Hypertension Criteria

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Hypertension Criteria Powered By Docstoc
					         Clinical Guidance
                   For
     Nurses in Primary Care
                    In
The Detection and Management of
     Essential Hypertension

                    By
    Nurses Hypertension Association, UK




                     1
                                        Contents


I. Introduction…………………………………………………………………….……...3
II. Summary List of Principles of Hypertension Care for Nurses …………….……4
III. The Rationale Behind The Choice Of Principles Of Care……………………...5

       1. Nurse Led Clinics ………………………………………………………...5
       2. Screening……………………………………………………………..…...6
       3. Blood Pressure Measurement…………………………………………..7
              a. Choosing and maintaining equipment…………………………7
              b. Taking accurate and reliable readings ………………………..7
              c. Determining frequency of repeat BP readings……………….9
              d. The use of 24 hour monitoring ………………………………..11
       4. Cardiovascular Risk Assessment……………………………………...12
              a. Interviewing the patient…………………………………………13
              b. Measurements…………………………………………………..16
              c. Risk factor scoring systems……………………………………17
       5. Non Pharmacological Treatment………………………………………19
              a. Changing lifestyles……………………………………………..19
              b. Dietary advice…………………………………………………..19
              c. Smoking cessation……………………………………………..20
              d. Activity levels……………………………………………………20
              e. Safe alcohol intake……………………………………………..20
       6. Pharmacological Treatment……………………………………………21
       7. Nurse Prescribing……………………………………………………….23
              a. Independent Prescribing……………………………………...23
              b. Guideline for drug treatment.………………………………….23
              c. Clinical management plan..……………………………………25
       8. Patient Monitoring and Support………………………………………..26
              a. Monitoring……………………………………………………….26
              b. Concordance……………………………………………………26
              c. Patient support………………………………………………….27
              d. Recall, Recording and Audit…………………………………..29
       9. Referral ………………………………………………………………….30
              a. Specialist lifestyle advice………………………………………30
              b. Specialist secondary care opinion…………………………….30
IV. References and Resources …………………………………………………….31




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                                      I. Introduction

The objective of this clinical guideline is to support nurses in primary care to lead clinics for the
detection, management and control of hypertension. Practice Nurses have increased their role in
monitoring this chronic disease and with the introduction of independent prescribing their
responsibility is likely to rise. The Nurses Hypertension Association (NHA) members developed this
guideline to assist nurses in providing evidence based nursing care in hypertension within a multi-
professional team. Principles of care are identified and linked to national guidelines or research
evidence. The practice team, including the nurse, can set local standards for each of the principles
that reflect their local conditions. These standards should be reviewed at regular intervals taking
into account a benchmarking process. This process includes repeat audit to compare the results of
regular data collection to the practice standard then compare the results with that from other local
areas and / or national data.

The subject area agreed by the NHA is:


           THE DETECTION AND MANAGEMENT OF ESSENTIAL HYPERTENSION

Principles of care were selected which indicate best practice for the role of the nurse in primary
care when detecting and managing essential hypertension so as to control blood pressure along
with the other main cardiovascular risk factors. The main reference source used was the guidelines
developed by the British Hypertension Society (BHS-IV) (Williams, Poulter, Brown et al, 2004)
(www.bhsoc.org) which are revised regularly and reflect the Joint Guidelines of the British
Hypertension Society, British Cardiology Society, Heart UK and Diabetes UK. Relevant NICE,
SIGN and National Framework documents are also referred to within this NHA guideline.




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II. Summary List of Principles of Hypertension Care for Nurses

1. Nurse Led Clinics
Nurses can effectively lead hypertension clinics. To do this safely they should have the necessary
knowledge and skills.

2. Screening.
Every five years a blood pressure check with healthy lifestyle advice is offered to all adults
registered within the General Practice and not known to have:
     Hypertension                       Taking medication requiring more regular BP monitoring
     CVD                                High normal BP (130 -139/85-89 mmHg).
     Diabetes
More frequent BP measurements are recommended if patients are known to have any of the above
conditions.

3. Blood Pressure Measurement
Use and maintain validated BP devices and ensure operators are fully trained to assess BP
accurately when diagnosing and managing patients with hypertension.

4. Cardiovascular Risk Assessment.
All modifiable and immodifiable cardiovascular risk factors assessed in patients found to have
blood pressure >140/90 mmHg.

5. Non Pharmacological Treatment
Patients offered lifestyle advice as necessary for:
     Healthy eating                                      Activity levels
     Weight management                                   Safe alcohol intake.
     Smoking cessation

6. Pharmacological Treatment
All patients assessed for pharmacological treatment and offered appropriate therapy.

7.Nurse Prescribing
Patients suitable for pharmacological treatment can be managed by a nurse who is a Nurse
Independent Prescriber and is competent in hypertension management.

8. Patient Monitoring and Support
Principles:
Patients with hypertension should be monitored by:
     Offering three to six monthly BP monitoring.
     Giving an individual BP target level.
     Offering an annual review.
Patients with hypertension should be supported in:
     Taking medication.
     Making lifestyle changes.

9. Recall, Recording and Audit.
Establish and maintain a General Practice hypertension register. Patients with hypertension are
reviewed at least annually (NICE, 2004) and have a BP check six monthly (GMS, 2004).
The General Practice maintains a standardised Read Coded computer database of patients with
hypertension. Each General Practice monitors principles and sets standards for regular
comparison of quality hypertension management.

10. Referral
Patients referred when appropriate for specialist lifestyle advice and / or for specialist secondary
care opinion.


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III. The Rationale Behind The Choice Of Principles Of Care

III.1. Nurse Led Clinics
Principle: Nurses can effectively lead hypertension clinics. To do this safely they should have the
necessary knowledge and skills.

A postal survey of practice nurses (n= 73) in Sheffield found that their level of autonomy varied, i.e.
some practices had nurse led services while others used nurses to undertake tasks for general
practitioners (Eve, Waller and Gerrish, 2001). Approximately half of all visits to the nurse for
chronic disease management were for BP checks confirming the important role of practice nurses
in hypertension detection and management. In Bengston and Drevenhorn‟s (2003) systematic
review of studies of nursing in hypertension six randomised controlled trials for assessing nurse
effectiveness in lowering BP compared to physicians found statistically significant reductions in
each. The studies were also examined to find out about the nurses‟ role and skills. Nurses seemed
to provide information, educate in self–measurement of BP, give advice about diet, control the
intake of medicine, control laboratory tests and encourage the patient. Two of the studies were
based in the UK, one in primary care (Jewell and Hope, 1988) and one in secondary care (Curzio,
Rubin, Kennedy and Reid, 1990).

In a Swedish qualitative study of a comparison between nurses and doctors managing patients
with hypertension Aminoff and Kjellgren (2001) found:
     Average longer conversations with nurses than doctors.
     Nurses talked to patients about other vascular risk factors more often than doctors.
     Doctor consultations focused on medication more than nurse consultations.
     Patients raised more new topics with nurses than doctors.

Communication skills were identified as an important distinctive feature of the nurse‟s role.
Therefore length of appointment times will vary according to patients needs but at least 30 minutes
is needed for an initial cardiovascular assessment and 15 to 20 minutes for an annual review.


           The Nurses Hypertension Association produced this guidance for nurses in primary care
to help them manage patients with hypertension effectively. This guidance can be adapted into a
local hypertension protocol as it can be downloaded from the NHA website. This publication has
attempted to provide nurses with aspects of hypertension that are of particular relevance to them in
the primary care setting, therefore, for example, there is little about physical examination or
checking fundi as this is currently the role of the medical practitioner. Further information is
available from the list of recommended books. This guideline was written in 2005 and updated in
2006, future updates are planned. Further information about the NHA and educational meetings
and courses on hypertension can be found on the website www.nha.uk.net




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III. 2. Screening
Principle: A blood pressure check and healthy lifestyle advice offered every five years to all adults
registered within the General Practice and not known to have:
      Hypertension
      Cardiovascular disease
      Diabetes
      Taking medication requiring more regular BP monitoring
      High normal BP (130 -139/85-89 mmHg).
More frequent BP measurements are recommended if patients are known to have any of the above
conditions.

