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Good evening, everybody and welcome to Oh, it's looking very dark. Sorry, I'm trying to make the lights go a bit better. Welcome everybody to another of our learn with nurses session. I'm just gonna pop in the chat. Can you hear me? I've got a new headset and it says you can hear me but I wanna make sure that you can. So it's gone. Shouty on here. Caps Locks, hear me. So hopefully you can have a look in that and someone can let me know that you can hear me. I'm just gonna crack on as if you can. Oh yes. Lots of people can hear me. Lovely, lovely, lovely. Um Let's share these then and get the first of two sessions. Yay, lots of people can hear. Lovely July. Lovely July. Get the first of tonight's session. We've got two sessions for you tonight and the first one is all around understanding BP. So I don't want something exciting to tell you in a moment. I get something exciting to tell her. So my name is mckellan at all founder here at L with nurses. Good evening everybody. It's so lovely seeing everybody. I say Good evening. It's evening for me. It's 7 p.m. for me, but it might be a slightly different time where you are. So this is understanding BP. Um Don't forget all the social media if you want to. If you do that, we are at LW nurses hashtag alone with nurses that's across Twitter, Instagram. Although I don't, I'm not very good with Instagram but my Twitter is at, this is Michaela, let us know in that chat. Um where you're from, what your role is. And uh yeah, let's see if we can get some discussions going around BP and something else. I'm going to be asking you about celebration is our 5/100 webinar. 5/100. We started learn with nurses back in about May 2020 when COVID kicked in and our training went and I did the first one and it was all around understanding BP. So it was the lovely owner who said to me, do you know he ought to want tonight? It's a five 100th webinar and it happens to be BP as well. I actually don't think I've changed a lot of what I say because BP hasn't really changed. Oh, we've got Stanmore practice nurse from Stanmore. Occupational health is Stephanie. I think you've been around a few times. Lisa's from books. Holly's down on the aisle of whites. Lovely. Um So quite a lot of you from all over Lisa's a GP assistant. We've got a registered nurse, Marie in Rotherham, a practice nurse. Sorry, Holly's a nurse student. Wonderful, wonderful. We love seeing people here with us and, uh, we've got a lot of you here already. We've got lots and lots of you and Alison from Wales. Oh, GP assistant in books. I get all excited. Alice is from Rome. Ok. You get the badge for being furthest away so far tonight. But lovely seeing all of you there and I'm, I'm, I'm gonna, I'm not gonna carry on reading out all, all your roles cos otherwise we'll be here for the whole time. But Lovely. K from Saint Andrews. Good to see you again. Kay. Lovely. Right. I am going to um crack on with BP but I want you to use that chat function for me. Oh, I thought I'd put it in. Oh, hang on. Anyway, what I want you to do in that chat function? I thought I'd done it. Maybe. Hopefully I've uploaded the right. I have uploaded the right one. I want you to just think about me before we get into BP. Think about what we do here at, learn with nurses and the different sessions that we run and how could we make it better? I'm not necessarily thinking about clinical content, but is there any other style or other way of doing things that you think? Do you know what I would really love it if so, I know there's a place in here that we can use for our certificates. But is there somewhere where you think, do you know what I'd love to be able to do a bit and be reflective, uh, for revalidation or I'd really like to have a small group discussion about something where we can all have a wider chat about things or I'd really like to, um, yeah, just, just think about the different styles that you might like, learn with nurses to develop into not saying we can make it happen. But, um, but you've gotta be in it to win it, haven't you? So have a little ponder either put it in the chat or pop it into your evaluation. But now let's get to what we're here to talk about, which is understanding BP. Now, if you came here, if it's your first time and you think you're gonna get a big academic lecture, that's not me. Ok. I don't do big academic lectures. I'm a cardiovascular nurse. I'm, I'm actually one of those old fashioned nurses. I've been around forever, I would say for a long, long time. Now, it's really sad when I think about it. 92 I qualified. So quite a while ago, started training in the eighties, which does sort of date me rather. But, uh, yeah. Uh, but you know what hasn't changed, what happens inside our bodies hasn't changed for years, decades, thousands of years, most millennia. So, um, and that's really where I want us to try and get to Italy thinking more we take blood pressures all the time. We tell people what their blood pressures is. We dish out BP tablets. But do we really understand what BP is all about across the world? And we do have people from, not just from the UK across the world. It was the number wrong risk factor for global death is to do with high BP. Ok. Causing so many problems, so many problems, it