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 UKIt is a major risk factor for cardiovascular diseaseAt least one quarter of adults (and more than half of those are above 60) in the UK have high blood pressure2mmHg rise in systolic BP causes 7% increased risk of mortality in IHD and 10% increased risk of mortality from strokeThe 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 higherStage 2 Hypertension:Clinic blood pressure is 160/100mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure of 150/95mmHg or higherSevere Hypertension:Clinic systolic BP is 180mmHg or higher, or clinic diastolic BP is 110mmHg or higher

Adequate initial training and periodic reviewAutomated devices regularly recalibrated. Do not use automated devices if there is pulse irregularityStandardize environment. Patient should be quiet and seated, with an outstretched and supported armFor 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 calculatorTest for proteinuria and haematuriaEstimation of the albumin:creatinine ratioBloods for plasma glucose, U&E, eGFR and lipidsFundus examination12 lead ECG

Lifestyle – Who? When? How?

Medication – Who? When? How? What?

Refer – Who? Where? When?

Lifestyle advice should be offered initially then periodicallyDiet patterns:Five a dayBulk of most meals should be starch basedNot much fatty foods – Use low-fat, mono- or poly-unsaturated fatsInclude 2-3 portions of fish per week, at least one should be oilyLimit 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 benefitsModerate physical activity means you get warm, mildly out of breath and mildly sweatyOn most days – You cannot ‘store up’ the benefits of physical activity

Alcohol:Men 21 units/week – No more than 4 units/dayWomen 14 units/week – No more than 3 units/day

Relaxation therapiesExcessive consumption of caffeinated productsDo not offer magnesium, calcium and potassium supplementsStop smokingLocal initiatives

Aged under55 years

Aged over 55 years/ black

person of African/Caribbean

family origin of any age

Step 1 A C

A + C

A + C + D

Resistant hypertensionA + C + D + consider further

diuretic or alpha- or beta-blocker

Consider seeking expert advice

Step 2

Step 3

Step 4

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 damageEstablished cardiovascular diseaseDiabetesRenal disease10 year cardiovascular risk higher than 20%

Offer step 1 treatment to people at any age with stage 2 hypertensionACEi (Low cost ARB) for people under 55 yearsCCB 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/ARBThiazide like diuretic if CCB unsuitableIf beta-blocker was used in step 1 add CCB rather than thiazide like diureticOptimise 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 functionIf serum potassium level ≥ 4.5mmol consider higher dose of thiazide like diureticIf further diuretic therapy is contraindicated/ineffective, consider alpha- or beta-blockersIf BP remains uncontrolled maximum tolerated doses, seek expert advice

Under 80s:Clinic BP – 140/90mmHgABPM/HBPM – 135/95mmHgOver 80s:Clinic BP – 150/90mmHgABPM/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