Management of Hypertension Flowchart by zjm11893

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									                                       Flowchart for Hypertension Management


                          Clinical consultation
                                                                                             1   SBP > 140 or DBP > 90*. Take a second
                                                                                                 reading at the end of the consultation.

                                                                                             2   Explain the potential consequences of HBP.
                                   Raised
                     No
                                clinic BP? 1
                                                                                                 Promote healthy diet, regular exercise and
                                                                                                 smoking cessation.
                                 Yes


                                                                                             3   Two monthly visits under ideal conditions
                          Offer lifestyle advice   2
                                                                                                 (eg practice nurse).

                           Measure BP on two
                                                                                             4   Hypertension: persistently raised BP on two
                            further occasions 3                                                  previous visits.

                                                                                             5   CV risk assessment to identify other
                     No
                             Hypertension?     4                                                 modifiable risk factors. NB charts are less
                                                                                                 valid if patient already on BP or statin Rx.
                                 Yes


                            Offer a formal CV
                                                                                             6   Refer patients with signs or symptoms of
                            risk assessment 5                                                    secondary HBP. Immediate Ix/Rx required
                                                                                                 of malignant HBP or phaeochromocytoma
                                                                                                 suspected.
                               Secondary
                                                       Yes       Specialist referral
                              hypertension? 6
                                                                                             7   Offer Rx for
                                  No                                                             A: BP 160/100 or
                                                                                                 B: BP > 140/90        and
                              Criterion for                    Offer to begin or step                10 year risk of CVD 20% or
                             drug therapy?     7       Yes        up drug therapy 8                  existing target organ damage.
                                  No

                                                                                             8   Add drugs as per “Guidelines on
 Diabetes?                                                         BP criterion
                   Yes                                   Yes          met? 9            No       Hypertensive Drug Choice”.
   No
                                                                                             9   BP 140/90 or further Rx inappropriate or
Review within                 Review within                                                      declined.
  5 years                       1 year 10

                                                                                             10 Check BP and review risk factors and
                                                                                                 lifestyle

                                                                                                        Target Organ Damage
                                                                                                  Heart Failure
                                                                                                  Stroke or TIA
                                                                                                  Peripheral Vascular Disease
                                                                                                  Chronic Kidney Disease
                                                                                                  Hypertensive or diabetic retinopathy
                                                                                                  LVH on ECG or echo



         *
                See “Hypertension + Specific Conditions” for stricter BP targets.
                Ambulatory BP targets are approximately 10/5 lower
         APPROVED BY: North East Essex Medicines Management Committee March 07                                      REVIEW BY: March 2009
         AUTHOR: Dr Alan Harkness, Cardiologist                                                                     VERSION: 2
         PAGE: 1of 4
                 Guidelines on Hypertensive Drug Choice

     <55 years old                                                   55 years old
     and non-black                                               or black of any age


             A                                                          C or D               Step 1


                                   A + C or A + D                                            Step 2


                                       A+C+D                                                 Step 3


                 Add    • further diuretic        or                                         Step 4
                        • alpha-blocker           or
                        • beta-blocker

                 Consider seeking specialist advice


Note:
A= ACE inhibitor (ACEi)
C= Calcium Channel Blocker (CCB)
D=diuretic
                                         Beta-Blockers
Beta-blockers are no longer the preferred routine initial therapy, however consider in:
• Younger patients who are cannot take either ACEi or ARB
• Woman of childbearing age
• Patients with increased sympathetic drive

Avoid beta-blockers + thiazides (increased risk of diabetes) – add CCB instead

For patients already on beta-blockers:
• If BP not controlled, switch beta-blocker to a drug from the chart above, provided there is
   no compelling reason to remain on a beta-blocker
• If BP is controlled, no need to switch
• If a beta-blocker is stopped, do it gradually

