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Chronic Care Programme Treatment guidelines Hypertension Chronic condition Consultations protocols Preferred treating provider Notes preferred as indicated by option referral protocols apply Maximum consultations per annum Initial consultation Follow-up consultation Tariff codes Consultations: Dietician Initial consultation Follow-up consultation Tariff codes Option/plan Provider GMHPP Gold Options G1000, G500 and G200. Blue Options B300 and B200. GMISHPP General Practitioner Pulmonologist Physician Gastroenterologist Neurologist Cardiologist Paediatrician Surgeon Thoracic Surgeon Mild No target No target organ organ disease: no disease: other risk no other risk New Existing Patient patient 1 0 2 1 0183; 0142; 0187; 0108 Moderate Blood pressure controlled on medication. Minimal risk factors Severe/Resistant Severe and/or uncontrolled, high risk factors; on medication New Patient Existing patient New Patient Existing patient 1 3 1 1 1 5 1 5 New Patient Existing patient New Patient Existing patient New Patient Existing patient 0 0 0 0 0 0 0 0 1 0 1 0 051 Investigations protocols Type Urine dipstick 24 hour ambulatory blood pressure measurement: hire fee Microalbuminuria: thin layer chromatography one way Provider GP; Specialist; Pathologist GP; Specialist (see list) GP; Specialist; Pathologist Maximum investigations per annum Tariff code New Patient Existing patient New Patient Existing patient New Patient Existing patient 4188 2 1 2 2 4 4 1237 0 0 1 0 1 0 4265 0 0 1 1 1 1 Blood glucose ECG without effort Chol/ HDL/LDL/Trig Total cholesterol Serum urea Serum creatinine Serum potassium Serum sodium Aldosterone Renin activity (aldosterone: rennin ratio) Renal ultrasound Cardiac examination: 2 dimensional Cardiac examination: (M mode) CXR ICD 10 coding GP; Specialist; Pathologist GP; Specialist (see list) Pathologist 4057 or 4050 1 1 1 1 1 1 1232 1 1 1 1 1 1 4025 1 0 1 0 1 0 Pathologist Pathologist Pathologist Pathologist Pathologist Pathologist 4027 4151 4032 4113 4114 4515 0 0 1 1 0 0 1 0 0 0 0 0 0 1 1 1 1 0 1 1 1 1 1 0 0 1 2 1 1 1 1 1 2 1 1 1 Pathologist 4511 0 0 0 0 1 1 3628 0 0 0 0 1 1 3622 0 0 0 0 1 0 Specialist (see list) 3621 0 0 0 0 1 0 Radsiologist 3446 0 0 0 0 1 1 Radiologist; Specialist (see list) Specialist (see list) I10. - I15. General Hypertension, most commonly referred to as "high blood pressure", HTN or HPN, is a medical condition in which the blood pressure is chronically elevated. It was previously referred to as nonarterial hypertension, but in current usage, the word "hypertension" without a qualifier normally refers to arterial hypertension. [1] Hypertension can be classified either essential (primary) or secondary. Essential hypertension indicates that no specific medical cause can be found to explain a patient's condition. Secondary hypertension indicates that the high blood pressure is a result of (i.e., secondary to) another condition, such as kidney disease or tumors (pheochromocytoma and paraganglioma). Persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysm, and is a leading cause of chronic renal failure. Even moderate elevation of arterial blood pressure leads to shortened life expectancy. At severely high pressures, defined as mean arterial pressures 50% or more above average, a person can expect to live no more than a few years unless appropriately treated.[2] Hypertension is considered to be present when a person's systolic blood pressure is consistently 140 mmHg or greater, and/or their diastolic blood pressure is consistently 90 mmHg or greater.[3] Recently, as of 2003, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure[4] has defined blood pressure 120/80 mmHg to 139/89 mmHg as "prehypertension." Prehypertension is not a disease category; rather, it is a designation chosen to identify individuals at high risk of developing hypertension. The Mayo Clinic website specifies blood pressure is "normal if it's below 120/80" but that "some data indicate that 115/75 mm Hg should be the gold standard." In patients with diabetes mellitus or kidney disease studies have shown that blood pressure over 130/80 mmHg should be considered high and warrants further treatment. Hypertension is labeled resistant if a person’s blood pressure remains above their target blood pressure despite taking three or more medications to lower it. The American Heart Association released a scientific statement[5] in May 2008 with guidelines for treating resistant hypertension.