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Okay, good evening and welcome to this share the pressure session. Um Share the pressure is a new and exciting project that we at Smart Health Solutions are involved in in partnership with the race equality foundation, Younger Lives and BP UK. 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. My name is Joe Horse. I'm the clinical Director of Smiled Solutions also with learn with nurses and I'm a registered nurse by background, specialized in cardiovascular disease and I have a number of other jobs that I do as well. So lovely to have you with us this evening. I hope you can hear me and see me. I know I had a session on the other day on BP and lifestyle and we had a few issues with people being able to see in here. So hopefully we are all good. Um If someone wants to let me know that would be brilliant. Um I'm doing this project along with my colleagues Michaela and David, who you may have seen on some of these webinars to and we've also got some podcasts and some other resources that are available as part of this project, our educational content that smart health are responsible for all delivering this via medal dot org. And congratulations, you found your way to medal this evening. If you are used to it, then I'm sure you love it. If you're new to medal. Hopefully, in finding your way in, you found a couple of these that all slide across buttons. One for requesting catch up content that basically means being able to access the slides after the event. Although all of these share the pressure sessions are being recorded, so they're available to view on demand via the smart health website. Uh And the other one is to generate that all important attendance certificate. So you can use that for your revalidation, your portfolio, whatever you need it for. There is a in the bottom right hand corner of your screen, a little chat box. If you have any problems at all with using medal or getting the information that you need, then do have a click on that. And the amazing team of medal will be only too happy to help you find what you need. So let's crack on with this evening session. So why look at this particular issue? Well, we know that ethnicity is significant risk factor when it comes to cardiovascular disease. And in the case of high BP, we know that it disproportionately affects black people of African and Caribbean descent. And unfortunately, this does lead to a higher incidence of stroke and end stage kidney failure in this population. This is confounded by the fact that often members of this population are less likely to come forward and access routine screening and health checks. And this particularly applies to men. And even once a diagnosis of hypertension, high BP is made, it seems that black people are less likely to have their BP controlled than white people. We know that COVID 19 has made this situation even worse than before and it wasn't that great in the first place. But we know there's been lots of opportunities missed for people to get their BP taken and for people to have other routine screening where this might be found and people generally have been less likely to access routine health care. So for this particular webinar, I'm going to be talking about the medications that we're using to control high BP. And the really good news is that we have a fantastic range of treatments out there available that will perfectly well control high BP in the vast majority of cases alongside lifestyle changes and generally being in, in a better state of health and well being that controls your BP. Now, I must just apologize with a little bit of black background noise that you might hear if in case you haven't worked out what it is, it's um, one of my dogs having a really big drink right beside me. He's on lots of steroids at the moment. He's not been well and he's constantly thirsty. So, apologies. If we get a little lapping sound coming in the background now and again, that's, that's real life of being at home, isn't it? So, I'm going to introduce you to Tony here. Um, Tony is a 47 year old black male who was previously fit and well, he's married, he has grown up Children and recently he joined a gym because he feels he's getting old and out of shape. And I'm sure some of us can empathize with Tony on that one. When he went for his gym induction, his BP was found to be high and, and they recommended that he made an appointment at his G P practice to go and get his BP rechecked. So indeed, that's what he did. And when we recheck that BP, we found it to be 100 and 68/86 millimeters of mercury. So, as you might expect, we don't rely on clinic based readings alone to make a diagnosis of hypertension. We need to have an element of home reading included there to be able to see what somebody's BP is doing over the course of a day because our BP will fluctuate and go up and down during the day to deal with whatever our day throws at us and that's what's supposed to happen. So we want to get more of a feel other than this one off. Plus we know that people's BP is likely to be higher when they're in a clinical setting than it is when they're in their own home. So Tony went and had uh an ambulatory BP monitor fitted that recorded his BP over a 24 hour period. And what we were looking for was his average daytime reading to be able to make the diagnosis. And this average daytime reading was found to be 100 and 56/92 millimeters of mercury. So hopefully you can see from the table that's there that both the clinic, BP and the home readings support the diagnosis that Tony does in fact have stage two hypertension. So we need to think about together with Tony, what can be done about that? Now, if you joined any of the share the pressure sessions previously or looked at any of our offerings that are available on