          Preferred Drug Choice For Simple Hypertension
(where no compelling indication for a particular drug, listed in order of preference)
ACEi                     Ramipril, Lisinopril, Enalapril
ARBs                     Candesartan, Irbesartan, Valsartan, Losartan
BBs                      Atenolol, Bisoprolol
CCBs (rate control)      Diltiazem (Slozem), Verapamil
        (rate neutral)   Amlodipine, Lercanidipine, Felodipine, Nifedipine
Diuretics                Bendroflumethiazide, Indapamide
Alpha Blockers           Doxazosin (not m/r)
APPROVED BY: North East Essex Medicines Management Committee March 07     REVIEW BY: March 2009
AUTHOR: Dr Alan Harkness, Cardiologist                                    VERSION: 2
PAGE: 1of 4
                      Hypertension & Specific Conditions†
Post-MI
BBs should be prescribed first line, esp if a large infarct, heart failure or arrhythmias
ACEi should also be prescribed if there was evidence of signs or symptoms of heart failure
peri-infarct or evidence of LV impairment post-infarct

Heart Failure / LV dysfunction
ACEi are first line in all patients with LV dysfunction, even if asymptomatic
BBs should be added after ACEi titration to all symptomatic patients (NYHA II-IV)
Bisoprolol, Carvedilol or, in the elderly, Nebivolol are licensed
ARBs are an alternative to ACEi, where there is ACEi cough (ideally Candesartan)
Sub-maximal doses of ACEi+BB are probably better than the full dose of only one class
Spironolactone should be added to all NYHA III-IV patients if BP is OK and K+ is < 5.5
If hypertensive despite full dose ACEi+BB, add Spironolactone, even if NYHA I-II
Diuretics (thiazide or loop) have no prognostic benefit in heart failure and should usually be
prescribed only to control excess fluid
Only use for BP control only when the above agents are at maximum tolerated doses
CCBs have no benefit in heart failure – Verapamil and Diltiazem are negatively inotropic
If required for BP control, Amlodipine is the preferred agent

Coronary Artery Disease Target BP <130/80
BBs are first line if the patient has angina
CCBs are alternatives to beta-blockers in angina – rate limited CCBs are most appropriate
ACEi may have some prognostic benefit in this group (Ramipril)

Stroke Target BP <130/80
ACEi + Thiazide combination therapy has particular prognostic benefit in this group

Left Ventricular Hypertrophy
The main evidence for regression is with Losartan and Indapamide. Although LVH is a
marker of increased risk, there is no evidence yet that reducing it has independent
morbidity/mortality benefit.




†
 JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. British
Cardiac Society, British Hypertension Society, Diabetes UK, HEART UK, Primary Care Cardiovascular
Society, The Stroke Association


APPROVED BY: North East Essex Medicines Management Committee March 07             REVIEW BY: March 2009
AUTHOR: Dr Alan Harkness, Cardiologist                                            VERSION: 2
PAGE: 1of 4
Diabetes ± Chronic Kidney Disease Target BP <130/80
ACEi have definite prognostic benefit in type I diabetic nephropathy and possible benefit in
type II diabetic nephropathy and chronic renal failure in general
ARBs have definite prognostic benefit in type II diabetic nephropathy and possible benefit in
chronic renal failure in general (esp if proteinuria present – use Losartan or Irbesartan)
Caution should be used with either of these agents where renal artery stenosis is suspected
(eg any vascular bruit or PVD present)
ACEi and CCBs are first line for diabetics

Chronic Kidney Disease Target BP <130/80
If proteinuria > 1g/day, target should be < 125/75

Pregnancy
Many agents are teratogenic – specialist advice should be sought


                                      Dose Equivalents
                    Perindopril                  Ramipril               Lisinopril
                       2mg                     1.25-2.5mg               5-10mg
                       4mg                       2.5-5mg                10-20mg
                       8mg                       5-10mg                 20-40mg

NB: there is little evidence for head-to-head comparison between ACEi. If BP is low, pick the
lower-range (usually seen in CHF) and if BP still high, pick the higher-range.




APPROVED BY: North East Essex Medicines Management Committee March 07   REVIEW BY: March 2009
AUTHOR: Dr Alan Harkness, Cardiologist                                  VERSION: 2
PAGE: 1of 4

								
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