Hypertension is a modifiable cardiovascular risk factor. The higher the blood pressure the higher
the risk of stroke, heart or renal disease, this applies for any level of blood pressure (He and
Whelton, 1999). Because risk is continuous there is no absolute level of blood pressure below
which subjects are at low risk and above which subjects are more likely to have a premature death.
Essential hypertension normally has no symptoms, except in a few severe cases presenting as
frontal headache and visual disturbance, therefore screening is required. Opportunistic screening
of BP is recommended. More intensive screening requires five yearly computer recall.

Recall for BP measurement varies for patients who belong to the following groups:
    Hypertension - at least annually.
    Cardiovascular or renal disease - at least annually.
    Diabetes – at least annually.
    Taking medication requiring regular BP monitoring - frequency depends on medication type
        e.g. combined oral contraceptives, steroids.
    High normal BP (130-139/85-89 mmHg) - ideally annually particularly in the elderly.

Frequency for repeat BP readings depends on initial screening level.
    If BP <135/85 mmHg - a computerized five year recall system should be established (BHS-
      IV, 2004).

      If BP = 135-139/85-89 mmHg recall should be sooner, preferably annually (WHO, 1999).

      If BP >140/90 mmHg then repeat BP according to guideline in Section III.2.c

The health care team should be alert for repeat screening schedules. Administrative systems to
ensure accurate data recording and regular computer searches are necessary to identify
individuals that require a screening prompt.




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III.3. Blood Pressure Measurement
Principle: Use and maintain validated BP devices and ensure operators are fully trained to assess
BP accurately when diagnosing and managing patients with hypertension.

BP measurement forms the basis of accurate diagnosis and management of hypertension. This
guideline contains criteria for:
    - a) Choosing and maintaining equipment.
    - b) Taking accurate and reliable readings.
    - c) Determining frequency of repeat readings.
    - d) The use of 24 hour monitoring.

III.3.a Choosing and maintaining equipment
Cuff selection, for whichever device is used to measure BP, is important. Use a cuff in which the
enclosed bladder encircles 80% of the upper arm. It is necessary to have available a variety of cuff
sizes; a minimum of standard and large is required.
BP is measured indirectly using manual (mercury or aneroid sphygmomanometers), semi-
automatic or automatic devices. Not all devices are recommended for hypertension clinics. The
aneroid sphygmomanometer is the least robust device as it works by pressure springs. Dropping or
banging the device can reduce its accuracy. Routine six monthly intervals are recommended for
calibration. Nevertheless this device is not recommended for routine use in hypertension clinics
(O‟Brien, Asmar, Beilin et al, 2003). The wrist and digit BP devices are also not recommended
(BHS-IV, 2004) mainly because the research evidence for treatment thresholds were based upon
upper arm measurements.
Devices recommended for hypertension clinics in the community are the mercury
sphygmomanometer and validated semi-automatic and automatic devices.

The mercury sphygmomanometer
This is a reliable and robust device if used correctly in expert hands (BHS-IV, 2004). In any manual
recording of BP observer error is difficult to eliminate without intensive repeated training (O‟Brien,
Asmar, Beilin et al, 2003). In many areas the gold standard mercury devices are being replaced
because of the dangers to the environment from exposed oxidized mercury. If using devices
containing mercury care should be taken to store and place them in a stable position. A mercury
spillage kit should be available. Mercury sphygmomanometers should not be used in patients‟
homes due to the risks associated with mercury spills. The mercury devices need annual
calibration and cleaning by trained technicians using correct safety procedures, regrettably this is
becoming more difficult to access in some regions. Hospital technicians may be able to advise
community health practitioners on where to access such a service.

Semi-automatic and automatic devices
Only validated semi-automatic and automatic devices should be used. These are becoming
increasingly available, a list can be found at www.bhsoc.org or www.dableducational.com. Choose
one with a robust design able to withstand the wear and tear of multiple readings in a busy clinic.
These devices should be calibrated according to manufacturers instructions but normally annually.
Cuffs become soiled with heavy use but many are not removable for washing unlike manual
sphygmomanometer cuffs or 24 hour BP recording devices. Disposable cuff covers are available
from some manufacturers. Obtaining accurate readings with automated devices can be
problematic in patients with tremor (such as in Parkinson‟s Disease) or with an irregular pulse.
Three readings are advised to obtain an overall average. Occasionally it is not possible to obtain a
reading from an automatic device because of patients‟ involuntary movements or irregular pulse
therefore a manual device should be available.

III.3.b Taking accurate and reliable readings
Accurate measurement of BP is essential, key points are listed in Table 1. The pulse should be
counted and assessed before BP is measured. A patient with an irregular pulse requires multiple
readings to assess BP. If the pulse is regular three BP measurements should be taken at each visit
after the patient has rested for at least five minutes with a minute between readings, the first
reading should be discounted an average of the other two be calculated. Normally BP is measured


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in the sitting position with the arm fully supported with the cuff at heart level. All manual readings
should be recorded to 2 mmHg. Assessment of standing BP should be considered if the patient is
elderly, has diabetes or reports episodes of lightheadedness or falls. Both systolic and diastolic
readings are of importance in estimating cardiovascular disease risk.
Systolic pressure is when the heart ventricles contract and force the blood through the arteries. In
manual readings of BP it is read as the first Korotkoff sound, i.e. at least two repetitive tapping
sounds. It is important to palpate for the systolic reading so as not to miss the true systolic as some
people have an auscultatory gap i.e. sound disappears between 2nd and 3rd Korotkoff sounds.
Diastolic pressure is when the heart is relaxed and filling with blood for the next contraction.
Diastolic BP in manual readings is taken as the fifth Korotkoff sound i.e. disappearance of sound.
Occasionally disappearance of sound does not occur until nearly zero e.g. in some pregnant
women or elderly people with anaemia. In this instance the 4th Korotkoff sound, muffling should be
used. This should be shown as e.g. 142/84/18 or 142/84 -18 mmHg. Further information and
details about BP measurement can be found on the website www.bhsoc.org.

Table 1. Factors Influencing Blood Pressure Estimation
          Manual Recordings only                    Manual & Automatic Recordings
Observer bias                                 Defense reaction (the actual measurement
                                              increases BP)
Digit preference (observer prefers certain Beat to beat variability (each time the heart
numbers and subconsciously records this)      beats BP can alter)

Auscultatory gap (silent gap following the true     Irregular heart beat
systolic)
             Over estimation of BP                             Under estimation of BP
Cuff bladder too narrow                             Cuff bladder too wide
Cuff applied too loosely                            Leaks in tubing
Bladder not centred over artery                     Heavy pressure on stethoscope (diastolic)
Too rapid deflation (diastolic)                     Too rapid deflation (systolic)
Hearing impaired (diastolic)                        Hearing impaired (systolic)
Arm with cuff held below heart level                Arm with cuff held above heart level
             Factors increasing BP                              Factors decreasing BP
Talking during technique. Exercise, smoking or      Rest (sleep). Peaceful environment.
taking caffeine in previous 30 minutes. Pain.
Anxiety.
Standing (diastolic)                                Standing (systolic)
White coat hypertension                             Standing (in some elderly and those on alpha
                                                    blocking drugs)
Low environmental temperature                       High environmental temperature




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III.3.c Determining frequency of repeat BP readings.
Diagnosis of hypertension is an important health care event for patients. It can occasionally restrict
the work of certain occupational groups e.g. divers, airline pilots and affect insurance premiums. If
such a diagnosis is made on too flimsy evidence the patient may be committed to a lifetime of
unnecessary drug taking, whereas failing to act on good evidence for hypertension exposes the
individual to an increased risk of cardiovascular disease. The frequency of repeat BP readings
depends on the level of the BP found and this is summarized in Table 2 with detailed explanation
below. At the time of BP assessment the nurse has an important role in:
      Completing the cardiovascular risk assessment.
      Counseling and negotiating with the patient about beneficial lifestyle changes.
      Providing appropriate materials to inform the patient about raised BP so they are able to
         make informed treatment decisions.