is heart attacks and strokes and cardiovascular complications. Meaning that over 10 million people every year they've lost their lives. Needlessly, we don't have to have it because we know BP can be identified, diagnosed and managed. Yeah, only half the people with high BP actually know about it if we go um, a bit closer to home. And this is from what was called, uh Public Health, England, which no longer exists. But what we do know and, and apologies for all of you, great people over in Scotland because we've got Fife and Edinburgh and Glasgow and everybody there. But I just have to have the, the, the, you know, the way the whole country and the world gets chopped into sections. And I'm sure it's uh, probably not, I was gonna say not much different but possibly a little bit worse than in England. More than one person in four adults have hypertension and I can tell you now I'm a newly diagnosed hypertensive. Thank you very much. Start with my medication a couple of weeks ago. It's my diastolic. That's particularly awful. And it's our third biggest risk factor in England, probably for the UK for cardiovascular disease. Whereas across the world, it's the first biggest and we know that people from the poorer areas are more likely to have hypertension, more likely to and not just from the poorer areas, but also ethnicity makes a big difference as well when it comes to hypertension. And we know people who are Afro Caribbean way more likely to have hypertension and pretty much half of all the heart attacks and strokes that happen is to do with high BP. And it's a major complication for chronic kidney disease. And if you're not booked on for my chronic kidney disease, one at eight o'clock tonight, there's still time to get registered. And not only if all that wasn't bad enough. Every 2 mg rise of mercury in systolic BP is associated with an increased risk of death. So each time it goes up just that little bit more, it's only two more, it's only two more. You're increasing your chances of dying. So, quite scary stuff really when we start to look at it. But what is BP? Well, we have the circulatory system and the circulatory system is how we pass stuff. You can tell I'm technical, pass stuff around our bodies. We have all different systems, don't we? For moving things around. And the circulatory system is our blood and it flows around the body. It flows around the veins and the arteries. Remember, arteries are powerful blood vessels that take blood away from the heart. Veins are floppy creatures that bring it back. And the blood carries all sorts oxygen nutrients, whatever we want, it carries lots and lots of useful things in the blood and we need our circulatory system. Now, the system I want you to think about it in two different ways. There's a, there's a, a volume, there's a, you know, there's the capacity of the system. So that's if we could measure the inside of all the arteries and all the veins that would have a certain volume. And then we have got the sorry, I need a quick thing. I've got a bit of me tea in the back of me, not my cup of tea, but you know, me supper on my back of my tooth and I just needed to get it out. Sorry. And then you've got the blood that's circulating in and that creates a pressure on the inside of those arteries and, and that keeps everything open. So we have two different ways that I want you to think about BP. One, the space, all the blood sits in and two, the blood itself and how much blood we actually have going around. And that's, and that allows our blood to be pumped around the body and um yeah, taking oxygen to wherever it needs to go to. And so that system that I wanted us to think about is controlled in two ways. OK. The system of how much blood we've kind of got and the space for it to be in. And so the space for it to be in is controlled by what we call the peripheral resistance. Now, I want you to imagine there's space here and the space can expand and contract can expand and contract cos our arteries and our arterioles. So remember it leaves the arteries, leave the heart and they get smaller, smaller, smaller, smaller, smaller before they go to capillaries and veins and come back back back. So imagine all those little bits they have the potential to expand and contract, expand and contract, making more space less space for that blood to be in. And when we're taking a BP, we're putting the cuff say around the arm and we're feeling the pressure of the blood exerted in the middle of the arteries. And we can see that in the middle bit of the picture here, in the middle of bit of the arteries and that's what we're taking. So that's partly on the, the, the, the volume, how much space we've got or let's call it space rather than volume, how much space we've got for the blood to be in. And then we have something called cardiac output and the cardiac output is when our heart beats, it pushes more blood into the system, ok? It pushes more blood into the system. Remember, your heart relaxes and contracts and the top relaxes and contracts and it pushes more blood in and that cardiac output can change as well in trying to maintain and keep our BP on an even keel. So I remember I want you to remember when we're going through cardiac output, that heart beating and pushing blood into the system and a system