypertension A consistent blood pressure of 140/90 mm Hg or higher is considered pathological. It increases chance for multiple problems including heart disease, kidney disease, and stroke. Has no real warning signs or symptoms. Target Organs that are Damaged: The heart heart disease The brain - cerebrovascular disease The kidneys - renal disease Arteries - large vessel disease How Does It Effect the Body? The Brain High blood pressure is the most important risk factor for stroke haemorrhagic (bleed) or thrombotic (clot). The Heart High Blood Pressure is a major risk factor for heart attack and Coronary Artery Disease Is the number one risk factor for Congestive Heart Failure. Indirect effects: AF Image: 1

2 The Kidneys The Eyes High blood pressure can cause microvascular damage to the small blood vessels in the kidneys. Worst case scenario: dialysis. Major cause of CKD along with diabetes. Can eventually cause blood vessels to break and bleed in the eye hypertensive retinopathy Can result in blurred vision or even blindness. Image: Image: The Arteries Hypertension can cause shear stress and non-linear blood flow, creating a vicious circle of atheromatous damage to arterial wall. What causes High Blood Pressure? -Genetic factors (implicated in majority) -Being overweight or obese -High salt intake -Narrowing or stiffening of the arteries (arteriosclerosis) / Aging -Alcohol -Secondary causes renal parenchymal disease, renal artery stenosis, endocrine drugs Image: Causes of years of life lost and years of life with disability What s all the fuss about? I feel fine Murray et al Lancet 2013 UK Paper for 2010 Global Burden of Disease Study. 2

3 Years of Life Lost by Cause: In considering mortality data, it is important to consider health risks Top 5 causes of YLL A = all ages IHD Lung Cancer Stroke COPD Lower Resp Tract infection B = 20 to 54 yrs old IHD Self Harm Cirrhosis Breast Cancer Lower Resp Tract infection Top 5: Tobacco BP BMI Activity Alcohol Area Outcomes attributable to HTN Cases cerebrovascular disease Cases ischaemic heart disease CVD deaths, preventable Bradford District Bradford City CCG Bradford District CCG Airedale, Wharfedale, Craven CCG Most HTN is undiagnosed. Even in diagnosed still room for improvement. Scope for improvement in BP related outcomes Hypertension is a major risk factor for: ischaemic and haemorrhagic stroke myocardial infarction heart failure chronic kidney disease cognitive decline premature death Risk Factors Prevalence At least one quarter of adults have high blood pressure. The prevalence of diagnosed hypertension in Bradford is 12.2% But: and more than half of those older than 60 About 62% of cerebrovascular disease and ~50% of ischaemic heart disease are caused by suboptimal blood pressure control (WHO, 2002). Reducing mean population blood pressure levels by 5% would result in discounted annual savings of approximately 0.9 billion (NICE, 2011). 3

4 Prevalence local data Is it worth treating? Estimate of true prevalence of hypertension in Bradford: 55,763 have undiagnosed hypertension (estimated prevalence from the East of England Public Health Observatory Prevalence Model) Blood pressure: Each 10mmHg systolic or 5mmHg diastolic (=10/5) drop = 22% reduction in cardiac events and 41% reduction in stroke Benefits seen down to 110/70 mmhg (Law et al, BMJ 2009;338:b1665) Adherence Potential Lives Saved Nearly 10% of CVD events due to poor adherence Patients can reduce risk of event by a quarter by simply taking medicines as prescribed (Choudhury et al. Eur Heart J (2013): ) Cooney et al (2009) found that a 10% population reduction in blood cholesterol, blood pressure and smoking prevalence would save approximately 9120 lives per million population over 10 years ( e.g. = 4978 lives in Bradford over the next 10 years) So, what do I do about hypertension? Definitions Stage 1 hypertension: Clinic blood pressure (BP) is 140/90 mmhg or higher and ABPM or HBPM average is 135/85 mmhg or higher. Stage 2 hypertension: Clinic BP 160/100 mmhg is or higher and ABPM or HBPM daytime average is 150/95 mmhg or higher. Severe hypertension: Clinic BP is 180 mmhg or higher or Clinic diastolic BP is 110 mmhg or higher. 4

