Share The Pressure - Medicines for Managing Hyertension



This session is an on-demand teaching seminar focusing on the management of hypertension among Black African and Caribbean people. Through this session, participants will learn about the disproportionate burden of high BP in this population and how to address this using the shared decision-making tool. The session will also cover a case study, diagnostic pathway and lifestyle changes through the Clinical Effectiveness Group's local guidance. Throughout the session, participants will be able to access slides, ask questions and generate certificates of attendance.
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This series is for Healthcare Professionals from GP practices in the South East London Integrated Care System.

Please only register if you work in the London Boroughs of Bexley, Bromley, Greenwich, Lewisham, Southwark or Lambeth.

If you are interested in running similar events in your area, please email info@smarthealthsolutions.co.uk for more information.

Learning objectives

Learning objectives: 1. Identify the key risk factors for cardiovascular disease, with a particular emphasis on ethnicity. 2. Understand the blood pressure thresholds for the diagnosis of hypertension and the pathways to diagnose it using ambulatory readings or home readings. 3. Outline the principles of hypertension treatment and recognize its link with other disease states. 4. Explain the overall cardiovascular risk assessment and available treatments in the context of the Southeast London Clinical Effectiveness Guidance. 5. Demonstrate the rationale for performing blood tests, fundoscopy and lifestyle counselling for people with diagnosed hypertension.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Good morning and welcome to this share the Pressure webinar on Medicines, the Managing hypertension. This is part of the share the Pressure Series, a project that we at Smart Health Solutions are running in partnership with the Race equality Foundation, Younger Lives and BP UK. And it's wholly funded by the Burdette Trust for Nursing. The aims of share the pressure are to address the disproportionate burden of high BP amongst Black African and Caribbean people using a shared decision making tool. I'm Joanne Horse, I'm the clinical Director of Smart Health Solutions as well as doing lots of other jobs around and about. And I'm delivering this training program along with my colleagues, Michaela and David. Um who you may have seen on some of the other webinars in this series or you may have heard on some of the podcasts that we've recorded as additional training aids for this project. So if you are new to Medal, congratulations, you found your way onto the platform because you're watching now. Um Medal is an amazing platform that we've, we've used for a long time now to deliver our educational content um so easy to use and the brilliant thing about it is that it's also a repository for your certificates of attendance and also somewhere that you can go back to, to look at slides or in fact, these series of webinars are going to be available on demand. So if you want to, you can go back and watch at another point in time or indeed share with colleagues who can go back and have another look. Um There will be a couple of little slide across buttons that you may have already seen which will generate your attendance certificates and allow you to catch up with the slides. There's also in the bottom corner of the screen, I can see it in mind right now. A little chat button. So if you have any problems with medal medal at all, you can just click on that button and somebody will assist you to get to where you need to go. So why are we doing this project? And this is a recap. So if you've already been watching this series of webinars, you'll already have seen this slide. So we know that ethnicity is a significant risk factor when it comes to cardiovascular disease. And this is something that's been known about for a very, very long time and particularly high BP disproportionately affects Black people of African or Caribbean descent. And as a direct result of that, we see a higher incidence of stroke and end stage kidney failure in this population now confounding, confounding that is that black people are less likely to come forward for routine screening and health checks and less likely to find these accessible. And this is a particular issue for black men. And actually, even once diagnosed black people are less likely to have their high BP under good control compared to other ethnic groups and certainly to a white population. So we've all obviously been living with COVID 19 for the past few years. And given that the situation wasn't brilliant in the first place. Unfortunately, COVID has made this situation and this access to diagnosis and access to treatments and getting control much worse. So I'm going to take you through a case study um to illustrate some of the guidance uh for addressing hypertension. So I'm going to introduce you to Tony here. So Tony is a 47 year old black man who's generally fit and well, he's married and he's got grown up Children and he's recently joined a gym feels he is getting old and out of shape. And I'm sure some of us know how that feels. I certainly do. So he went along for his gym induction and they did a variety of checks including checking his BP and they found his BP was high. So advised him to make an appointment at his G P practice, which he did and came along, checked his BP and clinic and found that it was 100 and 68/86 millimeters of