Table 2. Frequency of BP Monitoring for Diagnosing Hypertension
  Mean Clinic BP Level     End Organ Damage              Frequency of BP Monitoring
(mmHg) of at Least Two            Status
         Readings         i.e. CHD, stroke, LVH, (to include a minimum of two further BP
                          Heart Failure, PVD,    readings at separate clinic visits)
                          Renal disease,
                          diabetes.
Sys > 220                 Present or Not         Very Severe Hypertension
and / or dias >120        Present                Seek immediate medical advice.
Sys 180-219               Present                Severe Hypertension, seek medical advice
and / or dias 110 -119                           Consider hospital admission; but if not
                                                 minimum of weekly for 1-2 weeks; if
                                                 confirmed treat.
Sys 180-219               Not Present            Severe Hypertension
and / or dias 110 -119                           Minimum of weekly for 1-2 weeks if
                                                 confirmed treat.
Sys 160-179               Present                Moderate Hypertension
and / or dias 100 -109                           Weekly for 4 weeks then treat if persists.
Sys 160-179               Not Present            Moderate Hypertension
and / or dias 100 -109                           Weekly initially then treat if persists over 4 to
                                                 12 weeks.
Sys 140-159               Present                Mild Hypertension
and / or dias 90 - 99                            1-2 weekly for 4-6 weeks, if sustained treat.
Sys 140-159               Not Present            Mild Hypertension
and / or dias 90 - 99                            Monthly for 3 to 6 months if confirmed assess
                                                 CVD risk if 140 -149/90-99, treat if >160/100
                                                 mmHg, reassess annually if <140/90.

If very severe hypertension is found i.e. systolic >220 mmHg and/or diastolic 120 mmHg malignant
hypertension should be excluded because patients with malignant hypertension are admitted to
hospital for treatment. To exclude malignant hypertension the nurse should ensure that a
practitioner skilled in examining the eye for papilloedema and/or retinal haemorrhage assesses the
patient. If malignant hypertension is excluded pharmacological treatment should be started.

If severe hypertension is found i.e. systolic 180 - 219 mmHg and / or diastolic 110 –119 mmHg,
malignant hypertension should be considered. If not present then monitor BP over 1 to 2 weeks; if
confirmed pharmacological treatment is commenced. A cardiovascular and end organ damage
assessment should be completed over the next few weeks in all patients with severe hypertension.
End organ damage includes a personal history of cardiovascular or renal disease, diabetes or left
ventricular hypertrophy (LVH). If BP is sustained above 180/110mmHg in patients during this
period of assessment there are certain occupational groups who should seek advice from their
occupational health department or GP about whether it is safe to continue working e.g. airline pilot,
heavy goods vehicle drivers, divers, bus and train drivers (DVLA). If there is a clear falling pattern
over the 2 weeks consider monitoring for a further 4 weeks.


                                                  9
If moderate hypertension is found i.e. systolic 160 -179mmHg and or diastolic 100-109mmHg the
frequency of monitoring depends on whether there is end organ damage (see above). During the
period of repeat BP an assessment for cardiovascular risk factors should be done (see section
III.3).

Where end organ damage is present, BP should be monitored weekly for 2 weeks.
  - If there is a clear falling pattern then this monitoring can be continued for 4-6 weeks
      depending on last reading and falling pattern being maintained.
  - If at that time BP is >140/90 mmHg then treatment should be started.
  - If BP falls below 140/90 mmHg then at least annual reassessment is required.
  - If BP is not clearly falling treatment should be commenced at 4 weeks.

Where no end organ damage is present, BP can be monitored weekly for 4 weeks.
  - If there is a clear falling pattern BP can be monitored monthly for a further 3 months.
  - If systolic BP is >160 and / or 100 mmHg then treatment should be commenced. If BP is
     140 –159 mmHg and or 90 – 99 mmHg then a 10 year CVD risk assessment can be made
     (see section III.3.c).

If mild hypertension is found systolic i.e. 140 - 159 mmHg and or diastolic 90 - 99 mmHg,
frequency of monitoring depends on the presence or not of end organ damage. Other
cardiovascular risk factors should also be assessed.

Where end organ damage present then 1 to 2 weekly BP assessment should be made over 4 to 6
weeks.
   - If systolic BP remains >140 and / or diastolic >90mmHg then treatment should be
       commenced.
   - If there is a clear falling pattern BP should be monitored for another 3 months.
   - If at this time BP is less than 140/90mmHg then at least annual reassessment of BP is
       required.

Where no end organ damage is present then monthly readings over 3 months.
  - If BP remains 140 - 149/90 – 99 mmHg an assessment of CVD risk over 10 years is
      required to decide if pharmacological treatment should be offered. NICE Clinical Guideline
      18 (www.nice.org) and the BHS-IV (www.bhsoc.org) recommend using the Joint British
      Societies revised CVD risk factor scoring tool. If patient‟s CVD risk > 20% treatment should
      be commenced. See section 3 for more details.




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III.3.d The use of 24 hour monitoring
Use of Ambulatory blood pressure measurement (ABPM)
This is not recommended for use in general practice in the NICE Guidelines on essential
hypertension (2006). Despite this it is known that there are individual surgeries and Primary Care
Trusts that carry out this procedure therefore this guideline has included some advice on their use
for pragmatic reasons.
The BHS–IV guideline states ABPM is not needed in all patients but does provide indications for its
use:
      Unusual BP variability
      Possible „white coat‟ hypertension
      Informing equivocal treatment decisions
      Evaluating nocturnal hypertension
      Evaluation of drug resistant hypertension
      Determining the efficacy of treatment over 24 hours
      Evaluation of symptomatic hypotension
      Diagnosis and treatment of hypertension in pregnancy.
When the above situations are present patients are best assessed within a specialist unit where
accurate interpretation is available.

If ABPM is used to identify patients with „white coat hypertension‟ (an alerting response in
individuals during clinic BP measurement) then repeat ABPM is necessary to screen for developing
hypertension. As a general rule mean daytime and night-time readings taken 15-30 minutes apart
are used. The threshold and target for BP should be adjusted downwards by 10/5mmHg (BHS-V).
Only validated well-maintained machines with appropriate cuff sizes should be used, see
www.bhsoc.org or www.dableducational.com for a list. A disadvantage of ABPM is that there are
relatively high start-up costs, including buying the monitors, analysis software and batteries. Staff
will also require training in fitting the monitor, educating the patient and interpreting the results.

Fitting the monitor and instructions to patient
     - The monitor will require programming for each patient prior to fitting.
     - Ask the patient to be still and quiet whilst the monitor is taking their BP, preferably sitting
         with their arm supported.
     - Advise the patient that they will be unable to bath / shower / drive safely / undertake
         strenuous exercise whilst wearing the monitor.
     - Provide the patient with a diary to complete. This aids interpretation of the results and
         should include details of medication, dose and time taken, sleep times and a note of
         anything unusual during the monitoring period.
     - Tell patient to have a normal day - not to spend the day relaxing.
Self blood pressure measurement (SBPM) is also not recommended for use in the assessment of
hypertension in the NICE Guidelines on essential hypertension (2004). Nevertheless the sale of BP
measurement devices has increased markedly in recent years suggesting that patients value the
idea of being able to monitor their own BP. Nurses in primary care are in an ideal position to advise
patients on how to do this appropriately therefore this is discussed in section III.6.c.




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III.4. Cardiovascular Risk Assessment
Principle: All major modifiable and immodifiable cardiovascular risk factors to be assessed in
patients at screening found to have blood pressure greater than or equal to 140/90 mmHg.

If practice nurses have the necessary knowledge and skills required to make a cardiovascular
assessment they should complete an interview, questionnaire, observations and physical
measurements. Sufficient time should be set aside to undertake these various tests in a relaxed
and informative manner. As this assessment may lead to many years of follow up and intervention
each part should be explained to the patient. The independent risk factors known to cause
cardiovascular disease are smoking, hypertension, hyperlipidaemia and type 2 diabetes.
Individuals with more than one risk factor are at greater risk from the combination than the sum of
the two (Kannel, Neaton, and Wentworth et al, 1986). Other important risk factors are shown in
Table 3 as modifiable or not.