5 Scope Clinical management of primary hypertension in adults who may, or may not, have pre-existing cardiovascular disease. Groups not included are people with secondary causes of hypertension, accelerated hypertension or acute hypertension, pregnant women, and children and young people aged under 18. Diagnosis (1) If the clinic blood pressure is 140/90 mmhg or higher, the GP should offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. Initiating drug treatment Monitoring drug treatment (1) Offer antihypertensive drug treatment to people: who have stage 1 hypertension, are aged under 80 and meet identified criteria who have stage 2 hypertension at any age. If aged under 40 with stage 1 hypertension and without evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider: specialist evaluation of secondary causes of hypertension Use clinic blood pressure measurements to monitor response to treatment. Aim for target blood pressure below: 140/90 mmhg in people aged under /90 mmhg in people aged 80 and over If diabetic, aim <140/80 or if end organ damage (stroke, eyes, CKD), then <130/80 Monitoring drug treatment (2) CBPM 140/90 mmhg & ABPM/HBPM 135/85 mmhg Stage 1 hypertension CBPM 160/100 mmhg & ABPM/HBPM 150/95 mmhg Stage 2 hypertension Care pathway For people identified as having a white-coat effect consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor response to treatment. Aim for ABPM/HBPM target average of: below 135/85 mmhg in people aged under 80 below 145/85 mmhg in people aged 80 and over. If target organ damage present or 10-year cardiovascular risk > 20% If younger than 40 years Consider specialist referral Offer lifestyle interventions Offer antihypertensive drug treatment Offer patient education and interventions to support adherence to treatment White-coat effect: a discrepancy of more than 20/10 mmhg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis. Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication 5

6 Aged under 55 years A Aged over 55 years or black person of African or Caribbean family origin of any age A + C 2 A + C + D C 2 Resistant hypertension A + C + D + consider further diuretic 3, 4 or alpha- or beta-blocker 5 Consider seeking expert advice Step 1 Step 2 Step 3 Step 4 Summary of antihypertensive drug treatment Key A ACE inhibitor or low-cost angiotensin II receptor blocker (ARB) 1 C Calcium-channel blocker (CCB) D Thiazide-like diuretic See slide notes for details of footnotes 1-5 Choosing antihypertensive drug treatment Offer people aged 80 and over the same antihypertensive drug treatment as people aged over 55, taking into account any comorbidities. Drug treatment Standardise the environment and provide a relaxed, temperate setting with the person quiet and seated. When using an automated device: palpate the radial or brachial pulse before measuring blood pressure. If pulse if irregular measure blood pressure manually ensure that the device is validated* and an appropriate cuff size for the person s arm is used. Measuring blood pressure Measuring blood pressure (during diagnosis) 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 two measurements as the clinic blood pressure. * See notes Lifestyle interventions Offer guidance and advice about: diet (including sodium and caffeine intake) and exercise alcohol consumption smoking. Additional recommendations Patient education and adherence Provide: information about benefits of drugs and side effects details of patient organisations an annual review of care. Lifestyle benefits in hypertension Lifestyle modification Weight loss Dietary Approaches Low sodium diet Recommendation Maintain a normal body weight based on BMI Diet high in fruits and vegetables, and reduced fat Range of systolic blood pressure reduction (mm Hg) Less than 6 grams 2 8 Exercise 30 min of aerobic activity at least 4 d/wk Moderate Alcohol consumption 2 drinks or less per day for men, and 1 drink or less per day for women

7 Losing lbs or 4-5kg lowers BP by 10/5 mmhg. This is often more than one medication! Reduce daily salt: average 10 to 6 grams Teach patients to read food labels DASH Diet Counseling Patients: Dietary Changes Diet and Hypertension Non-pharmacologic way of treating hypertension DASH diet Dietary Approaches to Stop Hypertension High in whole grains, fruits, vegetables, and low-fat dairy Adequate Calcium, Potassium, Magnesium Low in red meat, sweets and sugar beverages Low in saturated and trans fat, cholesterol DASH Diet Pattern based on a 2,000 calorie diet Food Group Servings* Grains 6-8 Vegetables 4-5 Fruits 4-5 Low-fat or fat free dairy 2-3 Meats, poultry, fish less than 6 Nuts, seeds, dry beans and peas 4-5/week Fats and oils 2-3 Sweets 5/ week Sodium 2300 mg * Per day unless indicated Exercise 30 minutes at least 5 days a week Can divide into minute periods Work up gradually Do something that you enjoy Physical Activity Use stairs instead of lift, get off bus 2 stops early, park your car at the far end of the car park and walk! Remove salt shaker Add little if any salt to cooking Buy more fresh or plain frozen no added salt veggies Use more herbs and spices Make soups and stews ahead without salt and let flavors blend Use fresh poultry, lean meat, and fish Ways to Cut Sodium 7

8 Adherence Useful links 1. Simply explain what medicine is for and why treat hypertension. Most patients respond to risk of stroke and heart attack. 10% of CV events due to poor adherence. 2. Titrating medical therapy based on home readings sh.pdf (google search for DASH Diet) 3. Once daily dosing 4. Pill boxes, dosette etc. You will be experts in this! Thank you 8