mercury. And so the next step from that, because we never rely on a one off reading. We want to get a clearer picture of what's going on with Tony's BP so that we can either make the diagnosis of hypertension if he does indeed have persistently high BP, or we can clear it up and say actually his BP is okay for the most part, it was just up on these particular days. So Tony went forward and had ambulatory BP monitoring. So he was hooked up to a monitor for 24 hours that gave us a full set of readings. Now, what we're interested in for the diagnosis of hypertension is what somebody's BP is doing over the course of a day. So it's the average daytime reading that we're looking for. So we already knew that Tony's clinic reading was 100 and 68/86. And on analyzing the results of his ambulatory BP monitor, we found he had an average daytime reading of 100 and 56/92 millimeters of mercury. So you can see the table below there that reflects the different stages of hypertension where we need to take into account what somebody's original clinic BP was. But also the daytime average from their ambulatory readings or alternatively, the home BP readings that they would do themselves over the course of a week if ambulatory wasn't available or wasn't appropriate for whatever reason. So, as you'll see with the clinic readings as they were and the daytime average readings as they were, Tony does in fact have stage two hypertension. Now, Tony was previously fit and well as we've seen and he wasn't experiencing any symptoms as most people don't. Um, they walk around sometimes with frightfully high blood pressures and don't realize that there's anything wrong. So if we wait for people to develop symptoms, then we're probably going to be waiting a very, very long time if ever. And we really are going to miss the opportunity to make that diagnosis and make a difference to that individual and their family. So I'm going to bring in here um The guidance that has been published for Southeast London specifically because we are working directly with Southeast London uh Integrated care System, integrated care board uh for this um share the pressure project. And these fantastic guides were produced by the Clinical Effectiveness Group for Southeast London. And there is a different set for each of the boroughs in Southeast London. So I've selected Lambeth here just because, and I don't know if there's anyone from Lamberth on the call. It's probably the first one that I got to. And you may well be familiar with these already know now, for anybody who isn't in Southeast London, if you happen to be watching this webinar on, on catch up or indeed live. Um These absolutely mirror the nice guidance for the management and the diagnosis and management of hypertension. It's been localized to Southeast London and to the specific burrows in Southeast London. So that the links and the sources of help and support the choices of medication through the formulary and all of the things are specific and local to that area. So people are getting the right information but the principles, thresholds of treatment and the agents to choose medication, the lifestyle advice, the diagnostic pathway. Absolutely, everything is in line with what our national guidance are. Nice guidance tells us to do for hypertension. So our front page gives the key messages. Um One of which is around optimizing BP management and aiming for the night BP target. So you can see it's there, it's reflected and all of the other things that we need to do to try and reduce the burden of hypertension. So this is a very busy page. Um This is the diagnostic and assessment pathway for people from the very start of when you get that initial BP reading, go through, do your ambulatory readings, get that average daytime result and act upon that. So on the left hand half of the screen, you'll see where our Tony fits into their because we found that he has stage two hypertension. Now, on the right hand side with lots of pink in it, you will see a slightly different approach. And that is for somebody who is found to have severe hypertension, who may need an urgent same day review and possibly referral to urgent care to secondary care on that day. So that that side is over there if you get somebody with a diagnosis of severe hypertension, so that is equal to or above 100 and 80 over 100 and 20 millimeters of mercury. And there are people you may know who do come in never had a days problem with their BP, who are found to have a BP, that tie, but we'll go back to Tony on the other side. So we've confirmed his diagnosis. We need to do some blood tests. We need to do his albumin creatinine ratio. We need to check for any complications or damage that's already occurred as a result of this BP. And of course, we need to get those readings and I'm going to come onto that checking for complications. Bit on the next slide, we diagnosed the stage two hypertension and the first port of call in all of this is to discuss lifestyle. Now, of course, that's not just to give, you know, lots of unsolicited advice around lifestyle, but to talk to Tony about what he's doing, what his thoughts are and what he may feel able to make changes in terms of his lifestyle. Now, we know he's already joined the gym. So hopefully he is on the right page with making some changes, but that's open for discussion. And the last webinar that I did, excuse me just a second, it's always handy when you've got your phone connected up to your computer and you lose your screen, but hopefully it didn't disappear for you. Um Yeah, so the last webinar that