[6] Classification Hypertension can be classified either essential (primary) or secondary. Essential hypertension indicates that no specific medical cause can be found to explain a patient's condition. Secondary hypertension indicates that the high blood pressure is a result of (i.e., secondary to) another condition, such as kidney disease or tumors (pheochromocytoma and paraganglioma). Persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysm, and is a leading cause of chronic renal failure. Even moderate elevation of arterial blood pressure leads to shortened life expectancy. At severely high pressures, defined as mean arterial pressures 50% or more above average, a person can expect to live no more than a few years unless appropriately treated. Signs and symptoms Hypertension is usually found incidentally - "case finding" - by healthcare professionals during a routine checkup. The only test for hypertension is a blood pressure measurement. Hypertension in isolation usually produces no symptoms although some people report headaches, fatigue, dizziness, blurred vision, facial flushing, transient insomnia or difficulty sleeping due to feeling hot or flushed, and tinnitus [14] during beginning onset or prior to hypertention diagnosis. Malignant hypertension (or accelerated hypertension) is distinct as a late phase in the condition, and may present with headaches, blurred vision and end-organ damage. Hypertension is often confused with mental tension, stress and anxiety. While chronic anxiety and/or irritability is associated with poor outcomes in people with hypertension, it alone does not cause it. Accelerated hypertension is associated with somnolence, confusion, visual disturbances, and nausea and vomiting (hypertensive encephalopathy). [15] Diagnosis Diagnosis of hypertension is generally on the basis of a persistently high blood pressure. Usually this requires three separate measurements at least one week apart. Exceptionally, if the elevation is extreme, or end-organ damage is present then the diagnosis may be applied and treatment commenced immediately. Obtaining reliable blood pressure measurements relies on following several rules and understanding the many factors that influence blood pressure reading[17]. For instance, measurements in control of hypertension should be at least 1 hour after caffeine, 30 minutes after smoking or strenuous exercise and without any stress. Cuff size is also important. The bladder should encircle and cover two-thirds of the length of the arm. The patient should be sitting upright in a chair with both feet flat on the floor for a minimum of five minutes prior to taking a reading. The patient should not be on any adrenergic stimulants, such as those found in many cold medications. When taking manual measurements, the person taking the measurement should be careful to inflate the cuff suitably above anticipated systolic pressure. The person should inflate the cuff to 200 mmHg and then slowly release the air while palpating the radial pulse. After one minute, the cuff should be reinflated to 30 mmHg higher than the pressure at which the radial pulse was no longer palpable. A stethoscope should be placed lightly over the brachial artery. The cuff should be at the level of the heart and the cuff should be deflated at a rate of 2 to 3 mmHg/s. Systolic pressure is the pressure reading at the onset of the sounds described by Korotkoff (Phase one). Diastolic pressure is then recorded as the pressure at which the sounds disappear (K5) or sometimes the K4 point, where the sound is abruptly muffled. Two measurements should be made at least 5 minutes apart, and, if there is a discrepancy of more than 5 mmHg, a third reading should be done. The readings should then be averaged. An initial measurement should include both arms. In elderly patients who particularly when treated may show orthostatic hypotension, measuring lying sitting and standing BP may be useful. The BP should at some time have been measured in each arm, and the higher pressure arm preferred for subsequent measurements. BP varies with time of day, as may the effectiveness of treatment, and archetypes used to record the data should include the time taken. Analysis of this is rare at present. Automated machines are commonly used and reduce the variability in manually collected readings [18]. Routine measurements done in medical offices of patients with known hypertension may incorrectly diagnose 20% of patients with uncontrolled hypertension [19] Home blood pressure monitoring can provide a measurement of a person's blood pressure at different times throughout the day and in different environments, such as at home and at work. Home monitoring may assist in the diagnosis of high or low blood pressure. It may also be used to monitor the effects of medication or lifestyle changes taken to lower or regulate blood pressure levels. Home monitoring of blood pressure can also assist in the diagnosis of white coat hypertension. The American Heart Association[20] states, "You may have what's called 'white coat hypertension'; that means your blood pressure goes up when you're at the doctor's office. Monitoring at home will help you measure your true blood pressure and can provide your doctor with a log of blood pressure measurements over time. This is helpful in diagnosing and preventing potential health problems." Those using home blood pressure monitoring devices are increasingly also making use of blood pressure charting software.