Table 3. The Risk Factors for Coronary Heart Disease (CHD)
Lifestyle               Biochemical or Physiological            Personal
Tobacco smoking*        Raised cholesterol*                     Age+
Poor diet*              Raised blood pressure*                  Gender+
Physical inactivity*    Low HDL-cholesterol*                    Ethnicity
Excess alcohol*         Raised triglyceride*                    History of cardiovascular disease+
Obesity*                Diabetes mellitus                       Family history+
Stress*                 Thrombogenic factors*
                        Left ventricular hypertrophy (LVH)
+ = immodifiable risk factor                               * = modifiable risk factor




                            Figure 1- Measuring BP in General Practice




                                                12
III.4.a Interviewing the patient
Age
In developed countries such as the UK, the rise in blood pressure that occurs with age           is well
recognized and in the main is due to environmental factors. Tracking is the tendency of           higher
blood pressure to rise faster with advancing age. While systolic blood pressure continues        to rise
with age, it has been observed that diastolic tends to plateau in men and women over the         age of
60 years. Isolated systolic hypertension (ISH) carries an increased risk of stroke.

Gender
The natural course of coronary heart disease is different for males and females. Young males (35 -
44 years) have a CHD rate six times higher than that of women of the same age. With advancing
age this difference between the sexes lessens. After the menopause CHD becomes the leading
cause of death and disability in women.

Ethnicity
No race is immune from cardiovascular disease, the level is controlled by the prevalence of risk
factors. The African Caribbean population in Britain has a higher incidence of hypertension with a
different salt metabolism, increased rate of strokes, lower cholesterol levels and less CHD. People
originating in the Indian sub continent show higher incidence of central obesity, diabetes, coronary
heart disease with no difference in blood pressure levels but higher cholesterol levels.

Personal history of cardiovascular disease
It is important to establish whether the patient has cardiovascular disease i.e. had a stroke,
transient ischaemic attack (TIA), myocardial infarction or has angina, peripheral vascular disease
or renal disease. If so this patient is being assessed for secondary prevention of cardiovascular
disease. As they are at very high risk the management of such patients is of high priority. Similarly
if there is a diagnosis of type 2 diabetes their risk of a cardiovascular event is also very high. Other
patients are described as being assessed for primary prevention of cardiovascular disease i.e. at
screening one or more independent risk factor was identified.

Personal family history
Before inquiring about family history there are some important aspects to establish:
     Does the patient know about their family tree e.g. adopted?
     Is the patient willing to discuss their family tree with you?
Having a close family history of type 2 diabetes, hypertension, stroke and CHD (established CHD
before the age of 65 years in women and 55 years in men) increases the personal risk of
developing cardiovascular disease. Close means either a parent or sibling relationship to the
patient. Assessing all cardiovascular risk factors and providing advice is particularly important in
such families.

Assess smoking
Smoking causes cardiovascular disease (Doll, 1997). Current smokers are three times more likely
to have a heart attack compared to those that have never smoked. Nicotine and carbon monoxide
increase the production of atherosclerosis. Passive smoking is also linked with coronary heart
disease (Law, Morris and Wald, 1997).
There is really only one vital question - Do you smoke?
If the answer is no, never, then congratulate the person and encourage them to never smoke. If
they used to smoke but have stopped then you also congratulate them and reinforce how important
it is to stay off the cigarettes. It is important to let the patient know that you are recording their
smoking status in their medical record. The patient who answers 'Yes' should be told that they
have a risk of heart disease because they smoke, advised to stop and offered support in doing this.

Assess alcohol consumption
Excessive alcohol consumption is a risk factor for hypertension, and can also contribute to obesity,
and raised serum triglyceride levels. Taking over 21 units of alcohol / week in men and over 14
units of alcohol / week in women has been shown to increase the risk of cardiovascular disease.
The pattern of excessive alcohol consumption is important as risk increases with “binge drinking”.


                                                  13
“Binge drinking”, where most of the weekly intake is consumed over one to two days, is assessed
from patterns of daily and weekly alcohol consumption. The standard questions in Box 1 can help
(Anderson, 1991).

Box 1 Questionnaire to Assess Alcohol Intake
1. On average, how many days a week do you have an alcoholic drink?
2. On average, on a day when you have had an alcoholic drink, how much do
   you usually have?
     - Half pints of beer, lager, cider
     - Glasses of wine, sherry, martini
     - Single measures of spirits, e.g. gin, whisky, vodka

                                                         Total
* One unit equals half a pint of ordinary beer, lager etc.; a single measure of spirits; a small glass
of sherry; a standard glass of wine (125mls). Home measures are invariably more.
* Add up the number of units of alcohol on each drinking day. Multiply this number by the number
of drinking days a week to find the patient's total weekly consumption.
* Record the amount of alcohol consumed in the practice note or computer.

Assess physical activity
To assess activity levels it is necessary to ask about the intensity, frequency and duration of
exercise. The minimum effective exercise to reduce the risk of cardiovascular disease means
taking on 5 different days of the week 30 minutes of moderate exercise (HEA,). The activity should
cause the person to feel warm and their pulse to rise slightly. This can include lifestyle activity
(such as walking to work) or structured (such as sport or gyms etc). It can also be done in short
bursts of time that accumulate over one day e.g. three or more sessions of ten minutes. It can be
quite difficult to make an accurate assessment of a person‟s physical activity level but the aim is to
determine if this could be improved.

Assess diet
Assessing diet involves the person being able to recall both the type and quantity of food and drink
consumed regularly. Dietitians do this when they take a diet history. In primary care a 24 hour
recall can be useful for basing nutritional advice. Asking about type of milk and spreading fat
normally used and how many pieces of fruit and vegetables are taken daily is useful. The
Mediterranean diet was found to be cardio-protective for individuals at high risk of CHD (Burr 1989)
(Singh 1992).
 Randomised control trials of sodium salt restriction suggested that the salt intake of most
populations could be halved, for example from 10-12g to 5-6g per day, without adverse effect and
cause a mean drop of blood pressure in the population by 4 -5 mmHg. Therefore asking about
adding sodium salt and taking salty foods is particularly important in patients with raised BP.
Although rare it is worth asking if patients with high BP ingest large quantities of liquorice as this
raises BP.

Assess medication
Ingested drugs such as the Oral contraceptive pill, adrenal steroids, nonsteroidal anti-inflammatory
drugs, sibutramine hydrochloride, sympathomimetics, antidepressants, nasal decongestants,
cyclosporine, erythropietin, and cocaine can increase BP. As certain herbal or complimentary
medicines can also raise BP the nurse should enquire and report whether the patient is taking any
of these.

Assess psychosocial stress
It is known that sudden stress can raise blood pressure acutely - the act of taking blood pressure
for example can increase systolic blood pressure markedly - and it has long been suspected that
chronic stress may be a risk factor for hypertension. However the role of chronic stress has been
difficult to assess partly because stress means different things to different people, and partly
because stress has not always been easy to measure. It has been shown that job strain in men is


                                                 14
associated with an elevated blood pressure, not only at work but also while at home and during
sleep (Pickering et al, 1995). Job strain is defined here as the result of a highly demanding job with
low control, as in a shop floor worker. The effect of job strain on blood pressure is independent of
other environmental influences and is said to be as strong as that of obesity. Defining, assessing
and supporting people with chronic stress are difficult.

This completes the assessment of patients by the interviewing methods. Other risk factors
                                require to be measured.




                                                 15
III.4.b Measurements
Obesity
Obesity is a significant risk for heart disease because it can lead to the development of high blood
pressure, diabetes and high blood cholesterol. Weight alone is not a useful measurement for
assessing obesity. Body Mass Index (BMI) is advocated for adults i.e. weight (kg)/ height (m)
squared. BMI is limited by age, gender, size of the body frame and the proportion of lean mass. It
does not take into account body fat distribution. The figure provided by the BMI calculation is
classified as shown in Table 4.