I delivered, which is available on demand and there's another one that you can book onto is around lifestyle and hypertension. So do have a look at that one if you want to explore more the guidance around lifestyle. So we then need to go on and look at Tony's results and also assess his overall cardiovascular risk because the two questions that we need answering is has this BP caused a problem yet? And is it likely to so bearing in mind that all of this is about the prevention of events and the delay of the progress of any disease that may be starting up to keep Tony as healthy and as clear of cardiovascular disease, cardiovascular events as we can. So we talked about doing albumin creatinine ratio and also testing for hematuria using a re agent strip. We need to do the full remit of blood tests. So we are going to be assessing his renal function because we know that having persistent high BP can damage your kidneys. We're going to do a measure of glucose. So we'll be doing an HBA one C because we know that there's a very close relationship between all of these risk factors and um diabetes. So we're also going to check looking at for blood count thyroid function to look overall at his health. And these are also significant when it comes to cardiovascular disease. And also we are going to look at Tony's lipids as well because we're going to need that to assess his overall cardiovascular risk. Now, it's also really important that somebody looks in the back of his eyes. So either somebody doing the fundoscopy on site in the practice or in the pharmacy or wherever we happen to be doing these checks, um or he goes to the optometrist down the road, but somebody needs to check to see if there's any damage to the back of the eyes from this BP because we know that that's one of the key areas that also gets affected. And then the other check is to do a 12 lead E C G. And what we're really looking for a to have a look and to rule out any arrhythmias. But we also particularly in the case of hypertension, want to check for the presence of net then track trick left ventricular hypertrophy early to get your words out. Because what can happen over time with a persistently high BP where the heart is having to be extra forceful and work extra hard to reach all of the smaller blood vessels around the body. The body is that that heart muscle can become thickened, hypertrophied over time. When it becomes thickened, it is stiffer and the heart's unable to relax properly to fill properly. And over time, it then is unable to function as and pump as well, which ends up in heart failure. And I'm sure everybody watching will be all too aware of how unpleasant heart failure is and the limitations on people's lives that that gives. So if we do detect that this BP is already leading to changes in the heart, then if there is a sign of left ventricular hypertrophy on the C G, it's really important that they then go for an echo and further studies. So we can see if there's any structural damage because believe it or not, if you then treat that BP really, really well, get the person down to target possibly beyond it's possible to reverse this process and stop that individual from getting heart failure. We also need to then do a full cardiovascular risk assessment. And so we're going to be using the Q risk tool for that. I've got Q risk three up here. You may still have Q risk to of your operating in practice and you're using whatever is built into your system. The very similar key risk is newer, it's preferred. But as long as you have a validated method of checking risk than that's okay. So put all of Tony's um uh numbers into here and as you'll know, this gives you your percentage risk of having a heart attack or stroke in the next 10 years. And for Tony, with the information that we have about him, it tells us that he has a 12.6% chance of having a heart attack or stroke in the next year, 10 years. So we know that that is above the 10% threshold. So anything above 10% we consider to be a higher risk and warranting um additional measures to reduce that risk. Now, that tenure risk can be quite tricky to understand um for healthcare professionals as well as for patient's. Um and when we're communicating what that risk actually means, it's so important that the person that we are communicating with can understand what that actually means. And this is where the share the pressure tool comes in because it will take the same information, you can click the two minute assessment button and it will take in all of the information about the BP, the cholesterol, etcetera, etcetera. And it will present that result rather than as a 10 year risk score as a heart age. So when we put Tony's information into there, and we know Tony's 52 years old, his heart age comes out as 69 years old. So even if Tony struggles to get his head round, what 12.6 or 13% risk over the next 10 years, whether that's significant or not, more than likely we can all understand that if we're 52 years old in our heart ages 69 that, that's not so good. And it may help in informing us to make decisions about whether we are wanting to make any changes to our lifestyle or indeed, whether we are going to want to try medication to reduce this BP. And that blue button there is where you can click um to see how many years off you can take from your heart age if you are able to get your BP under control. So, it's a really helpful tool in communicating this back to our South East London chart here. So we know that um Tony has stage two hypertension. We've gone through heart age, we've given him