1、Hypertension Blood Pressure Management Facts, Myths & Legends,Jill Bunker Clinical Nurse Specialist Hypertension and Cardiovascular Disease Prevention Peart-Rose Clinic & Clinical Investigation Unit 9th September 2007,Hypertension Control in Europe and North America,13.0%,9.3%,5.7%,7.7%,5.0%,11.6%,2
2、6.8%,0%,5%,10%,15%,20%,25%,30%,USA,Canada,England,Finland,Germany,Spain,Italy,Control in %,Wolf-Maier K et al, Hypertension 2004;43:10-17,British Hypertension Society Guidelines for hypertension management (BHS-IV): summary (2004) Bryan Williams, Neil R Poulter, Morris J Brown, Mark Davies, Gordon T
3、 McInnes, John F Potter, Peter S Sever, Simon McG Thom; the BHS guidelines working party, for the British Hypertension Society. BMJ 328 634-640. Joint British Societies Guidelines on Prevention of Cardiovascular Disease in Clinical Practice (2006) British Cardiac Society, British Hypertension Societ
4、y, Diabetes UK. HEART UK, Primary Care Cardiovascular Society, The Stroke Association. 91 Supl. V Hypertension-management of hypertension in adults in primary care (2004 and 2006). NICE. Clinical guideline 18 and 34 www.nice.org.uk,Guidelines,Guidelines,Guidelines,Topics to be covered,Definition, Th
5、resholds for intervention and treatment goals Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring,Classification of blood pressure levels of the British Hypertension Society,Hypertension is BP 140 systolic and/or 90 mmHg diastolic.Medication Required if; Susta
6、ined raised BP 160 systolic and/or 100 mmHg diastolic (despite non-pharmacological treatment)OR if BP 140 systolic and/or 90 diastolic AND patient has Target Organ Damage, CVD, Diabetes or 10 year CVD risk 20%,When to treat?,Suggested target blood pressures during antihypertensive treatment.,Clinic
7、BP (mmHg)No diabetes Diabetes Optimal treated BP 140/85 130/80 Audit Standard 150/90 140/80,Systolic and diastolic blood pressures should both be attained Target = 140/85 mmHg This means systolic BP is less than 140 and diastolic BP is less than 85 (BHS & JBS Guidelines) NICE- treat to 140/90,BHS Gu
8、idelines,Definitions Definition, Thresholds for intervention and treatment goals Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring,Mercury Myth Mercury sphygmomanometers have been banned? Fact You can still use mercury. It will eventually be phased out, but
9、not yet, no date set,FACT Inaccurate blood pressure tests could affect millions,The Times, Saturday 13th August, 2005,MHRA Blood pressure measurement recommendations 2005,Auscultation method: e.g Greenlight; mercury Should be available in all clinical areas Taught to healthcare workers Auscultation
10、method used to check oscillometric (automatic) monitors Always used in certain clinical conditions: arrhythmias; pre-eclampsia; certain vascular disorders 2. Non-mercury auscultation method: Available in all clinical areas (e.g. Accoson Greenlight 300) Mercury Spillage kits: Available in all clinica
11、l areas if using mercury,MHRA Blood pressure measurement recommendations 2005,Oscillometric monitors (automatic): Dont assume its suitable for use in diagnosis of hypertensionOscillometric (automatic) method not suitable for all: Arrythmias; pre-eclampsia; certain vascular diseasesAneroid monitors:
12、Aneroid dial gauges easily prone to damage from dropping, causing significant errors in zero & calibration7. Calibration/Servicing Calibrate and service all your monitors regularly,Examples of recommended blood pressure monitors.,Mercury sphygmomanometers (gold standard). Greenlight 300 (accoson)Ind
13、ependently validated automated upper arm devicesConsider MANDAUS 11 for community use (available BHS website),Blood pressure measurement Myths, Facts & Legends,what size cuff?,Size does matter,Using too small a cuff/bladder can overestimate the blood pressure Bladder should encircle arm by 80-100%,5
14、,For cuff size follow manufacturers recommendationsGrowing obesity problem-cuffs may not be big enough especially automatic monitors-max large cuff tends to be 42 45cm depending on monitor. Patients arm circ can be 65cm,Too tight clothing,if the sleeves are too tight or bulky they act as a tournique
15、t giving inaccurate readings,6,MYTH: Mercury sphygmomanometer should be positioned level with the patients heart?,It should be level with the nurses eye,9,MYTH: The position of the arm is immaterial During BP measurement?,FACT: The arm should be well supported at HEART level (both sitting & standing
16、) An unsupported arm is performing isometric exercise thus raising BP,4,At what rate should the cuff be deflatedon a mercury or Greenlight sphygmomanometer?,FACT: 2mm/Hg per second,FACT: BP should be recorded to the nearest 2mm/Hg on mercury or Greenlight sphygmomanometer,LEGEND: Nikolai Korotkoffs
