Hypertension. Implementing NICE guidance South Manchester GP training updated. August 2011 Updated Sept 12. NICE clinical guideline 127

Transcription

1 Hypertension Implementing NICE guidance South Manchester GP training updated August 2011 Updated Sept 12 NICE clinical guideline 127

2 GP Curriculum 2.01 The GP consultation 2.04 Enhancing Professional Knowledge 3.12 Cardiovascular Health DOMAINS Primary care management- working with colleagues and teams

3 Updated guidance This guideline updates and replaces Hypertension: management of hypertension in adults in primary care (NICE clinical guideline 34, 2006). NICE clinical guideline 34 was a partial update of Hypertension (NICE clinical guideline 18, 2004). This update was produced in collaboration with the British Hypertension Society

4 NICE Pathway The NICE Hypertension pathway shows all the recommendations in the Hypertension guideline Click here to go to NICE Pathways website

5 High Blood Pressure: Background Major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension can cause vascular and renal damage leading to a treatment-resistant state. Each 2 mmhg rise in systolic blood pressure associated with increased risk of mortality: 7% from heart disease 10% from stroke.

6 Epidemiology Hypertension is common in the UK population. Prevalence influenced by age and lifestyle factors. 25% of the adult population in the UK have hypertension. 50% of those over 60 years have hypertension. With an ageing population, the prevalence of hypertension and requirement for treatment will continue to increase.

7 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.

8 Scope Clinical management of primary hypertension in adults who may, or may not, have pre-existing cardiovascular disease. Groups not included are people with diabetes, secondary causes of hypertension, accelerated hypertension or acute hypertension, pregnant women, and children and young people aged under 18.

9 Key priorities for implementation Diagnosis. Initiating and monitoring antihypertensive drug treatment. Choosing antihypertensive drug treatment.

10 Diagnosis (1) If the clinic blood pressure is 140/90 mmhg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.

11 Diagnosis (2) When using the following to confirm diagnosis, ensure: ABPM: at least two measurements per hour during the person s usual waking hours, average of at least 14 measurements to confirm diagnosis HBPM: two consecutive seated measurements, at least 1 minute apart blood pressure is recorded twice a day for at least 4 days and preferably for a week measurements on the first day are discarded average value of all remaining is used.

12 Initiating drug treatment 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 further assessment of potential target organ damage.

13 Monitoring drug treatment (1) 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

14 Monitoring drug treatment (2) 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. 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.

15 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 If target organ damage present or 10-year cardiovascular risk > 20% Offer antihypertensive drug treatment If younger than 40 years Consider specialist referral 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

16 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 angiotensin II receptor blocker (ARB) 1 C Calcium-channel blocker (CCB) D Thiazide-like diuretic See slide notes for details of footnotes 1-5

17 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

18 * See notes Measuring blood pressure: updated recommendations 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.

19 Assessing cardiovascular risk and target organ damage: updated recommendations Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension. For all people with hypertension offer to: test urine for presence of protein take blood to measure glucose, electrolytes, creatinine, estimated glomerular filtration rate and cholesterol examine fundi for hypertensive retinopathy arrange a 12-lead ECG.

20 Additional recommendations Lifestyle interventions Offer guidance and advice about: diet (including sodium and caffeine intake) and exercise alcohol consumption smoking. Patient education and adherence Provide: information about benefits of drugs and side effects details of patient organisations an annual review of care.

21 Costs and savings for total population of England Costs and savings of using ABPM to confirm diagnosis of hypertension Year Change in diagnosis cost ( m) Change in treatment cost ( m) Net resource impact ( m) Year Year Year Year Year

22 Afternoon Discussion What innovative ways can we think of to enhance our capacity to deliver ABPM to people who need it? But I don t feel ill, why do I have to take pills. How would you tackle this view. Everyone in my family has a stroke, its inevitable, what can I do? How would you go about dealing with this?

23 CVD Risk Framingham, JBS2 Risk score or QRISK2 Why? What does the QoF indicator say?

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26 Risk Communication What tools are there to help you communicate risk more effectively? Mrs F has a 15% chance of developing CVD in next 10 years. Explain this to her? Mr B has a 35% chance of developing CVD in next 10 years, explain the options to him?

27 Mrs F has a 15% chance of developing CVD in next 10 years. Explain this to her? Mrs F 45 years old FH Mother father both had MI s in 60 s Eats what she can afford, shops in Iceland and Aldi Works as cleaner BMI 33, Smoker, BP 130/80, TC 5.2 LDL 3.5 HDL 0.9

28 Mr B has a 35% chance of developing CVD in next 10 years, explain the options to him? Mr B South Asian origin Diet, home cooked food, sedentary job, Taxi driver BP162/92, TC 6.8 LDL 4.5 HDL 0.8, BMI 29

29 Identification of high BP

30 Identification of high BP Random checks Pre op Diving courses Medicals Symptomatic NHS Health Checks

31 NHS Health Check Tiered LES Everyone aged between 40 and 74 in Tameside and Glossop, who doesn t have a pre-existing heart-related condition, is eligible. Patients will be invited by their GP to make an appointment for a health check. They may be asked to attend a different practice to the one they are registered with, but it will still be local to them.

32 LES Payment

33 Pricing Tier 1 service only per practice once per annum. LES Payment Tier 2 (practices must have applied for, and are delivering the tier 1 service, to qualify for tier 2). Practices signing up for the tier 2 service will receive an additional 250 to support the administration of 500 invites over the annum (suggested 100 invites bi monthly) Tier 3 & - The Health Check Providers will be paid for each, completed health check episode. A completed episode equates and includes any further administration costs / Health care provider time delivering the health check / recording and passing on outcome data to GP and Quality and Development Lead NHS Health Check. Payment will be 28 per health check episode.

34 What will a health check include; The Health check will include within a minute consultation the recording and assessment of: Age Gender Family History Ethnicity Smoking Status Brief Intervention for current smokers Height Weight Waist circumference Body Mass Index Dietary / alcohol intake Physical activity levels via GPPAQ Cholesterol Test TC / HDL (via LDX point of care testing device) Blood Pressure Pulse Check for the over 60 years for Atrial Fibrillation Screening

35 Debate and Analysis You firmly believe that these NHS checks are a waste of time. Most people wont come in for them anyway. You think this is just government pushing more and more work your way. Your plate is already over following with work, this will generate far too much extra stress on admin, nurses and GPs and you will oppose this at every opportunity You need to present your reasons against the proposals to the partnership in order to stop the LES

36 Debate and Analysis You firmly believe that prevention is better than cure, ensuring all of you population have access to healthcare is essential. You want to implement this into your practice for the up coming year You need to present your proposals to the partnership before you sign up for the LES

37 Hypertension session summary Guidance update knowledge Difficult questions - skills CVD Risk assessment - knowledge Communicating risk- skills NHS Health checks, GP contract, enhanced services Knowledge Case studies- application of knowledge Debate and analysis attitudes, working in teams, management and leadership

38 Further reading QOF _contractors/quality_outcomes_framework/qofguidance2011.j sp NICE Guidance. QRISK. Qrisk.org.

39 Find out more Visit for: the guideline the quick reference guide Understanding NICE guidance costing report and template audit support baseline assessment tool clinical case scenarios implementation advice podcast Visit to access the hypertension NICE pathway (see slide 3)