Ep 4 – Tips and hacks on managing hypertension in primary care including NICE NG136 key messages

Hello, I'm Kevin Fernando, a GP partner at North Berwick Health Centre near Edinburgh and Education Director of GP Notebook Education. Welcome to our new GP Notebook podcast, a bite-size regular chat for all of us working in primary care. Podcasts will cover clinical tips and hacks as well as hot topics to help make our lives a wee bit easier but ultimately to help improve the lives of our patients in primary care. Today we'll be covering key take-home messages from the recently updated Nice High Potention guideline as well as some tips and hacks on diagnosing and managing hypertension, particularly the importance of lifestyle modification. Now the World Health Organization tragically reminds us that there are around about 15 million strokes worldwide annually and hypertension contributes to over 12 million of them. So hypertension is indeed one of the most important preventable risk factors for cerebrovascular disease. Now a nice update to their guideline, hypertension in adults, diagnosis and management during late August 2019 and I'm going to take you through some key take-home messages from it relevant to us all working in primary care. Now thankfully nice NG136 remains pragmatic with respect to the diagnosis of hypertension. Nice suggests we diagnose hypertension, if clinic blood pressure is greater or equal to 140 over 90 and a subsequent home or ambulatory blood pressure daytime average is greater or equal to 135 over 85. Incredibly colleagues in America have guidance from the American cardiology college and American Heart Association college which now define a systolic blood pressure of 120 to 129 is elevated and stage one hypertension with a systolic blood pressure of 130 to 139. In my opinion this is over medicalization but that is what our colleagues do follow across the pond. So in terms of nicest recommendation as you can see very much direction of travel is home or ambulatory blood pressure monitoring and suddenly this is the practice we have adopted in North Berwick. So when might we consider treatment? Well as always lifestyle interventions recommended first line as always the first step in healthcare is self care we must always educate before we medicate. So nice does recommend we consider anti-ipotentive therapy in addition to lifestyle for everyone up to the age of 80 with persistent stage one hypertension and a 10 year cardiovascular risk of greater or equal to 10%. So you can see this is the first key change in this updated nice guideline. Nice of half that 10 year CVD risk threshold from 20% to just 10%. Now in reality though I suspect the majority of us have already been using a lower risk threshold probably somewhere between 10 to 15%. But nice have now formalized this lower risk threshold to use. So what do we mean my persistent stage one hypertension stage one hypertension a nice define as a clinic blood pressure of 140 over 90 to 159 over 99 and home or ambulatory blood pressure daytime average of 135 over 85 to 149 over 94. Now of course we do need to individualize this recommendation as the suggestion here then is that a patient with a systolic blood pressure of 138 and a 10 year risk of over 20% will not be recommended for treatment whereas a person with a systolic blood pressure of 142 and a 10 year risk of 10% will be of course this doesn't make sense as that person with the systolic blood pressure of 138 is likely to gain more benefit from blood pressure lowering. So as always we should consider guidelines as handrails rather than train tracks. Nice also reminders that we should consider anti hypertensive therapy for those with persistent stage one hypertension with either end organ damage such as left ventricular hypertrophy, established cardiovascular disease, renal disease or diabetes. We also recommend that we directly offer anti hypertensive therapy in addition to lifestyle to people at any age with persistent stage two hypertension. So how do we define stage two hypertension or a subtle change here. Nice suggests we define stage two hypertension as a clinic blood pressure of greater or equal to 160 over 100 but less than 180 over 120. So slightly relax the upper target from 180 over 110 to 180 over 120. And this is equivalent to a home or ambulatory blood pressure and daytime average of greater or equal to 150 over 95. So a really useful value to be fulfilled familiar with 150 over 90 over 5 when interpreting those home blood pressure measurements. How about those individuals over the age of 80? Well nice of course, a remain holistic here and tell us to use our clinical judgment particularly for those with multi morbidity or frailty but we should consider anti hypertensive therapy in addition to lifestyle if clinic BP exceeds a very pragmatic 150 over 90. So I was pleased to see that. Also a useful reminder nice for adults under the age of 40 with hypertension. Nice do suggest we consider forning a friend to exclude secondary causes of hypertension such as con syndrome or primary older steer