17、sounds (1906),Record readings atK1 as systolic(1st clear tapping sounds heard)K5 as diastolic (when sounds disappear)Use K4 (when sounds muffle) when K5 sounds continue to zero (document in notes - K4 used),10,Measuring Blood Pressure,Measure in both arms on 1st visit, always record in the highest a
18、rm thereafter. Consider standing BP in over 65, diabetic and those with symptoms of postural hypotension At least 2 measurements (1-2 minutes apart) More readings if 10mmHg difference in systolicIf 5mmHg difference in diastolic,The patient to be seated for at least 5 minutes,The monitorcuffs, bulbs
19、and tubing shouldnt leakIf using mercury; column-vertical clean,Assessment of hypertension,NICE BP confirmation If Initial BP 140/90 repeat monthly for 2 months,BHS Measure every 5 years all adults up to 80 years Measure annually those high normal (130-139 or 85-89) and anyone noted to have high rea
20、dings at any time Confirmation of hypertension If BP high repeat monthly over 4-6 months.(Unless BP very high, then measure more frequently)Do not treat on the basis of an isolated reading,BHS Guidelines,Definitions Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home mon
21、itoring,Urine strip test for protein and bloodSerum creatinine and electrolytesBlood glucose ideally fastedBlood lipid profile ideally fasted for consideration of triglyceridesElectrocardiogram,Routine investigations,Evaluation of hypertensive patients,Causes of hypertensionDrugs (NSAIDS, oral contr
22、aceptions, steroids, liquorice, some cold cures)Renal disease (present, past or family history, proteinuria or haematuria: palpable kidney(s) polycystic, hydronephrosis, or neoplasm)Renovascular disease (abdominal or loin bruit)Phaeochromocytoma (paroxysmal symptoms)Conns syndrome (muscle weakness,
23、polyuria, hypokalaemia)Coarctation (radio-femoral delay or weak femoral pulses)Cushings (general appearance),OverweightExcess alcohol ( 3 units/day for men; 2 units/days for women)Excess salt intakeLack of exerciseEnvironmental stress,Contributory factors,Suggested indications for specialist referra
24、l (part 1),Urgent treatment neededAccelerated hypertension (severe hypertension and grade III-IV retinopathy)Particularly severe hypertension (220/120mmHg)Impending complications (e.g. TIA, LVF),Possible underlying cause Any clue in history or examination of a secondary cause, eg. low potassium with
25、 increased or high normal plasma sodium (Conns syndrome)Raised serum creatinineProteinuria or haematuriaSudden onset or worsening of hypertensionResistant to multi-drug regimen ( 3 drugs)Young age (any hypertension 20 years; needing treatment 30 years),Suggested indications for specialist referral (
26、continued),Therapeutic problemsMultiple drug intoleranceMultiple drug contraindicationsPersistent non-adherence or non-complianceSpecial situationsUnusual blood pressure variabilityPossible white coat hypertensionHypertension in pregnancy,Suggested indications for specialist referral (continued),BHS
27、 Guidelines,Definitions Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring,Myth Stopping smoking reduces high blood pressure -,Smoking is a contributory factor for cardiovascular disease,FACT: Lifestyle intervention for blood pressure reduction,BHS Guidelines
28、,Definitions Measurement Evaluation of hypertensive patients Lifestyle measures ABPM and home monitoring,Home/self BP monitoring,Advise patients on accurate, independently validated, well maintained monitors Advise use of appropriate cuff size Wrist monitors are not recommended Suggested measurement
29、 routine for patients Measure BP for 7 days prior to appointment Record BP twice a day. Morning and evening Discard first 24 hours of readings Take an average of at least 12 of these readings,BHS IV, 2004,Indications for ABPM,24 hour BP monitoring (ABPM),Possible white coat hypertensionInforming equ
30、ivocal treatment decisionsEvaluation of nocturnal hypertensionDetermining efficacy of drug treatment over 24 hoursEvaluation of symptomatic hypotensionUnusual BP variabilityDiagnosis & treatment of hypertension in pregnancyEvaluation of drug resistant hypertension,Interpreting results,For both 24 ho
31、ur Ambulatory BP monitoring and Home monitor readingsAdd 10/5 mmHg to average daytime pressure. e.g. day-time average pressure = 158/89add 10/5 adjusted reading = 168/94Home BP 130/85 probably considered normal.,BHS IV, 2004),For information on Hypertension Management Guidelines, Recommendations for combining blood pressure lowering drugs, BP measuring recommendations, Validated BP monitors, CVD risk prediction chart CHD risk calculator,www.bhsoc.org.uk,To view N.I.C.E. guidelines go to www.nice.org.uk,NICE/BHS algorithm: June 2006,