                          Table 4. Classification of BMI (Garrow, 1981)
                      Grade        Body Mass Index        Description
                      0            <20                    Underweight
                      1            20-24.9                Normal weight
                      2            25-29.9                Overweight
                      3            30-39.9                Obese
                      4            >40                    Severely Obese

There is evidence to suggest that central obesity is a good indicator of health risk (Larson et al,
1988). Waist measurement has been found to identify people at increased cardiovascular risk
(Han, 1995). The waist is considered to be midway the lowest rib and the iliac crest. There are
different action levels recommended for men and women and lower thresholds for persons of Indo-
Asian descent supported by the International Association for the Study of Obesity, as shown in
table 5.

                    Table 5. Waist Circumference Guidelines for Action
 Action level of waist                 Measure                   Recommended action
    circumference
Men
                         > 102 cm (>40 inches)               Weight loss
Indo-Asian Men
                             > 90 cm                                   Weight loss
Women                        > 88 cm (35 inches)
                                                                       Weight loss
Indo-Asian Women
                             > 80 cm                                   Weight loss

Urinalysis
This simple procedure when accurately performed is a useful screening tool.
The presence of glucose is indicative of diabetes but not diagnostic. The
presence of protein and / or macroscopic haematuria may indicate renal
arterial necrosis in patients with malignant hypertension, hypertensive
nephrosclerosis, renal disease such as glomerulonephritis, polycystic kidney
disease, or chronic pyelonephritis (Beevers, Lip and O‟Brien, 2001). Blood in
the urine can also signify a urinary tract infection or could be a sign of
bladder, kidney or prostate cancer. Patients who have protein or blood in the
urine should be fully investigated; firstly the urine should have microscopy,
                                                                                         Figure 2-
culture and sensitivities performed to rule out infection.
                                                                                       Testing Urine
 A urine collection for protein creatinine ratio should be performed if > +1
protein is present on urinalysis and when MSU is negative. In cases where proteinurea is present
for a certain level of blood pressure and / or in diabetes the risk of death is approximately doubled.
It is quite possible to miss following up protein or blood in the urine if a culture and sensitivity test
for bacteria returns as normal unless there is a system in place to trigger further investigations.
Blood tests
In assessing patients with repeatedly raised blood pressure the following blood tests are useful to
identify other cardiovascular risks. Type 1 and 2 diabetes are linked to a high risk of cardiovascular
disease. The risk of coronary heart disease in diabetes is estimated to be as much as 4 times that
of the population as a whole. There is an association between high blood pressure, obesity,

                                                   16
impaired glucose tolerance and dyslipidaemia (particularly low HDL- cholesterol and high
triglycerides). Patients with type 2 diabetes have a high incidence of hypertension (50% or more)
and hyperlipidaemia therefore a blood glucose level should be taken, preferably fasted. The
Framingham Study showed that high levels of LDL cholesterol are associated with increased CHD
risk and that high levels of HDL cholesterol are protective associated with reduced CHD risk. It is
useful to think of LDL as the lipoprotein that carries cholesterol to the vessel wall where it promotes
the process of atheroma. HDL by contrast can be thought of as the lipoprotein that transports
cholesterol away from the blood vessels to the liver for elimination. An assessment of total
cholesterol level and HDL is required for a cardiovascular risk assessment.

In assessing patients with repeatedly raised blood pressure blood tests are useful to assess the
patient for signs of secondary hypertension. Only 5-10% of patients have a cause for raised blood
pressure. In the initial assessment abnormal results from simple biochemical measurements may
provide a guide. Therefore serum levels of urea, creatinine, sodium, potassium, calcium, urate and
gamma glutamyl transferase are advised. If there is a suggestion of renal impairment the primary
care team should refer the patient to a renal physician. In primary and secondary
hyperaldosteronism (Conn‟s syndrome) serum sodium levels may be raised or in the high normal
range with reduced plasma potassium. There is also sodium and water retention. This requires
referral to a specialist for management.

In assessing patients with repeatedly raised blood pressure blood tests are useful to assess the
patient for signs of target organ damage. Where hypertension has been prolonged or severe it can
cause renal impairment therefore serum creatinine should be assessed.

A total cholesterol and HDL cholesterol can be measured from random blood but lipid fractions can
only be analysed correctly if the patient has been fasting for the previous 8 to 12 hours and
avoided a heavy meal the evening prior to the test. Urea and electrolytes should be delivered to
the laboratory within 4-8 hours of withdrawing the blood if there is no centrifuge in the practice to
separate the serum plasma. Other samples can lie overnight in a fridge and not affect the result,
e.g. cholesterol or thyroid function tests.

Electrocardiograph
An ECG recording should be included in assessment of end organ damage in patients known to
have hypertension or hyperlipidaemia i.e. identify left ventricular hypertrophy (an independent
cardiovascular risk factor) and silent heart disease, e.g. an undiagnosed myocardial infarction.
Table 6 highlights the main abnormal ECG tracings in patients with hypertension.

Table 6. Possible Abnormalities in Patients' Presenting with Hypertension
 Diagnosis            ECG Interpretation
 LVH:                 The sum of the S wave in lead V1 or V2 and the R wave in lead V5 or V6 is
                      35 mm or more.
 Ischaemic Strain:    ST depression and / or T wave inversion in leads V5 and V6.
 Atrial Fibrillation: No visible p waves and a normal QRS occurring at irregular intervals.

III.4.c Risk factor scoring systems
If patients present with borderline BP or raised cholesterol it can be difficult to judge whether or not
they are at high absolute risk of developing cardiovascular disease over the next few years. It is
important that a complete risk assessment is made in all patients so that all CVD risk factors can
be identified and addressed. However scoring CVD risk is for use only in primary prevention i.e.
not when patients have diabetes, CHD, stroke or renal disease to help decide whether borderline
BP or raised cholesterol over 5 mmol/L should be treated with medication. It is used to identify
those at higher risk and would therefore most benefit from treatment.

Scoring systems evolved from the data collected in epidemiological studies. The most commonly
used risk assessment tool, devised from the Framingham Study (Dawber, Meadoro and Moore,
1951), is The Joint British Societies coronary risk prediction chart. However data is from mainly
white Americans and therefore underestimates coronary heart disease risk in the Afro Caribbean


                                                  17
and South Asian populations. It also underestimates risk in familial hypercholesterolaemia. The
initial formula in the first CHD absolute risk assessment chart and calculator program
underestimated risk in the younger populations and over estimated risk in the elderly. Also these
tables provided an estimate of CHD risk but not stroke risk. Therefore the next version did include
both CHD and stroke and the name was changed to CVD charts. These are recommended for
assessing risk and are available at www.bhsoc.org.

The CVD risk tables use these criteria:
     Age
     Gender
     Untreated systolic blood pressure
     Total cholesterol:HDL ratio
     Current smoker or not in last 5 years.
If CVD risk is >20% in patients with sustained systolic blood pressure of 140 -159 and / or diastolic
of 90 - 99 mmHg and / or a cholesterol equal or greater to 5 mmol/L then pharmacological
treatment is advised. It is important to remember that having a low risk does not offer immunity to
heart disease or stroke, the individual scores are only comparative to other individuals in the
population. Nor were these scores devised to predict a reduction in risk if risk factors are improved.

III.4.d Recording data
A patient record is the basic account of the care that has been given to a patient and the condition
of the patient when seen with dates and the results and effects of any tests or treatments (Dimond,
1989). A record of the assessment should be:
      written in a case record and/or computer record in a standardised manner accessible to all
         members of the health team
      given to patients who wish it in a modified form.


                       This completes the patient assessment.




                                                 18
III.5. Non Pharmacological Treatment
Principle: All patients who are diagnosed with hypertension should be offered non pharmacological
treatment advice.

III.5.a Changing lifestyles
Nurses should assess the patient‟s readiness to change lifestyles and document the stage of
behaviour change the patient is in. Prochaska and DiClemente (1984) identified five stages of
change – pre-contemplation, contemplation, planning, action and maintenance. Motivational
interviewing techniques encourage the patient round the cycle of behaviour change by using open
ended questions, reflective listening, showing empathy, promoting self esteem and providing
information to support change (Rollnick, Kinnersley, and Stott, 1993).
Supporting people to make behaviour changes is life long; often requiring addressing various
lifestyle issues at different times. Patients should be encouraged to identify for themselves lifestyle
changes they feel able to change first. This approach is more successful than imposing the health
professional‟s opinion on the patient. Some time should be spent explaining the different risk
factors and helping the patient to weigh up their priorities. Once this is done small manageable
changes should be encouraged and achievable realistic goals set. It is important to regularly
review these with the patient.

