This article provides an update on the management of hypertension mostly based on the recent clinical guidelines issued by the National Institute of Clinical Excellence (NICE). Key points being highlighted are the importance of assessment of the cardiovascular disease (CVD) risk and the fact that beta-blockers (BBs) are no longer considered as appropriate first-line agents (in the absence of other indications for beta-blockade). The importance of fully involving patients in treatment decisions on an on-going basis is also emphasised.peer-reviewe

Gauci, Marise

OAR@UM

6           Journal of the Malta College of Pharmacy Practice      Issue 13 Summer 2007An update on the management of hypertensionThis article provides an update on the management of hypertension mostly based on the recent clinical guidelines issued by the National Institute of Clinical Excellence (NICE).1 Key points being highlighted are the importance of assessment of the cardiovascular disease (CVD) risk and the fact that beta-blockers (BBs) are no longer considered as appropriate first-line agents (in the absence of other indications for beta-blockade). The importance of fully involving patients in treatment decisions on an on-going basis is also emphasised.Marise	Gauci	B Pharm (Hons), MScIntroductionHypertension is a major modifiable risk factor for cardiovascular disease. Any definition of hypertension is arbitrary.2 Consensus from published guidelines is that hypertension is defined as a persistently raised blood pressure (BP) of above 10/90mmHg. Key	words: hypertension, cardiovascular risk, thiazides, ACE inhibitors, calcium channel blockers, beta-blockersClinical Pharmacist, Zammit Clapp Hospital, St Julians, Malta.Email: marise.gauci@um.edu.mtCardiovascular	riskThe co-existence of other modifiable risk factors (e.g. elevated cholesterol, smoking, diabetes) and non-modifiable risk factors (e.g. old age, family history of CVD, male gender) has a bearing on the management strategy for the patient. Health professionals should use a validated risk assessment tool, such as that produced by the Joint British Societies (JBS), as an aid for deciding when treatment is necessary. The latest version of the JBS chart is available in the British National Formulary (BNF).3Treating hypertension should not be viewed in isolation and other interventions, such as statins and aspirin, should be considered on the basis of a person’s history of CVD or an assessment of their CVD risk. The NICE appraisal of statins recommends their use (i) for adults with clinical evidence of CVD (i.e. secondary prevention) and, (ii) as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD. Aspirin 7mg daily is recommended for all people with established CVD. Thresholds for using low-dose aspirin to prevent cardiovascular events in people without existing CVD are difficult to define. The British Hypertension Society recommends aspirin 7mg daily for primary prevention in patients with hypertension aged >0 years with BP controlled to <10/90mmHg and either target organ damage, diabetes mellitus, or 10-year CVD risk of >20%.6Treatment	thresholds	and	targetsThresholds for treatment of raised BP consider overall CVD risk, in addition to the absolute BP level. Drug therapy should be offered to patients with persistently high BP of 160/100mmHg or more, and patients at raised CVD risk (10-year risk of CVD of 20% or more, or existing CVD or target organ damage) with persistent BP of >10/90mmHg.1 Lower thresholds are recommended for patients with diabetes (Table 1).7,8The evidence base on optimal target BP for both systolic BP and diastolic BP remains incomplete. NICE guidance recommends a BP treatment target of 10/90mmHg for non-diabetic patients.1 Lower BP targets are recommended for those with diabetes (Table 1).7,8 Patients who are at the highest baseline risk of CVD have the most to gain from lowering of BP.9 Although it may not be possible to achieve target in all patients, any lowering of BP is beneficial. The aim is to achieve the Issue 13  Summer 2007     Journal of the Malta College of Pharmacy Practice         7largest reduction possible toward the target, considering tolerability and concordance for each individual patient.10Lifestyle	interventionsA healthier lifestyle, by lowering BP and CVD risk, may reduce, delay or remove the need for long-term therapy in some patients.9 All guidelines recommend that lifestyle interventions should form an integral part of the management of high BP either alone or in addition to drug therapy.  