that can expand and contract. Now, when we do take a BP, we get two numbers, we get two numbers. We get the top number. That's the systolic and that's when the heart contracts and pushes blood into the system, pushes blood in and that systole and that is the top number and the top number is always bigger than the bottom number because the bottom number is when the heart relaxes and fills again, it's that BP that's left in the arteries, keeping the arteries open. Remember we need, if we had no BP, our arteries would close, you know, would be floor. So we need BP. Um So we'll just do that one again as the heart contracts, that's the weaker. So systole in the heart that pushes blood into the system, that is the systolic. And when the heart is relaxed and filling with blood, that's diastole, that's the stroke of the heart. It's called diastole. And that is the diastolic. Now, there's also something called the afterload and it's not something we chat about a lot about the afterload, but it's something that's really important because I want you to imagine when that heart has to contract and push blood into the system, it's got to overcome whatever pressure is already in that system. So my diastolic which is not, you know, which is a bit high, there is a lot of pressure in that system already. And my heart has to work really hard to push the blood into the system and the effort. Ok. That, that heart has to, that how much heart the heart has to work to push it in is something called afterload, which sounded like it doesn't quite fit, but it's afterload and that will come up again in a little while when we think about how we manage hypertension. Now, many, many years ago, I was a cardiac rehab nurse and I used to talk about BP and a arteries. Um, like like the greenhouse pipes, ok? Like the greenhouse pipes. So they're quite rigid. But actually our, our arteries and our arterioles, they're more like that blue hosepipe. They have the potential to expand and contract, create more space and less space. But they're also, whilst they're very powerful blood vessels, they're also subject to trauma and they're subject to damage. And that's what happens when we have high BP. Now, our bodies weren't designed to last as long as we are using them for most of the time that humans have been around. And, you know, humans have been in quite a few different forms over the, over the millions of years. But most of the time, but 95% of the time that humans have been around, we lasted for about 20 to 30 years, 20 to 30 years. Oh, it's in good, high in good. And um for 20 to 30 years, that's how long our bodies usually lasted for. And we would die from things like, well, blood loss, we, we cut ourselves and we'd, we'd, we'd, we'd have lots of blood loss or infections or childbirth or a failure to find enough food from where we were hunter gatherers. And, you know, so there was lots of reasons why we died. We didn't live long enough to have heart attacks and strokes or develop high BP. Then with the advent of um farming, farming really made a difference to how we move our lives. So with the advent of farming, that meant we started to live a little bit longer. And then really once modern medicine kicked in, once we got antibiotics, vaccinations, uh immunizations, infection control all of those. Then our bodies you can see on the second chart, our life expectancy goes up and up and up. Absolutely brilliant. We are using our bodies way longer. They were designed to be used. And so that's great. You know, we're living to now to our seventies and into our eighties. But we're gathering different complications as we go along. And one of those is hypertension. Now, the way our BP is maintained is designed to keep us upright. And we, and I'm gonna talk about this in the context of dinosaurs and dinner ladies. Now, I know we weren't around when dinosaurs were around, but I want you to think it's something that's part of our bodies, our cells and everything, like in a specific way that is so old. It's always the way it's been in our bodies. It's been perfected over time. So it's that long ago. And dinner ladies now, dinner ladies to me where when I was at school, they were, they were always women and, and they used to not only dish out the food, but they would also hang around in the playground when it was play time and they would be there in those high risk areas. Now, I just thought they were just standing around chatting to their mates, but they weren't, they were often near a set of steps or they'd be where they would be like, you know, it would get narrow and kids would get bashed and pushed or they'd be where they could see the boys playing football cos it, the boys playing football when I was, when I was, you know, back in the seventies. Um So that's where dinner ladies hung around and what they would. So, which means what I mean is there are high risk areas where they've got a good view of things and what they would do is if there was ever a problem, if somebody fell over or if a fight and it was all kicking off, they would blow a whistle and a teacher would come to help would come. Well, we have barer receptors in our bodies and they hang around parts of our bodies. Looking for trouble. Well, well, yeah, looking for trouble. And that's how we maintain our BP. So