demand, you'll know that this particular phase of the project, we are working with the boroughs of Southeast London. Um Our project that's funded by the Burdette Trust is particularly the funding was obtained to work with the population here. And it's amazing that we have such good resources available to healthcare professionals and to the population of South East London. And one of those are these clinical effectiveness Southeast London guidelines for general practice with the management of hypertension. There's one for each borough, they're all available via our website. This one particular is um for practices in Lambeth. And so the key messages on there are around making sure that we find the BP checking every opportunity, making sure that we do pulse checks as well. Considering that lifestyle changes can prevent or reduce the need for medication. We need to check for complications and make sure that we do a full cardiovascular risk assessment. And we also need to optimize BP management and aim to be below the BP targets that are recommended by nice and of course, add courage adherence to any changes and medication and be sure that we review people at least annually. So this is the diagnostic and assessment chart which is lifted directly from nice but looks a little bit prettier, I think. Um and if we follow our way through here where we find that Tony has stage two hypertension, so we did the clinic reading, we then need to confirm the diagnosis which we did with some ambulatory home BP monitoring, needing to do some blood and check for complications. I'm going to come onto that. And then once that diagnosis has been made, talk to Tony about his lifestyle for him to consider if there are any changes there, he could make, look at that assessment for complications and cardiovascular risk assessment and then make a decision on treatment with Tony following on from that. So that assessing for complications is really asking a couple of questions. So we know that having high BP is a risk rather than a disease in itself unless it's left untreated and then it goes on and cause problems. So the first question is, has this BP caused a problem yet? And so we'll find that out by looking for target organ damage. So we know the areas that high BP can potentially affect if left untreated. And predominantly, we're looking here at the kidneys at the heart and we're looking at the small blood vessels in the back of the eyes. And then we're also assessing overall cardiovascular risk to be able to answer the question of, is this BP likely to cause a problem to this individual in the longer term. So we need to do some um blood tests. So the ones that we need to be looking at cardiovascular risk. So we're gonna look at the glucose doing an HBA one C because we know that diabetes is often a fellow bedmate of high BP and raised cardiovascular risk. We're gonna look at renal function and we're gonna look at full blood count thyroid function and the lipids again to be able to do the full cardiovascular risk assessment. Can we're gonna look at the albumin creatinine ratio um by taking a urine sample and also test for any signs of blood within that urine too. So it's important at this stage to really have a good look at the kidneys to see if there's any signs that they're leaking any protein and any damage could have been caused. So far, somebody needs to look in the back of the eyes, whoever that maybe somebody um within the practice or optometrist down the road and we need to do a 12 E D C G to look to see if there's any signs of left ventricular hypertrophy or indeed arrhythmia, but particularly this hypertrophy, are there any signs that this BP has led to any thickening of the heart muscle that could potentially go on and lead to dysfunction or heart failure in the future. So, all of those things were done and thankfully, there were no signs of target organ damage on Tony's blood results. Looking at his overall cardiovascular risk assessment in practice using the Q risk tool. His risk of having a heart attack or a stroke over the next 10 years came out at 12.6%. Now, for those of you that regularly look at cardiovascular risk, you'll know that this is above the 10% threshold where we start to consider the re risk to be at a higher level to think about offering interventions to reduce that risk. Now, specifically talking about offering statins but also managing the BP using medications as well as any lifestyle changes to reduce that risk. Now, one of the benefits of share the pressure and the main focus is our wonderful heart age tool developed by younger lives that will look to express that cardio vascular risk as a heart age. So it's the same information expressed in a different way as heart age that hopefully would be helpful to Tony in really getting to grips with what that risk means to him, possibly more meaningful than this 12.6% risk over the next 10 years by looking at what his heart ages and it's a quick two minute assessment. Um We do have a webinar on using heart age that will take you straight through that to be able to see exactly how all of that works. Now to save time having done that on Tony, it has shown us that his heart age turns out to be 69 which is significantly more than his chronological age of 52. So I'm sure Tony would be able to see him looking this that actually his risk is higher than it perhaps ought to be for a man his age. Going back to um the algorithm here, we know that Tony has a higher risk of developing cardiovascular disease. So it's time to start talking with him about BP treatment and the share the pressure talk and help him in making his decisions and giving him information about this. If we're looking at the treatment algorithm to guide the choices And of course, we realize that Tony may decide that he doesn't want to take