his curious call of his blood tests is E C G and everything were fine. Um However, he is um he's under 80 years old and he does have this um over 10% Q risk. So we're gonna talk to him about starting BP treatment and he's also going to be offered a statin because his risk is over 10%. And then we're going to get down to managing hopefully this BP. So I'm going to concentrate particularly here on the medication. Um But of course, we know that lifestyle has a huge part to play in this. Um And you'll see and this, this table is, is lifted directly from nice and presented on your clinical effectiveness for Southeast London group. So Tony doesn't have type two diabetes. However, he's under um 55 years, but he is black, he's a black Caribbean origin. And so we would move over to the right hand side. Now, these different categories for where we start with our first line treatment are really just by an individual's characteristics, trying to assess what is likely to have the biggest impact on their BP, the soonest. And we know that there are differences in how the the high BP develops and also how people respond to medication. So that is why depending on somebody's age and their ethnicity, we will make different choices as to where we start with their BP lowering treatment. So over here, we have Tony. So it doesn't matter what age he is. Uh he's 52 but he is of African Caribbean family origin. So we will start him on a calcium channel blocker. So amLODIPine being the local choice, but we could have the option of a Thiazide like diuretic. So in dapper mind, um if we wanted to go down that road, so if we were concerned about the calcium channel blocker effects or if he had heart failure, which he doesn't, um then we have those two choices to go for as his first agent. So we'll start him on amLODIPine. And then of course, we're going to have to get him back to us in a couple of weeks and see what's going on with his BP, see what sort of response he has to that and then potentially adding other agents if he doesn't get to control. And so the four steps of the hypertension treatment protocol are all adding in if somebody is not treated to target. Now often get asked, do we maximize the dosage on one treatment before we add in another? Uh And there are a number of things to take into consideration for that biggest of all being the choice of the patient because it may mean that they're going to obviously have to be taking more than one tablet rather than one tablet. We don't know how many other tablets that they're on. Uh we don't know if they're paying for their prescriptions. So there's all sorts of things to take into account. But what we're really trying to do is to address the BP from a number of different angles because we know that it is multifactorial in its origin to get the best result we can for Tony and treat this BP. So ideally, we will be looking to add in at each stage. So if the calcium channel blocker alone isn't enough or the in depth mind isn't enough to control his BP, then we will be uh looking to add the two together or potentially to add in an ace inhibitor or an angiotensin receptor blocker to the calcium channel blocker or the diuretic that we've added. Step three is going to be trying the three together. Now, most people, the studies have shown will need 2 to 3 different antihypertensive agents to be able to control their BP. So it's important that Tony knows this from the start that this is going to be a bit of a journey and it could take a bit of juggling with the medications and we're only going to start him off on a small dose of one medicine. He may end up needing more than one different medicine, more than one tablet to control it. Um, and that's normal. That's often what happens when it comes to managing BP too, to try and reduce his concern about that. If we're uncontrolled after uh, three agents being in place, then assuming we've done all the checks that, you know, he is actually taking his medication, um, as prescribed, then it could be that he has resistant hypertension. And then we need to look at different, um, possibilities for that to add into these three drugs that we've already given. And I'm going to come on to where these work and what that picture looks like to help with understanding how it all comes together to, to complement each other in treating this. But if Tony does have resistant hypertension, so if he doesn't respond to the medications that we give him, then we would need to consider further therapy. And the first choice for our further therapy would be an allergist Erion antagonist. So, low dose spironolactone, we know that spironolactone is potassium sparing. So we can only give that if his potassium is below 4.5 millimoles per liter and he's got good Riedel function. Um If that's not the case that it's going to be a bit too risky to give him the spironolactone and then we need to think about another option. So are other options that we have here will be our alpha blocker, doxazosin or a beta blocker. And these guidelines suggest Atenolol or by supper along and possibly seeking specialist advice as well to see if there's something going on secondary causes of this hypertension. Now, spironolactone will be your choice over the other two if possible, because the evidence tells us that that is more likely to get them to target than either the other two in the British and Irish Hypertension Society pathway studies, spironolactone got 60% of people with resistant hypertension to target. Whereas alpha blocker and beta blocker only got 30% of the people to start. So they're