III.5.b Dietary advice
The type of dietary advice give to patients will depend on their cardiovascular risk assessment.

If the patient is overweight the main is aim is to lose weight by introducing a healthy diet and
increasing physical activity to introduce a negative energy balance. BP can be reduced by
approximately 2.5/1.5 mmHg for each kilogram lost. There are a number of useful information
materials available to help support the patient from all good public health departments. Regular
weighing will provide feedback on changes made. Some patients find attending slimming clubs
useful.

If the patient is obese a more thorough assessment of diet and factors possibly contributing to
obesity should be considered. Community dieticians are the ideal health care professional to
undertake this. Pharmacological or surgical treatments are available but careful assessment by
practitioners who are expert in this field is required prior to prescribing these to patients.

If the patient has hyperlipidaemia the nurse support in dietary changes may lead to average
cholesterol reductions of approximately 6% or more. Lowering lipid levels requires reducing
saturated fat in the diet to approximately 10% or less, by replacing this preferably with
monounsaturated fats such as olive oil or rapeseed oil or alternatively with polyunsaturated fats
such as sunflower corn or soya bean oils. Trans fatty acids found in biscuits, fat spreads, meat and
meat products and dairy products should be reduced to less than 2% in the diet. In summary about
35% of dietary energy should be from total fat intake. Approximately 50% of the dietary energy
source should be from complex carbohydrates including non-starch polysaccharides (fibre). In
particular these increases should include the intake of soluble fibre such as fruit and vegetables,
beans and pulses, and oat based cereals.




General healthy eating advice includes:
   - Increasing consumption of fruit and vegetables to at least 5 portions per day and if possible
      7 per day for those with hypertension has been shown to be beneficial. Increasing from 2
      portions to 7 portions has shown reductions of 7/3 mmHg in the DASH research trial,
      information and copies of the diet sheets available at www.nhlbi.nih.gov .
   - Reducing sodium chloride salt from 10 to 5 grams per day lowers blood pressure by
      approximately 5/3 mmHg. Ways to do this are to stop adding salt to prepared food and in
      cooking. Many processed foods contain large amounts of salt in particular takeaways and



                                                  19
         snack foods. Avoid salt in soy sauce, stock cubes, and yeast extracts. Bread and breakfast
         cereals can also be high in salt.
   -     Lowering saturated fat and increasing poly and monounsaturated fat.
   -     Taking up to four portions of oily fish per week.
   -     Increasing soluble fibre content of diet.

Copies of diet information sheets for hypertension are available for the Blood Pressure Association
(www.bpassoc.org.uk).

III.5.c Smoking cessation
Smoking is a major cardiovascular risk factor and patients should be advised to stop. Research
has shown that even minimal advice will result in 2% of patients quitting. Each added intervention
technique doubles the cessation rate. Proven interventions include counseling individuals alone or
in groups, nicotine replacement therapy (NRT) and bupropion. For further advice in assisting
patients to stop smoking see www.ash.org.uk.

III.5.d Activity levels
Physical activity has the following benefits:
     - Helps in the management of weight loss which together results in lower BP
     - Improves lipid profile
     - Reduces insulin resistance
     - Decreases blood clotting and increases fibrinolytic activity
     - Helps in smoking cessation.

                              Contraindications to exercise are:
                                 - Unstable angina
                                 - Resting systolic BP >180 mmHg
                                 - Resting diastolic BP >110 mmHg
                                 - Symptomatic orthostatic BP drop of >20 mmHg
                                 - Certain heart conditions
                                 - Resting tachycardia >120 bpm
                                 - Acute illness
                                 - Uncontrolled diabetes
                                 - Recent embolism or surgical procedure.

                              Any patient who has a history of CHD should be considered for an
                              exercise tolerance test prior to taking up increased activity programs.



       Figure 3 - Exercise
       Tolerance Test           Effective activity programs to lower BP should include the following:
                                    - Exercise duration of 15 - 60 minutes.
   -     Exercise intensity of 12 on Borg‟s rating of perceived exertion scale slowly increasing to 16.
   -     Frequency of 5 sessions/ week at least.
   -     Include exercise such as aerobic, rhythmic, continuous activity such as walking, cycling,
         and swimming.
   -     Exclude weight lifting

III.5.e Safe alcohol intake
The recommended intake of alcohol in men is 21 units spread over one week as 3-4 units /day with
one or two alcohol free days. In women this is lower at 14 units / week, averaging 2-3 units / day
with one to two alcohol free days. There are screening questionnaires such CAGE (Beresford,
Blow, Hill et al, 1990) that can be used with patients to identify those at high risk of addiction and
therefore would benefit from appropriate referral.




                                                  20
III.6. Pharmacological Treatment
Principle: All patients assessed for pharmacological treatment and offered appropriate therapy.

There is now conclusive evidence that drug treatment of hypertension, including isolated
hypertension, significantly reduces the risk of myocardial infarction, cerebrovascular accidents,
renal failure, and heart failure (Collins & MacMahon, 1994). Patients whose blood pressure does
not fall below the recommended thresholds for drug treatment with or without making lifestyle
changes during the BP monitoring period should be referred to their doctor. The doctor will
prescribe medication as appropriate. The following section is a summary of the different 'classes' of
hypertension drugs and a discussion on their use.

III.6.a Diuretics
There are three classes; thiazide, loop and potassium sparing. Low dose thiazide diuretics are the
most useful and by far the most commonly used. NICE (2006) recommend thiazide diuretics as
one suitable first line treatment in essential hypertension in the over 55 years age group and black
patients of any age. There can be metabolic effects from their use and therefore monitoring of
venous blood is recommended annually. In particular hypokalaemia, low plasma potassium < 3.5
mmol/l, is thought to potentiate cardiac arrhythmia. High doses of thiazide diuretics can put
patients at risk of low potassium. Raised urate is another consequence of diuretic therapy. There is
a small increased risk of developing type 2 diabetes over time when taking thiazide diuretics but
this risk is increased if a beta-blocker is also taken (see Table 7).


III.6.b Calcium channel blockers
Also known as calcium antagonists there are two main types. The dihydropyridines which have a
greater effect on vascular smooth muscle (VSM) and so the adverse effects of vasodilatation such
as headache and ankle swelling are more pronounced than in the other types of calcium
antagonists. The newer longer acting drugs are either in a sustained release form or are naturally
longer acting. NICE recommend calcium channel blockers as another suitable first line agents for
patient over 55years and black patients of any age. Grapefruit should be avoided when taking
these drugs. The rate limiting calcium antagonists such as diltiazem and verapamil should not be
used with beta-blockers.

III.6.cAngiotensin converting enzyme (ACE) inhibitors
These drugs have an effect on the enzyme cascade of the renin-angiotensin system and NICE
(2006) recommends them as initial therapy for those under 55 years unless they are black. ACE
inhibitors block the conversion of the angiotensin I to angiotensin II. Angiotensin II is one of the
most potent endogenous vasoconstrictors. By limiting the effect of angiotensin II the drug acts by
vasodilating arterioles, reducing sodium and water retention, and relaxing the sympathetic nervous
system. The adverse effects of ACE inhibitors are dry irritating cough (at least 10% of men & 20%
of women in the UK population), deterioration of renal function in bilateral renal artery stenosis, first
dose hypotension and very rarely angioneurotic oedema. A low starting dose is recommended to
avoid either the hypotension or rare renal failure that can occur. Renal function should be checked
1-2 weeks after starting therapy, with increased doses and annually. There is a small risk of
hyperkalaemia especially in patients with renal impairment or taking potassium sparing diuretics or
potassium supplements including sodium salt replacements.

III.6.d Angiotensin receptor blockers (ARB)
This class of drug prevents angiotensin II binding at the receptor site. Since Angiotensin II receptor
antagonists do not inhibit ACE production their role in degrading bradykinin is not reduced
therefore the cough associated with ACE inhibitors is unlikely. The precautions taken with ARBs
are the same as with ACE inhibitors (see above).