organism. This actually classically presents with hypertension and hypochalemia but potassium levels can often be normal. So if we do suspect primary older steer organism we should check plasma older steer own levels and plasma renen levels and a high older steer own ren in ratio is suspicious of primary older steer organism and further investigation is warranted. So a useful tip there for those adults under the age of 40 with hypertension. So what blood pressure target should we aim for? Well again nice of quite pragmatic here they suggest we aim for less than 140 over 90 in everyone all the way up to 80 and interestingly including those with diabetes. So nice appearance have slightly relaxed blood pressure targets for those with diabetes from 140 over 80 to 140 over 90. The one exception though is if there's diabetes with coexisting chronic kidney disease in which case we should still aim for that tighter target of less than 130 over 80. And again for those individuals over 80 use your clinical judgment particularly for those with frailty or more multi mobility and broadly aim for less than 150 over 90. But of course we can take our foot off the pedal as one becomes increasingly frail. Terms of treatment a few, subtle changes from nice and ACE inhibitor or ARB is now recommended first line for everyone with type 2 diabetes irrespective of age or indeed ethnic background. So this was quite interesting because previous guidance suggested we don't use an ACE or ARB particularly for those from for example a black African background but this is no longer the case in the updated guideline. Secondly and we're probably a wee bit behind the curve here in Scotland or certainly I am. Starting or changing diuretic therapy nice recommend using a thiozide like diuretic for example in dapamide in preference to a more conventional thiozide diuretic such as bendroflu methiozide. So that's been a practice changing point for me. I've tended up to recently to still be using bendroflu methiozide. And what about resistant hypertension, forflite treatment so you've added in an ACE inhibitor than a calcium channel blocker diuretic what next? It's often a bit for melange next is it doxazazine, beta blocker, maybe change the diuretic. So we had a really useful study called the pathway to trial published a few years back looking at spinar actone compared to doxazazine compared to bizoprol compared to placebo for the treatment of resistant hypertension. And what they found was actually spironal actone resulted in the highest reduction in systolic blood pressure and the highest proportion of people achieving their blood pressure targets. So this is actually really simplified blood pressure management for me in primary care. I'll start now with an ACE or an ARB add in the calcium channel blocker, add in the diuretic and then add in low dose spironal actone 25 milligrams. And of course we need to keep an eye out. the UNEs, particularly the potassium. There was a useful MHRA drug safety alert published a few years ago giving us a protocol to consider checking UNEs' potassium levels after initiating spore and allactones. So well worth having a look at that. And finally, I was very interested to see the publication of a practice-changing paper in the European heart journal, the Higgya Chrono Therapy Trial. This was a large trial nearly 20,000 people with hypertension and they looked at blood pressure reduction and outcomes with bedtime dosing of anti-hypertensives compared to morning dosing. And what they found was that bedtime dosing of anti-hypertensives resulted in better blood pressure control and this actually translated into fewer cardiovascular events compared with morning dosing of anti-hypertensives. So a really interesting result and a nice simple take home practice-changing message. Tell your patients to if possible take their blood pressure medications at night. Now of course taking the drugs at any time is better than not taking them at all but certainly taking them at night does seem to have its significant advantages. Next a few tips on measuring blood pressure. There was a very provocatively titled editorial in the BGGP during 2014 why are doctors still measuring blood pressure which drew on the results of a large systematic review and meta-analysis comparing blood pressures measured by nurses and doctors. And they found that doctors consistently measured 7/4mm of mercury blood pressure higher than nurses. Very interesting result and of course there's implications on overdiagnosis and workload in primary care. Of course this does not negate the importance of blood pressure measurement by doctors and someone who is unwell or someone perhaps with symptoms of dizziness or fatigue but nevertheless food for thought. Nice also make a recommendation about measuring blood pressure. They suggest we measure erect and supine blood pressures in people with hypertension and everyone with type 2 diabetes because of the possibility of autonomic neuropathy. We measure erect and supine blood pressures in everyone with symptoms of postural hypertension and