The video version of this podcast can be found here:
· https://youtu.be/ab9q6W0B1OU
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
Primary Care guidelines podcast:
· Redcircle: https://redcircle.com/shows/primary-care-guidelines
· Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK
· Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148
There is a YouTube version of this and other videos that you can access here:
- The Practical GP YouTube Channel:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Hypertension in adults: diagnosis and management [NG136] can be found here:
· https://www.nice.org.uk/guidance/NG136
Transcript
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.
Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only.
In the last two episodes we covered the diagnosis and the criteria for urgent referral.
Today we will focus on initial management, when to start drug treatment and how to monitor hypertension.
Right, let’s jump into it.
And let’s remember that the recommendations in the hypertension guideline apply to all adults, including those with type 2 diabetes. However, in some situations, management differs, and NICE recommends referring to other relevant guidelines, including those on chronic kidney disease, type 1 diabetes, and hypertension in pregnancy.
Now let’s look at lifestyle interventions.
We should offer lifestyle advice and continue to reinforce this periodically.
We should ask about diet and exercise patterns, because a healthy diet and regular exercise can help reduce blood pressure.
We should ask about alcohol consumption, and encourage a reduced intake if the person drinks excessively, as this can lower blood pressure and has broader health benefits.
We should discourage excessive consumption of coffee and other caffeine rich products.
We should encourage people to keep their dietary sodium intake low, either by reducing salt or using substitutes, as this can also reduce blood pressure.
However, salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease, or those taking certain antihypertensive drugs, such as ACE inhibitors or angiotensin receptor blockers.
In these groups, we should focus on reducing salt intake rather than using substitutes.
Finally, we should offer advice and support to help people stop smoking.
Now let’s look at when we should start antihypertensive drug treatment.
We should offer antihypertensive drug treatment to adults of any age with persistent stage 2 hypertension. That is, a clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent daytime average on ambulatory monitoring, or average on home monitoring of 150/95 mmHg or higher.
We should use clinical judgement for people with frailty or multimorbidity in order to minimise overtreatment and the risk of side effects.
What about those with stage 1 hypertension, that is, a clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent daytime average on ambulatory monitoring, or average on home monitoring ranging from 135/85 mmHg to 149/94 mmHg? Well, treatment here will depend on risk factors.
For adults under 80 with persistent stage 1 hypertension, we should definitely start treatment if they have signs of target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk of 10 percent or more, again, we should use clinical judgement in people with frailty or multimorbidity.
In other situations, NICE is less prescriptive and advises us to “consider” treatment, which means using our clinical judgement more flexibly.
For example, in adults under 60 with stage 1 hypertension and a 10-year cardiovascular risk below 10 percent, we should still consider treatment, bearing in mind that a 10-year risk score may underestimate lifetime cardiovascular risk.
Similarly, in adults over 80 with stage 1 hypertension, we should consider treatment if clinic blood pressure is above 150 over 90.
And this distinction between “offer” and “consider” is important. It reflects the level of certainty in the evidence and reminds us that clinical judgement is crucial.
Finally, for adults under 40, we should consider specialist referral for secondary causes and assessment of long-term risks and benefits of treatment.
Now let’s go through clinic blood pressure targets.
For adults under 80, the general target is a clinic blood pressure below 140 over 90.
This applies to people with hypertension, with or without type 2 diabetes, and also to those with type 1 diabetes or CKD if the albumin to creatinine ratio is below 70.
However, if the albumin to creatinine ratio is 70 or higher, the target is lower, below 130 over 80.
For adults aged 80 and over, the general clinic blood pressure target is below 150 over 90.
And although this may feel counterintuitive, this target also applies to people with type 1 or type 2 diabetes, regardless of albumin to creatinine ratio. In this age group, albumin to creatinine ratio only changes the target for people with CKD.
NICE does not set lower blood pressure targets in people over 80 just because they have diabetes, as the evidence for lower blood pressure in this age group is limited.
So, if they have CKD with an albumin to creatinine ratio below 70, the target is below 140 over 90, and if it is 70 or higher, the target is below 130 over 80.
Now let’s look at monitoring in practice.
We should use clinic blood pressure measurements to monitor response to treatment.
We should check for postural hypotension in people with type 2 diabetes, symptoms of postural hypotension, or who are aged 80 and over.
If there is a significant postural drop, or symptoms, we should base treatment targets on standing blood pressure.
We should also consider ambulatory or home monitoring in addition to clinic readings if there is a white coat effect or masked hypertension.
For people who self-monitor, we should use home blood pressure monitoring and we should remember that out of clinic readings are about 5 mm of mercury lower.
So, in adults without relevant comorbidities, under 80, the target is below 140 over 90 in clinic, or below 135 over 85 at home.
Over 80, the target is below 150 over 90 in clinic, or below 145 over 85 at home.
We should use the same blood pressure targets regardless of whether the person has established cardiovascular disease. When type 2 diabetes is diagnosed, we should review blood pressure control and the medications used and make changes if the current treatment is not appropriate because of microvascular complications or metabolic problems.
Finally, we should provide an annual review for all adults with hypertension.
So that is it, a review of a section of the NICE guideline on hypertension.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