                                                   21
III.6.e Alpha blockers
The selective alpha blockers such as doxazosin, terazosin and prazosin require careful dosing to
prevent postural hypotension particularly if taken with other hypertension drugs. Standing BP
should therefore be checked. These are not normally prescribed before the classes above have
been used but are advised by the BHS (2004) and NICE (2006) as a 4th line agent.

III.6.f Beta - blockers
Beta blockers inhibit renin production and the rate and force of cardiac contraction. They also
decrease the normal cardiac response to stress and exercise, they are indicated for the treatment
of angina and post-myocardial infarction and now as a 4th line agent for the treatment of
hypertension (NICE 2006). However they should still be considered for treating younger women of
childbearing age or those intolerant to ACE Inhibitors or ARB. If a beta blocker is used and
another drug is needed for BP control then a calcium channel blocker should be considered before
a thiazide to reduce the risk of developing type 2 diabetes.
Adverse effects include lethargy, reduction of exercise tolerance (slowing of heart rate),
bronchospasm, raynauld's syndrome, and impotence. Beta blockers should not be prescribed in
asthma, bradycardia, heart block, and used with caution in heart failure.




                                               22
III.7.Nurse Prescribing

Principle: Patients suitable for pharmacological treatment can be managed by a nurse who is a
Nurse Independent Prescriber and is competent in hypertension management..


This is an outline of the prescribing process. The intention is to guide registered nurses who are
already qualified nurse prescribers with specialist knowledge and skills in the management of
hypertension and cardio-vascular risk and to provide information for those who are not. It is not
intended to cover all the legal and ethical aspects of prescribing as it is assumed the nurse
prescriber is fully versant in this and endeavours to practice safely.

The Nursing & Midwifery Council (www.nmc-uk.org), the Department of Health
(www.dh.gov.uk/PolicyAndGuidance) and the Medicines and Healthcare products Regulatory
Agency (www.mhra.gov.uk) provide advice on the legal and ethical aspects of nurse prescribing.

III.7.a. Independent Prescribing
The department of health definition of Independent Prescribing is „prescribing by a practitioner (e.g.
doctor, dentist, nurse, pharmacist) responsible and accountable for the assessment of patients with
undiagnosed or diagnosed conditions and for decisions about the clinical management required,
including prescribing.‟

The Medicines and Human Use (prescribing) order of May 2006 enables Nurse Independent
Prescribers (NIP), (formerly Extended Formulary Nurse Prescribers) to prescribe any licensed
medicine for any medical condition. Nurses who are a qualified independent, supplementary and
extended prescriber will not be required to undertake further training.
For the nurse who is already competent in prescribing for hypertension the requirement for a
written individualised clinical management plan agreed with an independent prescriber (doctor) is
no longer legally required. Use of a clinical management plan where a team approach to
prescribing is preferred may still be used if it is appropriate. An example (based on the
supplementary prescribing model) is included in this guideline which may copied/adapted for use.

Nurses qualified to extend their role to offer pharmacological treatment for hypertension and other
cardio-vascular risk factors are ideally placed to offer comprehensive hypertensive care thereby
promoting the principles of concordance. (section III.6.)

III.7.b Guidelines for drug treatment
NICE (2006) recommends the first line treatment of essential hypertension to be a low dose
diuretics or calcium channel blockers for all patients 55years or over and/or of black African,
American or Caribbean descent. For patients of less than 55 years an ACE inhibitor should be the
line first choice.

 The population is divided into high or low renin populations. The white, Asian and young (<55
years) population has high renin levels and therefore ACE or ARB therapy are more likely to be
effective at lowering BP. Secondly, calcium channel blockers and diuretics have been shown to be
effective at reducing mortality in the elderly population in randomized trials and are identified as
first line therapy for this group.

 The NICE algorithm shown below is useful for deciding which therapy to substitute or add to lower
BP. Only 30-40% of patients are likely to reach a BP of 140/85mmHg or below with monotherapy
(Hansonn, Zanchetti, Carruthers et al, 1998). This level of blood pressure is the BHS-IV target for
all patients except those with diabetes (<130/80 mmHg and lower still if there is any evidence of
renal damage). Most patients require more than one drug to control their BP to these targets. If
initial BP is very high even three drugs at full therapeutic doses may not achieve these BP targets
in all patients. Referral to a specialist should be considered once compliance is confirmed and



                                                 23
other factors considered. Information on drug therapy for patients can be found in „Medicines for
High Blood Pressure‟ from the Blood Pressure Association (www.bpassoc.org.uk).


ADAPTED FROM NICE 2006




                                               24
Patient Details                                  Allergies/ Contra-indications




Independent Prescriber                           Supplementary Prescriber(s)

Conditions to be treated                       Aims
    Hypertension                                  Reduce Blood Pressure to target
    Cardiovascular risk >20%                      Reduce total cholesterol to <4mmol/l /by
                                                      30%
Medicines that may be prescribed by the Supplementary Prescriber
Ace inhibiters                       Lisinopril                 Specific indications for referral
                                     Perindopril
                                                                 back to Independent Prescriber
                                     Ramipril
Angiotensin Receptor                 Candesartan
blockers                             Irbesartan
                                     Losartan                       Target Bp not reached after
                                     Valsartan                          Step 4 (BHSiv)
                                     Amlodipine
                                     Felodipine                     Deteriorating renal
                                     Diltiazem                          function
Calcium Channel Blockers             Bendroflumethaside

                                       Spironolactone                     Adverse reactions related
Diuretics                              Amiloride                           to initiation and not
                                                                            relieved by discontinuation
Combined preparations                 

                                       Doxazosin
Alpha blockers                         Atenolol

Beta blockers                          Atorvastatin
                                       Simvastatin
                                      
Statins

Aspirin
Guidelines supporting the Clinical Management Plan.
Guidelines for management of hypertension, British Hypertension Society (BHS IV 2004)
NICE-Management of hypertension in adults in primary care (2006)
Joint British Societies’ guidelines on prevention of Cardiovascular disease in practice (2006)
Frequency of Review by Supplementary             Frequency of Review by Supplementary and
Prescriber                                       Independent Prescriber
Monthly post initiation or dose change           As per guidelines
Patient reports change in condition              6 month treatment review between IP and SP




                                                        25
Reporting Adverse Drug Reactions
Report to Independent Prescribers
Yellow Card reporting
Document in patients medical notes/ workstation/ letter to G.P.
Agreed by Independent Prescriber Date             Agreed by Supplementary           Date
                                                  Prescriber(s)


     III.8. Patient Monitoring and Support
     Principles:
     Patients with hypertension should be monitored by:
           Offering three to six monthly BP monitoring.
           Giving an individual BP target level.
           Offering an annual review.
     Patients with hypertension should be supported in:
           Taking medication.
           Making lifestyle changes.

     Hypertension is an example of a chronic condition that requires monitoring of life long therapy
     supported by lifestyle changes.

     III.8.a Monitoring
     Patients with hypertension should have their BP reviewed monthly following changes to treatment
     until their target is reached (see below). Three to six monthly checks of BP are recommended if BP
     is controlled. General practice procedures for repeat prescription should be explained to patients
     and individual needs such as quantity, collection and cost should be discussed. All patients should
     be reviewed at least annually for:
           BP, the current BHS-IV recommended target blood pressures are: <130/80 mmHg or lower
              for patients with co-existing diabetes or renal disease and <140/85 mmHg for all other
              patients.
           Pulse, if irregular then refer.
           Monitoring for associated CVD risk factors.
           Medication review.
           Monitoring for target organ damage.
           Urinalysis for proteinurea, haematuria and glucose.
           Urea & electrolytes.
           Glucose (preferably fasted).
           Cholesterol.
           Assessment of well being in particular: ECG if pulse irregular; and refer if there is new ankle
              oedema, symptoms of chest pain, or breathlessness.