there we go. We have our dinner ladies and I want you to think of why do we need dinner ladies? Well, imagine when you're lying flat, it might be eight when you're lying flat and here's piglet. When you're lying flat, height, gravity doesn't do anything really to our bodies. When we're lying flat, it, it doesn't do much. Then we stand up and gravity starts to pull the blood down. And many of you will have stood up too fast before now and gone a bit dizzy for a second. And then you've righted yourself. Well, that is, your BP has come down. Yeah, your bloods come down. Your BP has come down quicker than what your body's responded to. Push it back up. And it's the dinner ladies hanging around different parts of our body that makes our body respond to this change, this postural change here and it pushes push blush, it pushes blood back up to the brain because so many things in our bodies are designed to keep the brain looked after, ok, to keep the brain looked after. So we can, you know, amputate a leg, we can amputate an arm, we can do a heart transplant. You can chop your liver in half. We can do so many things, but we don't cut our heads off and we don't do brain transplants. So because we can't live without our brain and there are so many systems in our bodies. It's just there designed to protect our brain. We keep it in a hard box. That's our skull and we have it up here where it's quite safe. It's not dangling off our elbow where we can bash it onto different things and keeping it perfused with oxygen is really what the barrier receptors are there for. And they do that because of the old system. So imagine one day, years and years ago you're out playing with your favorite dinosaur and oh, he's got you by the leg, he's got you by the leg. He's bitten your leg off and blood is leaking everywhere. Blood's leaving your body all over the place your blood volume is going down, your blood pressure's going down, your brain is becoming less perfused. This is where our dinner ladies kick in. They're hanging around in high risk areas waiting for this. Ok? We don't know that they're just waiting for this. This is their moment to shine. They're in the neck, they're in the heart, they're in the kidneys or on top of the kidneys, they're waiting for it, for them to blow their whistle. And what they do is they stimulate the autonomic nervous system or A NS. So, remember your autonomic nervous system is the thing that just happens by itself. We don't sit there and think, oh, I just must produce more adrenaline or I'm going to dilate my pupils when I want to reach for a drink of water. That's a very different system I think. Oh, I'll just pick that up and there's muscles and tendons and all different things involved. This one, it just happens. I'm just dilating my pupils without thinking about it. So what do the dinner ladies do to help? They think the the blood flow is gone. Ok? Blood flow's gone. Your blood's gone down, your blood pressure's gone down. The dinner lady kick in. So one of the things they do is they shout to the heart and they say to the heart increase that cardiac output. There's a problem going on. The blood pressure's going down. We've got to look after that brain. Let's increase our cardiac output. Let's put more fluid into the system. So how do you increase our cardiac output? Well, we either increase our stroke volume, that's the amount of blood with each contraction or we increase our heart rate. And so remember when we've worked on surgical ward in the past, what is a sign of bleeding, the BP going down and the heart rate going up? Perfect sign of bleeding because of this. So that's one rate and actually that, that coincides with our, with a with another session that we do. Uh does that quite a lot for postural tachycardia syndrome when we stand up and our BP goes down and it doesn't go back up again. Our heart ends up beating faster and that's the tachycardia bit from it that we see here. Ok. Let's go back to these dinner ladies. What do they do as what? So this is in no particular order. All right, it's just in an order here. So now what we're gonna do, I'm gonna look at the kidney. So they tickle the kidney. Now, the kidney has a fantastic system um that it kicks off with something called the renin angiotensin system. Some of you, this will be a refresher now, running on your tension system. So we have the, I'm gonna turn it into a story. OK? I'm gonna turn it into a story because that's how I remember things. So I want you to think about the kidney and the kidney produces something that does lots of things. But one of the things it produces renin. Now it only produces renin when the dinner ladies tell them to our liver produces something called angiotensinogen and it's there all the time. It's all the time and our body is just hanging around. So I think of Angiotensinogen as like one of the old fashioned Disney Princesses. Like the modern ones are really kick ass now. But the other ones are old. So Snow white. Snow White was really passive. Wasn't she first Disney film I ever saw? But she was really passive and she would just sit around. Well, you know, she'd sit there waiting for her prince to come. Do you remember? Was she the one sitting on the well waiting. She just, you know, she didn't do. I mean, obviously she