any medication. But if he is willing to give this a try. And the last webinar idea this, that's available on demand on BP and lifestyle will give you the information and the evidence base around the diff different that high BP can make to, uh that lifestyle changes can make too high BP. And you'll see that some of those are as good as, uh if not better than single BP tablets. Um, in some cases, so it's worth having a look at that if he doesn't fancy the thought of tablets, but it's stage two hypertension. There really is a great deal of benefit to be had from commencing anti hypertensive medications. And that was what the guidelines would recommend that we do. The first bit of decision making is around where to start. As I mentioned, we've got lots of agents that work very effectively to manage hypertension. But we need to look at choosing the one that's most likely to have the greatest benefit in the first instances with Tony because at step one, we start one type of medication and that decision is based on our age, our ethnicity and the presence or otherwise of type two diabetes. Now, Tony doesn't have diabetes. He is a black man and he is um a young black man. I'm saying that because that's still a very young age at 52 years of age. So we're going to be on the right hand side of the chart here because of his ethnicity predominantly. So for Tony, our first line choice would be a calcium channel blocker. So something like a model pine would be the sensible choice for him. The other option is a Thiazide like direct ICK in which this case that would be um in dapper mind, those would be our choices because those are gonna be the options that are likely to have the most effect for Tony. So we're starting off with one tablet and see how we get on with that. Now, in reality, most people need more than one different BP tablet to control their BP. So we need to optimize the medication to the most effective tolerated doses and check adherence and step up to adding in therapies as we go along to try and get control of this BP. So if Tony's BP isn't controlled with his calcium channel blocker or his Thiazide type diuretic alone, then we should look at adding in the other one or one of the a drugs, the ace inhibitors or the angiotensin receptor blockers. So that would be Ramipril, Lisinopril or one of the statins, Losartan, Candesartan, etcetera. And so we would have a combination of two of those tablets. If we didn't get control at that, then it would be time to put the three together. And those three different agents would act in different ways on the mechanisms that are behind the high BP in all individuals. So we're most likely to get to target if we need to on the three different agents. And if you're unfamiliar with or you need a bit of a refresh on how these medications work and why a combination of them would work well. Together, we have this brilliant um back to basics chart. This is from the British um of primary care nursing, which you can now find under issues and answers in cardiovascular disease if you Google that. So this particular one, I think there's a new one come out now was um put together by Jan problems King, who's an amazing uh cardiovascular practice nurse as well as doing a wealth of other things up in Bradford, I think. And I really love these colorful, bright pictures of how things work. Um That's kind of my lining style. Um So if we look at where we are on here, we've got the two main systems that play here, we've got are sympathetic nervous system, uh speeding up our heart rate, um vasoconstricting, holding onto BP. And on the other side, we've got our renin angiotensin aldosterone system. So this cascade or traffic light of activity that releases angiotensin to this really potent vasoconstrictor that holds onto our circulation by constricting up the blood vessels and also promoting the release of the hormone aldosterone, which will hold on to fluid and sodium in the body. So all of this is really helpful if you are bleeding or you're really sick or something like that. But when these mechanisms kick in um unnecessarily or inappropriately, as is often the case in essential or primary hypertension, then what we're trying to do really is override these mechanisms to try and restore a normal order of things. So Tony being black is less likely to have um effective monotherapy with drugs that are acting on the renin angiotensin aldosterone system. There are some differences in our ethnicity of how we process and manage salt in the body circulating renin levels. So um giving Tony a calcium channel blocker which is on the green side here at the very bottom will open up his blood vessels have a vasodilator ori effect and will lower the BP. Now, if that calcium channel blocker alone doesn't work, and we look to bring in um either Indupa mide diuretic drug or to add in an ace inhibitor or an angiotensin receptor blocker, then we're going to move on to the blue hormonal side. So we are reducing vasoconstrictions, we are offloading this fluid that were holding on to and we are reducing the production of aldosterone which again is hanging onto the fluid and the sodium in reality, most hypertension is quite multifactorial as I've said in, in all populations. So that's why it's likely that people are going to need a combination of different treatments to be able to get them to target. But that's where those three um different groups are sitting on this chart. So if, if this is quite new to you then or you need some revision, hopefully that makes sense how that all comes together to work in harmony, to try and reduce the BP and get an effective result on that. Now, if um we get Tony onto these three drugs, if he needed them to get him to target and he still wasn't target, then we would consider that he may have resistant hypertension and we're