[21] These charting methods provide printouts for the patient's physician and reminders to take a blood pressure reading. Distinguishing primary vs. secondary hypertension Once the diagnosis of hypertension has been made it is important to attempt to exclude or identify reversible (secondary) causes. Over 91% of adult hypertension has no clear cause and is therefore called essential/primary hypertension. Often, it is part of the metabolic "syndrome X" in patients with insulin resistance: it occurs in combination with diabetes mellitus (type 2), combined hyperlipidemia and central obesity. Secondary hypertension is more common in preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension. [22] Investigations commonly performed in newly diagnosed hypertension Tests are undertaken to identify possible causes of secondary hypertension, and seek evidence for end-organ damage to the heart itself or the eyes (retina) and kidneys. Diabetes and raised cholesterol levels being additional risk factors for the development of cardiovascular disease are also tested for as they will also require management. Blood tests commonly performed include: Creatinine (renal function) - to identify both underlying renal disease as a cause of hypertension and conversely hypertension causing onset of kidney damage. Also a baseline for later monitoring the possible side-effects of certain antihypertensive drugs. Electrolytes (sodium, potassium) Glucose - to identify diabetes mellitus Cholesterol Additional tests often include: Testing of urine samples for proteinuria - again to pick up underlying kidney disease or evidence of hypertensive renal damage. Electrocardiogram (EKG/ECG) - for evidence of the heart being under strain from working against a high blood pressure. Also may show resulting thickening of the heart muscle (left ventricular hypertrophy) or of the occurrence of previous silent cardiac disease (either subtle electrical conduction disruption or even a myocardial infarction). Chest X-ray - again for signs of cardiac enlargement or evidence of cardiac failure. Treatment Lifestyle modificatiob (nonpharmacologic testment) Weight reduction and regular aerobic exercise (e.g., jogging) are recommended as the first steps in treating mild to moderate hypertension. Regular mild exercise improves blood flow and helps to reduce resting heart rate and blood pressure. These steps are highly effective in reducing blood pressure, although drug therapy is still necessary for many patients with moderate or severe hypertension to bring their blood pressure down to a safe level. Reducing sodium (salt) diet is proven very effective: it decreases blood pressure in about 60% of people (see above). Many people choose to use a salt substitute to reduce their salt intake. Additional dietary changes beneficial to reducing blood pressure includes the DASH diet (Dietary Approaches to Stop Hypertension), which is rich in fruits and vegetables and low fat or fat-free dairy foods. This diet is shown effective based on National Institutes of Health sponsored research. In addition, an increase in daily calcium intake has the benefit of increasing dietary potassium, which theoretically can offset the effect of sodium and act on the kidney to decrease blood pressure. This has also been shown to be highly effective in reducing blood pressure. Discontinuing tobacco use and alcohol consumption has been shown to lower blood pressure. The exact mechanisms are not fully understood, but blood pressure (especially systolic) always transiently increases following alcohol and/or nicotine consumption. Besides, abstention from cigarette smoking is important for people with hypertension because it reduces the risk of many dangerous outcomes of hypertension, such as stroke and heart attack. Note that coffee drinking (caffeine ingestion) also increases blood pressure transiently, but does not produce chronic hypertension. Relaxation therapy, such as meditation, that reduces environmental stress, reducing high sound levels and over-illumination can be an additional method of ameliorating hypertension. Jacobson's Progressive Muscle Relaxation and biofeedback are also used [1] particularly device guided paced breathing [2] [3]. Obviously, the effectiveness of relaxation therapy relies on the patient's attitude and compliance. Medications Unless hypertension is severe, lifestyle changes such as those discussed in the preceding section are strongly recommended before initiation of drug therapy. Adoption of the DASH diet is one example of lifestyle change repeatedly shown to effectively lower mildly-elevated blood pressure. If hypertension is high enough to justify immediate use of medications, lifestyle changes are initiated concomitantly. There are many classes of medications for treating hypertension, together called antihypertensives, which — by varying means — act by lowering blood pressure. Evidence suggests that reduction of the blood pressure by 5-6 mmHg can decrease the risk of stroke by 40%, of coronary heart disease by 15-20%, and reduces the likelihood of dementia, heart failure, and mortality from vascular disease. The aim of treatment should be blood pressure control to <140/90 mmHg for most patients, and lower in certain contexts such as diabetes or kidney disease (some medical professionals recommend keeping levels below 120/80 mmHg).