cleaned up for the, I can't say dwarfs but you know, it was cleaned up for the, for the, for the dwarfs and then she made some food and she, yeah, but she didn't do a lot. Yeah. Not like the modern ones. So a bit passive and Wimpy hanging around. Renin was the Prince Charming only popped in from time to time. But when they got together, they were quite powerful and they made angiotensin one. So that's what happens. We have angiotensinogen hips produce renin because the dinner ladies have told them to and boom, they are full of potential. All of the magic can happen. But it's only when that in the presence of angiotensin converting enzyme and the potential of an ace does that potential turn into action? And that action is angiotensin two. An angiotensin two is a really powerful, I forgot to do that, but I don't do that, but it won't kick on my kidneys. And angiotensin two is a really powerful vasoconstrictor. So, follow it down and down vasoconstrictor. So what that means is it makes the, the space for our blood to circulate in uh up. Ok. It makes less space. So it increases our BP. Ok. So angiotensin two squeezes all the vessels uh increasing our BP. It also tickles, the adrenal glands and the adrenal glands produce aldosterone. And we're going to talk about Aldo steroid now. But all of this is about increasing our BP. So that aldosterone, where does it come from? Well, it comes from on top of our kidneys, from our adrenal medulla and the adrenal. So remember the dinner ladies now. So not only do they get it through the system of the renin angiotensin system, but the dinner ladies also gave them a cheeky tickle and that aldosterone, it's a hormone that helps the body to keep in salt. Now. No, you know what happens if you eat too much salt, you get really thirsty and you need to keep in more fluid. Keep in more water. Well, your body does that as well. And what that does, it increases amount of blood in the system. So this is two ways OK, of maintaining that BP to keep the head protected. So we're squeezing up the amount of space that the blood has to circulate in and we're increasing the blood volume by the aldosterone by keeping the salt in and therefore keeping more water in. And so that's where it works down here on the aldosterone all works in those kidneys, keeping the water in. And they also work on the peripheral resistance on the blood vessels. And here we go, vasoconstriction, squeeze it up. So there's just less space for that blood to be in fantastic system. Absolutely brilliant system when we were playing with dinosaurs, when we had problems with blood big, I mean, I know we weren't, but when we had problems with blood loss and this is how our bodies looked after itself. Ok? Is it had this system inside? Now, this system is now working against us. It's working against us because we're using our bodies for much longer than they were designed to be used, but we're not using them as they were designed to be used. We're putting the wrong fuel in. We're not exercising. So we're becoming, we might be smoking. So we're becoming very unfit, overweight and you know, our rates of hypertension are getting worse and worse because this system hasn't gone anywhere and it leads to lots and lots of complications. Oh, I thought I put my complications slide in. So let's look at the treatment, we're gonna look at how we manage and treat it now. So this is the nice guidance and Joe does a lot of I'm just going to touch on it. Joe does the managing hypertension session. So, uh, I'm just gonna touch on how the tablets work rather than thinking more of about it. So let's start with an Ace or an ARB. So this is for the nice guidelines for, for us. So you, that gets split into people. You've got hypertension. So you've either got type two diabetes or you haven't got type two diabetes and you're under 55 and you're not Black African or Afro Caribbean that gets you into the first group. Um and this is all to do with research of who responds best to which tablets first line. And so that's where we start people on an ace inhibitor or an ARB. So remember, ace inhibitors are the pills and the Arbs are the sartan. So how does an ace inhibitor work? Well, let's go back to our Renin angiotensin. So we've got snow white. Always hanging around dinner. Ladies are blowing their whistle. The kidneys produce Renin prince charming. Boom. They've got together to make potential. That's the angiotensin one. And then in the presence of an ace, it creates angiotensin two, which is full of action. So an ace inhibitor stops the conversion of angiotensin one to angiotensin two. OK? Reduces that happening, which means that the potential doesn't turn into action. Therefore, there's less vaso constriction and the blood vessels don't constrict quite as much and your blood vessel, your BP goes down. Ok. That's our first line. That's one of the first lines. That's the ace. That's the pris, what about the abs, the angiotensin receptor blockers? Well, we still have Prince Charming. We still have snow white. They get together, they make potential, but we haven't blocked the ace here at this point. We're just given the ab so, so the potential turns into action, angiotensin two. But the receptors in our blood vessels in our arteries are blocked. So that action can't really do its