more likely to have resistant hypertension, the longer we are hypertensive without it being detected and treated. So there's a, you know, a really bonus to finding it early and you know, a lot of logic behind all of the case, finding work that we do to try and find people because the earlier we find them, the easier it becomes to treat them. But if Tony was uh if his hypertension was resistant, then we may need to consider further BP lowering therapy. And in that case, a low dose of spironolactone would be the preferred choice if it's possible to do that. And the one inhibiting factor in that could be his renal function. So because spironolactone which is an aldosterone antagonist, so it stops that holding onto the aldosterone, more fluid, more sodium, what it also though does is hang onto potassium. So if his potassium were above 4.5, then we wouldn't be able to use that. Um If there was any concerns about his renal function, which at the moment, we know there isn't. In which case we word need to look at a different fourth line option, which would be either an alpha blocker or a beta blocker. Both of which can be found on the green side of the heart. The back to basics diagram here. So beta blockers, slowing down the heart, less force in the beating, reducing the BP, alpha blockers, dilating the blood vessels, lowering the BP. They're, they're not as effective as spironolactone in reducing the BP. But it is an option if you can't use spironolactone. The British Irish hypertension society pathways studies um showed that spironolactone got about 60 to 70% of people with resistant hypertension to target. Whereas only about a third of the people that were on either a beta blocker or an alpha blocker got to target. So there is significant value to be had in spironolactone if it's a possibility. But of course, we know it may not be. So what are we aiming for in terms of targets? Well, for essential hypertension. So this is people that don't have diabetes, haven't had a previous stroke or any of those things, kidney disease, that mean we want to push for BP perhaps a little bit lower than most people. We will be looking for a BP of below 100 and 40/90 millimeters of mercury in the over eighties. So the much older people, then we have a bit more leeway and we're looking at a BP below 1 50/90. So for Tony would be looking for his BP in clinic to be below 1 40/90. But we would want his home readings to be below 100 and 35/85. Just to take into account that we expect it to be lower when he's at home. Once Tony's BP is controlled, um we need to be sure that he's invited for a minimum of an annual review that is comprehensive and structured. And so as well as checking his BP, we also need to make sure that we are checking his bloods. Um thinking about his overall cardiovascular risk, talking to him about what he's doing to look after himself in terms of any lifestyle changes he may have meant made and how he's getting on with those. Thinking about how he's managing and coping with his condition. Are there any signs that this could be progressing? Are there any signs and symptoms of cardiovascular disease emerging? And it's really the opportunity for Tony to gather all of the information that he needs to be able to go and continue to manage his high BP for the remainder of the year until he needs to see us again. Now, obviously, we want him to come back sooner if he has any questions or any problems at all. But we kind of need this annual workshop together to be able to give him all of the information that he needs. And of course, also to gather up the information that we need to make sure that we are looking after him properly. So to summarize um ethnicity is a significant risk factor when it comes to cardiovascular disease. And with black people of African or Caribbean descent, it is particularly high BP that is disproportionately affecting them leading to a higher incidence of stroke and end stage renal failure. So there is a massive health inequality here, particularly when we think that members of this population are less likely to come forward for routine screening for health checks, men in particular. So we really need to consider how we're reaching out to people. What that access is like, what the offer is like is that offer relevant and appropriate and capturing the interest of this population. Because if not, then they're not coming in and this health inequality will continue and it can't continue because people are dying, they're being ill, they're having cardiovascular events, they're being unable to work, they're being taken from their families, they're having a poor quality of life, all for reasons of something that could be managed, could be prevented. We know that once the diagnosis has been made, black people are less likely than white people to have their high BP controlled. And again, that's a really unacceptable health inequality that we have. We know that COVID has, has caused untold problems to this situation. So there is a lot of catching up to be done to be able to try and address this inequality. And we also know that most people are going to need combination therapy in order to reach their target. But we do have some really good options there. We've got the tools we need to be able to manage BP. We just need to work with our patient populations to be able to get to an agreement of something that's gonna work for them that they're going to be able to manage to reduce their overall risk. So, thank you so much for listening. Very happy to take any questions that you may have. Um And also just to tell you while you're thinking of any questions that um if you go to our website, smart health solutions dot co dot UK, you will see a link there to our share the pressure resources. I'll share the pressure community of practice. If you sign up to