twice as likely to get to target if they are able to have spironolactone. So the other mention to add down here and this comes in at your second step is if Tony's calcium channel blocker, if his amLODIPine or his indapamide, his thiazide like diuretic hasn't worked and we decide that we are going to add in uh one of the a drugs, it's actually better to use an angiotensin receptor blocker for Tony. So for people of Black African or African Caribbean family origin, because there is that increased risk of angioedema with the ace inhibitor in this population. So it would be an ARB one of the certain's that we would want to choose for Tony. And so I'm just going to share with you here um this lovely um infa graph that comes from the British Journal of primary care Nursing. And I believe there is an updated version of this now available and it sits on the issues and answers in cardiovascular disease website. So do Google, it do have a look because I think these are amazing and they are really back to basics charts and they've got them on everything, how different medications work, what the process for different diseases is. And I think this is a really lovely visual way of showing how all of the different agents act. And more importantly how they will act together to reduce the BP. So, on one side of the chart, we have our neuro pathway. On the other side, the hormonal pathway and the pathophysiology behind our BP, you know, it's likely that all of these factors are coming into play here. So if we address the high BP from different angles were more likely to get a better response. As I've said, we start off with the one that we are likely to get the best effect with. So with Tony, we have started him off over here right on the bottom with our calcium channel blocker and Lodipine. So that is going to vasodilator, it, it's going to open up the blood vessels by slowing down the movement of calcium into those cells, widening the blood vessels vessels and therefore lowering the BP. Now, that may or may not be enough to lower blood, Tony's BP significantly enough to reach target. So if not, then we're going to add in something to go with it. So our choices are to add in our thiazide like diuretic or in Tony's case. And Angie Ascent angiotensin receptor blocker would be most suitable for him. So if we come over onto the hormonal side at the top here, we've got our end up mind and what the indapamide is going to do is act on the kidney to excrete more sodium, more water, therefore, reducing the circulating volume of blood in the blood vessels, reducing the BP. So you can see how those two will act together. We've got our calcium channel blocker to dilate the blood vessel and our diuretic, reducing the flow. So it's gonna reduce the pressure overall by those two actions, if we decide to give Tony are antisense angiotensin receptor blocker. So Losartan is the example given here, then that is going to act on the region renin angiotensin aldosterone system. And after that cascade of activity has happened that results in vasoconstrictions. What the ARB will do is block the receptor site for that really potent vasoconstrictor that angiotensin two. So less vasoconstriction occurs and less aldosterone is promoted. So there's less fluid retained. So it will complement the other two. In that we've got over here, we've got Arviso dilation with our A ARB. We've got a reduction in vasoconstrictions. So similar thing but slightly differently and then reducing are circulating volume, reducing our sodium as well. So you can see how those three agents together really work together, really complement each other to reduce that BP. Now, part of that renin angiotensin aldosterone system, part of that cascade of activity will also promote the release of aldosterone. And we know that aldosterone is a hormone that supports the body to cling on onto fluid and sodium. And this system of course, kicks in when we're really unwell or if we particularly are bleeding and losing volume, this is what kicks in to hold onto our circulation, which can be very helpful if you've lost a limb, less helpful if it's kicking in inappropriately and raising your BP when it doesn't need to be. So where are spironolactone fits into? This is by antagonizing that aldosterone and therefore reducing those water retaining effect and the sodium retaining effects, reducing circulating volume, reducing the BP if we can't give him spironolactone because his potassium levels too high kidneys not working well enough then over on the other side, we see our beta blocker and our alpha blocker, which work on the neuro side of the pathway. So our beta blocker is going to slow down the heart rate. So the heartbeats more slowly and with less force, reducing the BP, it's not a mainstay of BP treatment these days. Um there are much better drug drugs for managing BP, but there is still some value to be had if we need some additional support. And the alpha blocker reducing that Faizo constricting effect of the Neuragen Elinor's as well. So also relaxing the blood vessels. So all of these drugs are looking to interrupt what our body is trying to do. In this case, probably inappropriately to redress the balance and get things back on an even keel for Tony. So in terms of targets, what we are aiming for is for Tonys BP to be below 1 40/90 millimeters of mercury, if Tony were over 80 years of age and he's got a long way to go and hopefully lots of healthy life ahead of him before he gets to 80 years of age, then we do allow a higher level of BP. So our target in the over eighties being a BP