[4] Each added drug may reduce the systolic blood pressure by 5-10 mmHg, so often multiple drugs are necessary to achieve blood pressure control. Commonly used drugs include: ACE inhibitors such as creatine captopril, enalapril, fosinopril (Monopril), lisinopril (Zestril), quinapril, ramipril (Altace) Angiotensin II receptor antagonists: eg, telmisartan (Micardis, Pritor), irbesartan (Avapro), losartan (Cozaar), valsartan (Diovan), candesartan (Amias) Alpha blockers such as doxazosin, prazosin, or terazosin Beta blockers such as atenolol, labetalol, metoprolol (Lopressor, Toprol-XL), propranolol. Calcium channel blockers such as nifedipine (Adalat)[23] amlodipine (Norvasc), diltiazem, verapamil Direct renin inhibitors such as aliskiren (Tekturna) Diuretics: eg, bendroflumethiazide, chlortalidone, hydrochlorothiazide (also called HCTZ) Combination products (which usually contain HCTZ and one other drug) Choice of initial medication Unless the blood pressure is severely elevated, consensus guidelines call for medically-supervised lifestyle changes and observation before recommending initiation of drug therapy. All drug treatments have side effects, and while the evidence of benefit at higher blood pressures is overwhelming, drug trials to lower moderately-elevated blood pressure have failed to reduce overall death rates. If lifestyle changes are ineffective or the presenting blood pressure is critical, then drug therapy is initiated, often requiring more than one agent to effective lower hypertension. Which type of many medications should be used initially for hypertension has been the subject of several large studies and various national guidelines. The ALLHAT study PMID 12479763 showed better cost-effectiveness and slightly better outcomes for the thiazide diuretic chlortalidone compared with a calcium channel blocker and an ACE inhibitor in a 33,357-member ethnically mixed study group.[24] The 1993 consensus recommendation for use of thiazide diuretics as initial treatment stems in part from the ALLHAT study results, which concluded in 2002 that Thiazide-type diuretics are superior in preventing 1 or more major forms of CVD and are less expensive. They should be preferred for first-step antihypertensive therapy. PMID 12479763 A subsequent smaller study (ANBP2) did not show the slight advantages in thiazide diuretic outcomes observed in the ALLHAT study, and actually showed slightly better outcomes for ACE-inhibitors in older white male patients.[25] Thiazide diuretics are effective, recommended as the best first-line drug for hypertension by many experts, and much more affordable than other therapies, yet they are not prescribed as often as some newer drugs. Arguably, this is partly because they are off-patent, less profitable, and thus rarely promoted by the drug industry.[26] The consensus recommendations of thiazide diuretics as first-line therapy for hypertension stand against a the backdrop that all blood pressure treatments have side-effects. Potentially serious side effects of the thiazide diuretics include hypercholesterinemia, and impaired glucose tolerance with consequent increased risk of developing Diabetes mellitus type 2. The thiazide diuretics also deplete circulating potassium unless combined with a potassium-sparing diuretic or supplemental potassium. On this basis, the consensus recommendations to prefer use of thiazides as first line treatment for essential hypertension have been repeatedly and strongly questioned.[27] [28] [29] However as the Merck Manual of Geriatrics notes, "[t]hiazide-type diuretics are especially safe and effective in the elderly."[30] Medicine formularies Plan or option [Link to appropriate Mediscor formulary] GMHPP Gold Options G1000, G500 and G200 Blue Options B300 and B200 GMISHPP Blue Option B100 [Core] n/a Epidemiology The level of blood pressure regarded as deleterious has been revised down during years of epidemiological studies. A widely quoted and important series of such studies is the Framingham Heart Study carried out in an American town: Framingham, Massachusetts. The results from Framingham and of similar work in Busselton, Western Australia have been widely applied. To the extent that people are similar this seems reasonable, but there are known to be genetic variations in the most effective drugs for particular sub-populations. Recently (2004), the Framingham figures have been found to overestimate risks for the UK population considerably. The reasons are unclear. Nevertheless the Framingham work has been an important element of UK health policy. References 1. Maton, Anthea; Jean Hopkins, Charles William McLaughlin, Susan Johnson, Maryanna Quon Warner, David LaHart, Jill D. Wright (1993). Human Biology and Health. Englewood Cliffs, New Jersey, USA: Prentice Hall. ISBN 0-13-981176-1. 