     III.8b Concordance
     Patient non-compliance with therapeutic regimes is a recognised problem in the management of
     hypertension. Studies that have measured non-compliance in hypertensive populations found rates
     from 23-50% (Mallion, Baguet, Siche, et al, 1998). Many individuals have good compliance during
     the first months of a new medication but this drops off as time goes by. The nurse should allow
     individuals to discuss their attitude towards their medication exploring issues such as the „sick role‟,
     drug actions, side effects, timing, and regular dosing. Strategies to improve compliance are listed
     in Table 8. The Blood Pressure Association (www.bpassoc.org.uk), a patient information group that
     was formed to promote fuller patient participation in the management of hypertension in the U.K.
     found that one of the most frequent topics on their advice telephone line is medication.




                                                       26
Table 8. Guide to improve compliance in therapeutic regimes
For all regimes:
Information            - Give clear written instructions on treatment regime
                       - Keep the information as simple as possible
Dosing regimes         - Where possible use once or twice daily dosing regimes
                       - Consider combined preparations
For long term regimes:
Reminders              - Call if appointment missed
                       - Prescribe medication to suit patient‟s daily routine
                       - Stress importance of following medication regime at
                           each visit
                       - Increase visits if compliance poor
Rewards                - Recognise patient‟s effort to comply at each visit
                       - Decrease visit frequency if compliance good
Social                 - Provide information about cost of prescription e.g.
                           annual subscription may be cost effective

III.8.c Patient support
Mullen, Simons-Morton, Ramirez et al (1997) in a meta-analysis of trials evaluating patient
education and counselling found health care personnel should focus on behavioural techniques
such as:
      Teaching self monitoring.
      Use of personal communication and goal setting.
      Written or other audiovisual materials.

Teaching self monitoring
Opportunities for self-monitoring in hypertension include self BP monitoring (SBPM) and body
weight measurements. BP monitors are widely available therefore patients should be encouraged
to discuss if they have been using these. Surgeries can offer advice on purchasing BP monitors
perhaps by placing a notice in the waiting room. If a patient is doing their own BP it is helpful to
advise them on the correct procedure for use and discuss other issues such as frequency of
readings, care of the machine, recording and interpretation of BP. Ideally further research trials
using SBPM would strengthen the case for promoting this as an evidence-based intervention.
Although international bodies have endorsed the use of SBPM to be used as supplementary
information for making treatment decisions (World Hypertension League 1988, WHO/ISH 1993) the
NICE (2004) guideline does not advocate its use for this. The BHS-IV guideline acknowledges that
the SPBM is increasing and there is a potential for its use.

Thresholds and target BP should be lowered by 10/5mmHg in home readings because these tend
to be consistently lower than clinic readings on which the evidence for the guidelines was based.
The mean of morning and evening SBPM taken on seven consecutive days excluding the first 24
hours of readings is recommended as the home BP level. The resulting readings can initiate useful
dialogue with patients about the variability of blood pressure and the value of good compliance.

Personal communication and goal setting
By providing the patient with personal information about their health, such as using shared
information cards, patients will be better informed and more in control. These cards allow patients
to monitor their lifestyle changes and BP levels. Setting small steps for lifestyle changes with the
patient is useful. Asking patients to return for checks also reinforces the importance of change. A
meta-analysis of disease management programmes found patient education and reminders were
associated with improvements in patient disease control (Weingarten, Henning, and Badamgarav,
2002).



Patient information materials



                                                27
Information materials are effective if used alongside exchange of information between doctors /
nurses and patients. Asking open questions allows the patient to tell the nurse what he / she needs
to know so that they can be supported or motivated to make lifestyle changes. This exchange can
be supported with a suitable information leaflet.
Many leaflets on blood pressure and other cardiovascular risk factors are supplied from
pharmaceutical and food companies. Others are available from charitable organisations such as
the Blood Pressure Association, British Heart Foundation, and Chest, Heart and Stroke
Association. Before distributing any of these health care providers should read and review them
using the following pointers (Lowry, 1995):

      Presentation (bold and clear text, colour used to aid understanding, well defined sections).
      Illustrations (diagrams to aid understanding, inoffensive cartoons).
      Language (considers ethnicity of population).
      Terminology (every day language, uses generic terms, explains key terms).
      Honesty and sensitivity (provides accurate facts about causes and prognosis).
      Summary of key points (provides a short two sentence summarising key issues).

Having a variety of patient leaflets with different styles and language level allows patient choice.
This encourages the patient to take control. Useful leaflets and books provide advice about
insurance, travel, working and other issues that people with hypertension need.




                                                28
III.9. Recall, Recording and Audit.
Principle: A General Practice hypertension register is established and maintained. Patients with
hypertension are reviewed at least annually. The General Practice maintains a standardised Read
Coded computer database of patients with hypertension. Each General Practice monitors
principles and sets standards for regular comparison of quality hypertension management.

III.9.a Recall
A system should be in place to ensure reminders are sent at least yearly so that patients are
offered an annual review (NICE, 2004). Patients found to have raised BP on screening require
recall to be set for 1-3 months depending on severity. Patients with known hypertension and
uncontrolled BP also require recall in 1-3 months depending on severity. If this is not done patients
can be lost to follow up.

III.9.b Recording
The presence of a disease register is a basic prerequisite for pro-active care. The increased risks
for those with concomitant diabetes and ischaemic heart disease mean that registers for these
conditions are also needed. To do this General Practices should maintain an accurate Read Coded
computerised database of patients with hypertension that includes the following criteria:
      Age, gender, and ethnicity
      Family history of cardiovascular disease
      Relevant past medical history
      Current blood pressure
      Current medication
      Cardiovascular risk factors such as BMI, smoking status, cholesterol etc (see section on
         measuring cardiovascular risk).

Current BP, as defined by the GMS contract for patients with hypertension, is within the last nine
months. To ensure that the BP is current therefore suggests that recall for hypertensive patients
needs to be more frequent than yearly. BHS-IV recommends six monthly BP checks. Good co-
operation within the health care team is needed to ensure BP levels are entered and recall set
accordingly. There is a danger of duplication of recall letters e.g. from hypertension, CHD and
diabetes disease registers. Careful planning is required by the whole team to streamline data entry
and recall.

III.9.c Audit
Each General Practice can monitor the criteria discussed in this document and set standards so
that there can be regular comparison of the quality of their hypertension management. These
standards can be set against local or national information. As part of the new GMS contract
software programs are in place to allow easy comparison between practices for the GMS
indicators. Good hypertension management is highly rewarded within the GMS contract therefore it
is worth ensuring staff are well acquainted with the procedures discussed in this document.
Changes within the practice may be needed once the audit is completed. This may include
allowing one individual, which could be a practice nurse with the knowledge and skills, to
coordinate the recall of patients with hypertension, monitoring of individuals and recording of data.




                                                 29
III.10. Referral
Principle: Where blood pressure and lifestyle targets are not achieved within General Practice
specialist opinion should be considered.

III.10.a Specialist lifestyle advice
State registered dieticians may be available in the community or in the local hospital. Patients
should be considered for referral if obese and if found to have diabetes should be seen by a
dietician on diagnosis.
Local exercise referral schemes may be available to support and promote activity in primary
prevention. Any patient who has a history of coronary heart disease should be considered for an
exercise tolerance test prior to taking up increased activity programs.
Alcohol or addiction teams are available to support patients with alcohol problems.

III.10.b Specialist secondary care opinion
Indications for referral include:
      Urgent treatment needed.
      Malignant (accelerated) hypertension.
      Very severe hypertension (e.g..>220/120 mmHg).
      Impending complications (e.g. TIA, left ventricular failure).
      Possible underlying cause;
           o any clue in history or physical examination of a secondary cause
           o hypokalaemia / increased plasma sodium
           o elevated serum creatinine
           o persistent proteinurea or haematuria
           o resistant to a three drug regime
           o young age (any hypertension < 20 years, needing treatment < 30 years).
      Therapeutic problem;
           o treatment resistance
           o multiple drug intolerance
           o treatment decline.
      Special situations;
           o unusual BP variation
           o possible isolated clinic hypertension
           o hypertension in pregnancy.




                                              30
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NICE (2004) Clinical Guideline 18 Hypertension:           working party of the British Hypertension Society,
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management of hypertension: report of the fourth


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