below 1 50/90. And that really just reflects the difference um that we see in blood pressure, how it, how high BP happens and how it's managed in very elderly people. And we have to be additionally cautious in the very elderly that we don't lower BP too much to the point that either it gives them symptoms and makes them fall or it interrupts the perfusion of the kidneys by reducing the BP. So low that it doesn't quite get as far as the kidneys and going of course, lead to problems in that area. So we do have a split target, but for Tony will be looking for his BP to be 1 40/90 all below. So hopefully we can offer him a range of treatments that's gonna suit him, that's going to reduce his BP. And hopefully by effectively communicating what his risk is going to be what it is as a result of this BP, he will be willing to take those tablets and also to look at what areas of his lifestyle he could possibly make changes in to reduce his BP. Tony will need to be reviewed at least annually in his practice normally. Um So practices will hopefully have a recall system in place to invite everybody with hypertension to come in for their annual review where everything will be checked through. So rechecking the blood tests, um checking the BP and then a review step by step of all the things that we're looking at. So how he's getting on with his medication with any lifestyle changes that he's looking to make importantly any symptoms. Um So, you know, we know he has an increased risk of developing cardiovascular disease. So, are there any signs and symptoms that this is progressing? Are there any issues with the medication, the treatment that he's on? But it's really important that Tony is a partner in all of this and you know, the rest of the year, the other 364 days, he's managing himself with this. So it's really important that we support him and give the information, the tools that he needs to carry on doing that um over the course of the year and beyond. So this is also from the guideline that will tell you exactly what needs to be covered. And a hypertension annual review is much, much more than a BP check as you can see here. So to summarize as we get towards the end of our time, we know ethnicity is a significant risk factor when it comes to cardiovascular disease. And again, that high BP disproportionately affects black people of African and Caribbean descent, leading to a higher incidence of stroke and end stage renal failure for this population. Black people are less likely to come forward for routine screening and health checks and men in particular and are less likely to have their BP controlled once it's diagnosed. So we really do need to think about how we are reaching out to this population. And indeed all of our populations to make sure that we are offering equity in the way that we are offering our screening and our interventions to people and that we're reaching them in a way that works for them as well as in a way that's working for the service that we're providing. Because if we don't reach people and they don't come for their screening, then we have no hope of offering them those potentially lifesaving interventions um that will support them to lead a happier, longer and healthier life. So as we are pulling things back together um through COVID, um there's a lot of work to be done and most people are going to need combination therapy to reach target once they make that diagnosis. So I would urge you to think about the services that are being offered in your area and how these fit and your population is it working for them and they are our most important partners in working out whether what we are offering is suiting our population and being effective. So, thank you so much for listening. I'm going to stop at that point. Hi Manu. I'm sorry, I didn't respond and say hello earlier, but great to uh have you along with us as well as everybody else that's on the call. Do feel free to drop any questions that you may have into the chat box. I'm going to now launch our feedback form as well. So please do provide some feedback on these sessions that will be very helpful to us in finding out if these are being helpful and uh also to plan for further events. Um do have a look at uh web page. So smart health solutions dot co dot UK and you will find a big icon there for share the pressure. If you have a click on that, uh you will see a multitude of educational and support resources that we have for healthcare professionals. We're also developing an area for patient's as well that will direct them to a number of different helpful sources including BP UK are partner in this project. And also there's a link there to the share the pressure website where have a go pop in your own details, see what your heart ages, encourage your patient's to have ago or perhaps go through it with them. Um It is a really useful tool and this particular uh edition of Share the Pressure has been developed in a partnership with the Race Equality Foundation. We've had a number of focus groups with Black African, Black Caribbean people to work through the messaging the images and everything that's in there to try and make it as relevant for this population as we possibly can. So do have a look, do you give us some feedback and I can't see any questions. So I'm going to close it there, but it is available on demand and the next session is coming up in a few weeks time. So if you've enjoyed it, do recommend to your colleagues have a wonderful rest of the day and I look forward to seeing you on another webinar soon. Thank you and take care. Bye bye.