2. Guyton & Hall. Textbook of Medical Physiology, 7th Ed., Elsevier-Saunders, p220. ISBN 0-7216-0240-1. 3. Hypertension - MeSH 4. ab Chobanian AV et al (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.". JAMA 289: 2560-72. PMID 12748199. 5. American Heart Association scientific statement: New guidelines issued for treating resistant hypertension. 6. Guidelines for treating resistant hypertension. 7. Silverberg DS, Iaina A and Oksenberg A (January 2002). "Treating Obstructive Sleep Apnea Improves Essential Hypertension and Quality of Life". American Family Physicians 65 (2): 229-36. PMID 11820487. 8. Hypertension Etiology & Classification - Secondary Hypertension. Armenian Medical Network (2006). Retrieved on 2007-12-02. 9. Harrisons Internal Medicine, online edition (2007-04-14) 10. a b Bakris G, Dickholtz M, Meyer PM, et al. (2007). "Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study". J Hum Hypertens 21 (5): 347–52. doi:10.1038/sj.jhh.1002133. PMID 17252032. 11. Sagnella GA, Swift PA (June 2006). "The Renal Epithelial Sodium Channel: Genetic Heterogeneity and Implications for the Treatment of High Blood Pressure". Current Pharmaceutical Design 12 (14): 2221-2234. doi:10.2174/138161206777585157. PMID 16787251. 12. Johnson JA, Turner ST (June 2005). "Hypertension pharmacogenomics: current status and future directions.". Current Opinion in Molecular Therapy 7 (3): 218-225. PMID 15977418. 13. Hideo Izawa; Yoshiji Yamada et al (May 2003). "Prediction of Genetic Risk for Hypertension". Hypertension 41 (5): 1035-1040. PMID 12654703. 14. Symptoms of High Blood Pressure. 15. Hypertension symptoms and signs. Systemic Hypertension - Hypertension Health Center. Armenian Medical Network (2006). Retrieved on 2007-07-24. 16. Hypertension in Children and Adolescents. Hypertension in Children and Adolescents. American Academy of Family Physicians (2006). Retrieved on 2007-07-24. 17. Reeves R (1995). "The rational clinical examination. Does this patient have hypertension? How to measure blood pressure.". JAMA 273 (15): 1211-8. doi:10.1001/jama.273.15.1211. PMID 7707630. 18. White W, Lund-Johansen P, Omvik P (1990). "Assessment of four ambulatory blood pressure monitors and measurements by clinicians versus intraarterial blood pressure at rest and during exercise.". Am J Cardiol 65 (1): 60-6. doi:10.1016/0002-9149(90)90026W. PMID 2294682. 19. Kim J, Bosworth H, Voils C, Olsen M, Dudley T, Gribbin M, Adams M, Oddone E (2005). "How well do clinic-based blood pressure measurements agree with the mercury standard?". J Gen Intern Med 20 (7): 647-9. doi:10.1007/s11606-005-0112-6. PMID 16050862. 20. The American Heart Association. Home Monitoring of High Blood Pressure. 21. Blood pressure charting software. 22. Luma GB, Spiotta RT (may 2006). "Hypertension in children and adolescents.". Am Fam Physician 73 (9): 1558-68. PMID 16719248. 23. Kragten JA, Dunselman PHJM. Nifedipine gastrointestinal therapeutic system (GITS) in the treatment of coronary heart disease and hypertension. Expert Rev Cardiovasc Ther 5 (2007):643-653. FULL TEXT! 24. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group (Dec 18 2002). "Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)". JAMA 288 (23): 2981-97. PMID 12479763. 25. Wing LM, Reid CM, Ryan P et al (Feb 13 2003). "A comparison of outcomes with angiotensin-converting--enzyme inhibitors and diuretics for hypertension in the elderly". NEJM 348 (7): 583-92. PMID 12584366. 26. Wang TJ, Ausiello JC, Stafford RS (1999). "Trends in Antihypertensive Drug Advertising, 1985–1996". Circulation 99: 2055-2057. PMID 10209012. 27. Lewis PJ, Kohner EM, Petrie A, Dollery CT (1976). "Deterioration of glucose tolerance in hypertensive patients on prolonged diuretic treatment". Lancet 307 (7959): 564 - 566. doi:10.1016/S0140-6736(76)90359-7. PMID 55840. 28. Murphy MB, Lewis PJ, Kohner E, Schumer B, Dollery CT (1982). "Glucose intolerance in hypertensive patients treated with diuretics; a fourteen-year follow-up". Lancet 320 (8311): 1293 - 1295. doi:10.1016/S0140-6736(82)91506-9. PMID 6128594. 29. Messerli FH, Williams B,Ritz E (2007). "Essential hypertension". Lancet 370 (9587): 591603. doi:10.1016/S0140-6736(07)61299-9. PMID. 30. Section 11. Cardiovascular Disorders Chapter 85. Hypertension Topic: Hypertension topic was last updated July 2005 http://www.merck.com/mkgr/mmg/sec11/ch85/ch85a.jsp 31. Sheetal Ladva (28/06/2006). NICE and BHS launch updated hypertension guideline. National Institute for Health and Clinical Excellence. Retrieved on 2006-09-30. 32. Hypertension: management of hypertension in adults in primary care (PDF). National Institute for Health and Clinical Excellence. Retrieved on 2006-09-30.