also we measure erect and supine blood pressures in everyone over the age of 80 because of course it is a risk factor for falls. And importantly if we are going to treat with drugs blood pressure we should base any BP target on the standing blood pressure rather than the sitting blood pressure. So really useful practical point there. Next some tips on lifestyle advice, lifestyle modification hypertension. We're all well aware aren't we of the robust evidence for exercise, for smoking cessation, for drinking alcohol within recommended limits, for weight loss and also maintaining a healthy diet to manage hypertension in a non-pharmacological way. But it's well worth spending a wee bit more time on salt because we have quite robust evidence actually that reducing salt to less than 6 grams a day or just over one teaspoon reduces blood pressure by 5 to 6 millimetres of mercury which is just as effective as many medications we use. So 6 grams is a equivalent to 2.4 grams of sodium which is equivalent to just over a teaspoon of salt. So well worth discussing this with people living with hypertension. Also a useful reminder we should be avoiding soluble medications, effervescent dispersal medications in anyone with background cardiovascular disease including hypertension because these are generally higher in sodium. The one exception is aspirin 75 dispersable. This does not have a high sodium content. And also worth discussing the dash eating plan. Dash stands for dietary approaches to stopping hypertension. It's an evidence-based validated eating plan published in the New England Journal of Medicine, way back in 2001. So I routinely give this out to all the people newly diagnosed with hypertension, not rocket science, a nice healthy diet, low in saturated fat, plenty of fruit and veg, low in salt and high in potassium actually. And also, well worth spending a little bit of time in potassium because we do have evidence, okay not quite as robust as sodium, but suddenly we do have evidence that increasing potassium to 3.5 to 5 grams daily can reduce blood pressure by 4 to 5 millimetres of mercury. The problem for me though is when I'm trying to think what's high in potassium, the only thing I can think of is bananas. But actually when I looked into this avocado, sweet potato, spinach, pulses, beans and chicken are all naturally high in potassium. So I've put together a GP notebook shortcut for you on lifestyle modifications to manage hypertension available on our website www.gpnotebookeducation.com where I've got a range of lifestyle modifications, the specific recommendations we should be discussing with individuals, and approximate systolic blood pressure reductions we might expect with that lifestyle modification and also key references if you do want to read a wee bit more about the background studies. So I hope you might find this shortcut helpful as a backbone of a consultation with someone with diet or with hypertension to reinforce the importance and indeed effectiveness of non-pharmacological management of hypertension. And then finally before we finish just a quick nice take-home message from European guidelines for hypertension published during 2018. Interestingly our European colleagues suggest if we are going to treat hypertension with drugs we should consider initial single pill combination treatment in most patients. So for example if we are going to start drugs, start a combination of both perindropyl and endapomide. Now nice I should point out do not make this recommendation they specifically said they don't feel the evidence was strong enough. I've got to say on an individual basis I do consider this particularly for my higher risk patients and that indeed is the combination I often consider perindropyl and endapomide and certainly for my own clinical experience I've got to say it does what it says on the tin and in reality most of our patients do require more than one drug to control their blood pressure. So suddenly that was the European guidelines rationale if most people do require more than one drug start that initial dual combination and that gets the blood pressure down effectively and quickly. In the UK of course we've been largely discouraged haven't we from using combination product products and very few available so whilst I do consider this on an occasional basis I've prescribed them separately and generically. So thank you all for listening I hope you found this podcast helpful please make sure to subscribe to our podcast which are available on all major platforms and please do get in touch via social media if you have any questions comments or ideas for future podcasts you should also visit us at gpnotbookeducation.com to not chop some cpd points register for our gp notebook clinic events our 2020 dates are now live and you can also download some free resources and our gp notebook shortcuts to make our lives a wee bit easier in primary care but ultimately to help improve the lives of our patients. The topic of our next podcast will be some tips and hacks on the best use of CRP and ESR in primary care.