action. So it's still there, but it can't do, it, can't do what it's got to do because we've blocked in our arteries. Um The way it works receptors, the receptors where we take it in, we've blocked that, which helps to keep our BP down. So that's our first line tablets. If you are got type two diabetes or if you're under 55 and not, and, or, and not Black African or Afro Caribbean. Now, let's imagine you haven't got type two diabetes and you're either over 55 or you're Black African or Afro Caribbean. Then what we do is we start you on a calcium channel blocker. So something like dilTIAZem. So what does a calcium channel blocker do? Well, to make, to make cells contract in our heart. Ok? To make things contract. Um So again, when I move my arm up and down, like this muscles and nerves and tendons, all sorts of things get involved when our heart contracts or when our arteries expand and contract, um they have to do it by themselves. So they don't have any help with muscles and things. So that happens with um that happens with each cell contracts and it contracts because it's got calcium passing over its action potential. So it's got this calcium and, and and each cell contracts. So imagine each little cell in the heart contracting, making the overall heart contract. If we reduce the amount of calcium going into those cells, it each cell will still contract. Let me maybe like this, each cell will still contract. But instead of being a heart contraction like this, it's a softer contraction still contracts at the same rate. But it's a softer contraction. That means the heart instead of it like this, it beats like this. Ok? It's a much softer contraction. It's a easier construction that reduces how much oxygen that heart muscle leads. Ok. So it reduces what's called myocardial oxygen demand. Just take some pressure off that heart itself for needing lots of oxygen, but also for our system. Ok. Do you remember we talked about the arterials and the arteries that contract and relax, contract and relax. Well, we've softened that a bit as well and we've softened that by reducing the calcium and the channels in those cells in our arteries means they will instead of instead of contracting what they actually do is they go and they just create a bit more space. They create a bit more give in the system. They're a bit more. Oh, you imagine that it just relaxes those arteries a little bit, which means the BP goes down, which is fantastic, but not only that, it, because there's a bit more give in the system. When the heart contracts and pushes the blood out, there's a bit more give to have, which means it reduces the afterload. Remember we spoke about afterload, about, well, it was about 20 minutes ago and that's the effort the heart has to overcome how much effort the heart has to do to push the blood into the system. It's a great tablet there. Ok. Great tablet there. I'm not going into doses or side effects or anything like that. That's the one that Joe does. I just want you to see how the tablets work now. Oh, there we go. So it's so instead of the construction we go and it gives us a little bit of relaxation. And then finally the three first line we use, I'm not going into anything more complicated than that. Tonight is a Thiazide like diuretic. And what does that do? Well, it works here. It makes us pee out it, we, we out more volume, we pee out we and therefore our BP goes down because we've just got less blood volume that's going on and all that helps to reduce our BP. Now, the hypertension itself how does it cause problems? Well, imagine when that BP has gone up a bit, that BP on the inside of those arteries damages that really special lining. And your special lining is called your endothelium. And I am pondering on doing a session about endotheliums because I don't that we realize just how magical they are. And so that endothelium, lovely, lovely and smooth. And the endothelium is what is lining all of our artery walls. And you can see those here with the endothelium on our, on the on the artery as it progresses through the different um developments of blockages and then the flow becomes quite turbulent. And that turbulence within the arteries because it's got high pressure in little areas that get real narrow, really start to damage the lining of those arteries. And that forms the basis of a lot of cardiovascular disease. Now, those arteries can be anywhere in our body. So they could be the arteries in our eyes. That's why you get hypertensive retinopathy. That's where. Oh, this looks a bit weird when I PDF apologies, but you can see what I'm talking about. So, top right, let's look at our eyes. That's why we look in our eyes. For people who are hypertensive, we're looking to see there's little cotton w spots at the back, there's little blockages in the, in the tiny, little red, red. So, yes, Amanda, I will do one on the endothelium. I think I will um so hypertension, the little arteries in our eyes, then let's go to our kidneys to the kidneys that just got so many tiny little vessels inside them that become damaged. The arteries in our neck, the arteries, if I had a penis, I could get erectile dysfunction in our legs, peripheral arterial disease. So where we get those arteries, we have the potential for damage, but also the heart itself becomes