that, you'll receive a mailing when we have new resources available to view on there. At the moment, we have a series of four webinars that are available to watch on demand. This is the fourth in the series. We've got an introductory one all about. In fact, there's five, the introductory one, we've got one on understanding BP. One, I'm using the share the pressure, heart age tool, hypertension, BP management and lifestyle. And then this one on medication, we've also got a couple of podcasts available for anyone that wants to have a listen on the go when you're out for a run, walking the dog, making the dinner or wherever you might like to listen to that. And we've got links to the guidance that I've shared with you and also to some publications that we've already had on this project. So I'm sure there will be something to suit. You. Have a go have a try at heart age, tell your mates about it, tell your patient's about it and hopefully it will be useful to them and to you. Um So I can see a question there. Is this being recorded? Yes. Um It is and it is there available to watch on demand. So if there's anything that I've spoken to quickly and you've missed or you didn't hear when my dog was having a drink, then um you will be able to go back and revisit that the slides will also be available to you. So we have a question here and I'm reading out the questions because if you're watching on demand, you won't be able to see the chat box. So thank you to everyone for your positive feedback that you've given so far on the webinar. That's that's great to hear that you found it useful. But a question we have here is once BP comes to within normal limits on antihypertensives, would you consider stopping them if it stays there for a while? And how long that I think that might be. Do you need to wait to do this? Well, that's a really good question. And when BP comes to within normal limits on anti hypertensive medication, that generally means that the medicines are doing their job. So if we look to take those medicines away, the BP will probably go back to where it was before. So it's unlikely that the medications will be stopped. Now, that's not to say never. Um, it is possible we know that making lifestyle changes can make a big difference to your BP as well. So if somebody were to lose weight, if they were overweight, if they were to improve on their diet, reduce the salt intake, be more physically active, reduce the alcohol intake, then it's possible that those things would make enough of a positive difference to the BP to perhaps be able to reduce or in some cases come off the BP medication. Also, a BP does tend to come down as we get older and frailer. Um, so sometimes as people do become quite frail, we might need to reduce the medications as well. For most people in reality, once they're on their BP, medicines they stay on them. Um But it is possible and it's, it's important for people to know that because it might be a real motivating factor if people do want to make some lifestyle changes to reduce the burden of the tablets that they're having to take. So it might work another question to hear this again. Are you saying this will become a podcast that we can click on your website? Well, actually, do you know that's a really good suggestion. I think we are looking at whether we can make these available um as a listen only, I think probably quite useful to have the visuals, but there is a simpler if you like version without reference to visual materials available. Um There are three podcast, I think we have to up at the moment and a third one coming that will give you um the same messages, but perhaps not in quite such depth. Oh And, and Wonderful Sue for a medal is here joining as high Sue. Um And she's given a link here to um share the pressure to where you'll find them available on catch up. Hello Sue. So, um yeah, they're available to you. Uh Oh, thank you. So good that you can put them on youtube. Well, we want to spread this out, make them available to people. So do tell your mates. Um Any more questions coming? I'm just gonna scroll up to see if I've missed anything. I tell you. What else I'm going to do? Cause I'm very good at forgetting to do this is I'm going to pop the feedback form into the chat. Um Please do give us some feedback. Now, we are evaluating the whole of the share the pressure program, both for users of the heart age tool, but also the education program. So if you could fill in your evaluation form, that will be really helpful because this is part of the feedback that will be given to the Burdette Trust who have funded this project. And um if it's useful for people, then we would like to be able to roll this out in more areas of the country and beyond as well. So um please do let us have your feedback. Um and if it's been useful to you, then hopefully it will be useful to others as well. Now, I can't see any further questions coming in. Um Yet more comments about putting them out their global following would grow. Yeah, we, we are all up for the global follow because this is relevant everywhere. I mean, we are looking particularly at this area of South East London for this project, but but this is relevant across the board and a problem across the board. So the more people we reach the better, but it is almost 10 past and so I'm sure you'll want to get on with your evening. Thank you again for joining me. Thank you for participating. In our share the pressure project. There's a way you can contact us through the website as well or pop your details onto your evaluation. If you've got any suggestions for us, the things that you would like to see or hear, then we would welcome them too. But for now, have a lovely evening. Stay safe and keep up the good work with managing BP for everyone. Take care, hope to see you soon. Bye bye.