thickened. It becomes, the heart muscle becomes bigger and thickened because it's got to work harder to push blood into that system. That's under high BP. And that gives us left ventricular hypertrophy. So that's why we have to do ECG SA lot on people with hypertension because we wanna see has it really made that heart have to work harder. The muscle has thickened a lot. We've got LVH and once we've got LVH with hypertension, then, you know, we really increased our chances of developing heart failure. So just a bit of high BP is no longer good. It's not good. I've only got mild, high blood, you've got high BP, let's get it down. And we know the longer that we leave it, the harder it is to bring it down. Now, lifestyle and using our bodies for a lot longer than they should be using, uh gets us into this problem. Now, if we all only live to about 25 or 30 most of us, then wouldn't have hypertension I'm not advocating, that's what we do at all. I'm advocating what we should be doing is living a healthier happier lifestyle. But I wanna see the impact I'm going to show you one of my last slides tonight, I'm going to show you the impact that lifestyle has on our BP. So for all of these tablets, all of these tablets we have here for hypertension. OK? All of these tablets, let's go back to them for them to get a license through all the trials and all the research and then to get a license, they have to show that the reduction of BP in the intervention arm is a, is more significant than the controller. And so usually it brings down the BP somewhere between 4 to 6 mgs of mercury, 4 to 6 mg. So not masses. I want you to see what lifestyle can do by being a normal body weight. You can reduce your BP anywhere between 3 to 20 mg of mercury. That's massive. Now, if you've got somebody with hypertension and they are a normal body weight, then of course, you're not going to realize those benefits. But for lots of people who are, who are overweight or living with obesity, then reducing weight is a really good way of helping to bring down that BP, eating the dash diet. That's diet and salt for hypertension. Yeah. Exactly. Rachel. Oh, wow. Look at the difference. We can get here with lifestyle. These are easy to say they're hard to do. And we're always expecting for tablets and actually most people need at least 2 to 3 tablets to get control of that BP. Cos we're blocking all of those different systemss. So if we eat a diet that's got lots of fruit and veg and really low in fat and low in saturated fat, we can reduce our BP more than a tablet. Ok, more than a tablet if we reduce our sodium right down. So reduce our salt right down. Now, this one is looking at 2.4 g a day. And on average, we eat about 5 to 6 g a day in the UK. Well, we can still reduce our BP more than a tablet, increasing your physical activity 30 minutes, five times a week. Well, that again is better than the better than the tablets. And this is the one we'll see the benefits of the quickest. So if you've got people who want to start trying, you know, as well as tablets, because remember we want to get that BP down as well. So often we need both and then as lifestyle kicks in, we might titrate the tablets or withdrawal one, we got to jiggle around with them and then alcohol consumption. So keeping all alcohol units down to less than one day, one a day for a woman or two a day for a man then that will reduce the BP by somewhere between 2 to 4. You might think, well, 2 to 4, that's not a lot. But it is, when you compare it to medication, you might get that with a medication. So we need to have people on multiple medications because we're blocking all different parts of that pathway. Remember where stopping, we're stopping the potential, turning into action or we're stopping, we're letting the action happen, but we are blocking the, the action going into the receptors or we are blocking the calcium, the calcium channel blockers, which makes that happen. Or we're making people peer out and the combination of this as well, so that my friends and colleagues is understanding hypertension or understanding BP. Now, if you don't sign up to a practice nurse, um we have just started to learn with nurses. Um our bite size elements of it. So this was led by my good friend and colleague, Joanne Hall, who I've mentioned tonight, we've done a few now. So we've done bite size learning atrial fibrillation, bite size learning hypertension. I've just done one on hyperlipide, no hypergly triglycerides. I've just done one on triglycerides. I'm doing a few more on cholesterol. So have a look out for it. But in summary, I want you when you're thinking about BP, it's what is going on inside that person. Really. Think about dinosaurs and dinner ladies. It's a system that's around for so long. And that work looked after us for a long, long time. It keeps us upright, it keeps us conscious, it keeps our brains perfused. But that system is now working against us mostly because we're not using our bodies the way we were designed to be used. We're no longer hunter gatherers. We haven't been for, you know, many thousands of years and this is all causing really significant health problems across the world. So if anybody wants to get involved with Loma nurses in any other way, remember, we have our close Facebook group so you can sign up for that. Now, you do have to sort of say yes, I'm a nurse, something like that. Cos you do get a lot of weirdos on Facebook that just wanna join a group that's got the word nurse in it. And also we have our social media on Instagram and we have, um, our evaluation. So at the end of this session, you will have the opportunity to do your evaluation, you get your certificates and all that. But you can ask me some questions now or you can if you haven't already rush towards registering for the C KD session. Oh, hang on. I wanted it. Why is that not doing? Send the feedback form. So rush towards the safe. Yes now. Oh Caroline. Great question. Being old school, there's nothing wrong with being old school place. A BP cuff on a bare arm. Um Does it make a difference. It does actually, it does, it makes a difference. So technique is really important. And so now the bare arm is really good, but only if you haven't pushed your jumper all the way up because if you push your jumper up lots and lots and lots and you're creating a tourniquet effect above the top of the arm here. So I would suggest if you can if it's, if this, if this is. Um so um if this jumper, sorry, I'm trying to read that if this jumper is tight, slip the arm out unless it's there. So yeah, um so do put the cuff on to a bare arm if possible left or right arm, well supported arm. Nice guidelines will say do one in each arm look for the one that's the highest. If the difference is really big, then worry about it. Most of us don't, I would go with the supported arm, remember back, feet flat on the floor back supported. This is not a supported chair. It wiggles back and support the arm at heart level. So left or right, whichever arm is near the table is near the table. So either one there but make sure it's supported. Uh Margaret wants to know why do we give fludrocortisone to treat major po postural er deficit. Fludac Cortisone keeps your weeing stops your wee in, just increases the volume. So the stuff when you've got hypotension is we just block everything we just like increase everything that would normally put your BP, you know, would normally stop your bleeding. So we might slow down that heart rate, we might increase that you can have a, an alpha antagonist. So instead of like reducing the bit and we would normally relax it, we make it increase even more. So that's something like midodrine and um and um food or cortisone, you just stop peeing, keeps the, the blood in. So serene wants to know what's the difference of the aces? Is there a better one? Um There are lots of, there are lots of aces out there and I would go by whatever your local prescribing guidelines say. Um, they usually have come up with what's the best one for the different people out there? I always think the ones that you could just take, you know, once a day is always better than anything. You can take twice a day in case you forget it. Ok. Well, thank you everybody for all your lovely, thank you. 00, how much do we? So j want to know how much to say that medication reduces the BP by. So, um, somewhere to get a license to get a license. Ok. To be able to have this, it's somewhere between 4 to 6 mg of mercury, some might get a little bit more. But you know that that will be the study endpoint of sharing, sharing a change and that will be a change that's there. So most of these and this is why we have to use more than one tablet because we are blocking different bits of the pathway. So it's not that we give one tablet and it's failed. It's done its first job. And then we've got to the next bit and then we've got to get to the next bit. So it really isn't about failing when we need multiple, multiple ones. So, what's my strategy for getting BP down my personal strategy? Well, I jumped straight on it. I just straight onto a knob as well as losing some weight. So I've lost some weight and I've jumped on a knob and it really is about whatever you can encourage and motivate patients to do and what are they able to do and what have they, what have they, what, what's within their potential to change if they're drinking lots of alcohol, then maybe there's a way they can reduce that. I once went for, um, I remember visiting people at home and I found a fellow's cupboard. Well, it was really odd, but I was a card, I was a cardiac nurse and I had this home visiting service for people who had heart attacks and they still gonna have a look at me. Well, I used to have a look in their cupboards and fridges and see what they were eating and somebody had masses and masses of licorice and if you and bizarrely, masses and masses of liquorice can put your BP up a bit as well. So, um, it was really finding out bits more but all of those things, reducing weight, exercising, reduce eating fruit and veg. It's no, it's not a magic thing. It's not a magic solution. You know, it's, it's hard to do but easy to say. So, caffeine is my very last question. Caffeine can short term, put your BP up a little bit, but it's not really for, we couldn't consume enough caffeine to really, to really do damage to our, to our arteries. So a lot of the studies show that you can still have 68, 10 cups of caffeine and still not have a significant effect. It will spike a little bit during, but that's ok to have a little bit there.