Key interventions and the associated	Thresholds	for	initiating	treatment	(either	systolic	or	diastolic	within	ranges)Patients	without	diabetes Treat if persistent BP>10-19/90mmHg and 10-year CVD risk ≥ 20% or existing CVD or target organ damage    Treat all patients with persistent BP ≥ 160/100mmHg   Patients	with Treat if BP ≥ 10-19/80-99mmHg and 10-year CVD risktype	2	diabetes >20% or concomitant microalbuminuria or proteinuria       Treat all patients with BP ≥ 160/100mmHg      Patients	with	 Treat if BP ≥ 13/8mmHg type	1	diabetes  Treat if BP ≥ 130/80mmHg and abnormal albumin excretion rate or two or more features of the metabolic syndrome      Targets	for	treatment	(both	systolic	and	diastolic	BP	to	be	achieved)Patients	without	diabetes ≤ 10/90mmHg      Patients	with < 10/80mmHg or ≤ 13/7mmHg if microalbuminuria type	2	diabetes	 or proteinuria present      Patients	with	 < 13/8mmHg or < 130/80mmHg if nephropathytype	1	diabetesTable	1:	Thresholds	and	targets	in	the	NICE	hypertension	and	diabetes	guidelines1,7,8Systolic	and	Diastolic	BP	reductions	in	trialsAdopt a healthy low calorie diet. -6mmHgTake aerobic exercise for 30-60 minutes, three to five times each week. 2-3mmHgLimit alcohol consumption to no more than 21 units/week (men) and 1 units/week (women), with  intake spread out over the week. 3-mmHgReduce dietary sodium intake to less than 2.g (100mmol) per day. This is equivalent to 6g of salt. 2-3mmHgAvoid excessive consumption of coffee (≥  cups) and other caffeine-rich products that can raise BP.Stop smoking. This has benefits on CVD, if not directly on high blood pressure.Table	2:	Key	lifestyle	advice	for	patients	and	associated	BP	reductions1,9changes in BP that have resulted from adherence in trials are given in Table 2.1,9 Lifestyle modifications can be difficult to achieve and patients need regular follow-up and support to maintain changes in the long-term.Drug	treatment	strategyA range of effective antihypertensive drugs from different pharmacological classes can be considered for the treatment of hypertension. In June 2006, NICE updated its guidance on the drug treatment of hypertension. Recommendations were made following a systematic review of randomised controlled trial data which found no difference between the classes of drugs with regard to the risk of death or myocardial infarction. However, BBs were considered less effective than comparable drugs in reducing the risk of stroke.11 Thiazide diuretics and calcium channel blockers (CCBs) were considered the most likely drugs to confer benefits in cardiovascular outcomes, except possibly in younger patients. BBs are no longer considered by NICE as an appropriate choice for initial treatment of hypertension unless there are compelling reasons to use them (e.g. coronary artery disease).1Figure 1 depicts an algorithm for the drug treatment of patients with newly diagnosed hypertension.1 Low-dose thiazide diuretics or CCBs are considered by NICE as equal first-line choices for patients over  years of age. As the recommendations do not distinguish between the two options, prescribers may decide on the basis of the patient’s risk of adverse effects, patient preference and costs. Angiotensin-converting enzyme inhibitors (ACEIs) are recommended for younger patients. Where an ACEI is indicated but not tolerated (e.g. because of cough), an angiotensin-II receptor blocker (AIIRB) is appropriate. BBs are indicated as initial treatment only in particular situations namely in patients with coronary artery disease, women of child-bearing potential, patients with evidence of increased sympathetic drive, or patients with an intolerance or contraindication to ACEIs and AIIRBs. NICE recommendations for patients already receiving BBs are summarised in Panel 1.1Many patients will require more than one drug to achieve BP control. Where the first-line drug does not adequately control BP, additional drugs should be added in a sequential manner according to the algorithm. The drug combinations recommended are not supported by large clinical outcome studies, but is based on sound pathophysiological grounds.10  Treatment of patients with hypertension and diabetes was not considered in the development of the updated NICE guideline, and although not explicitly stated, the recommendations do not apply to patients 8           Journal of the Malta College of Pharmacy Practice      Issue 13 Summer 2007 < years  ≥  years   or black+ (any age)Step 1 A‡  C or D      Step 2  A+C or A+D     Step 3  A+C+D  Step   A+C+D     +     further diuretic therapy, or α-blocker, or β-blocker  Consider specialist advice      +of African or Caribbean descent, and not mixed race, Asian or Chinese   ‡ β-blockers are an alternative to A in patients younger than  years if A is not tolerated or is contraindicated (including women of childbearing potential)       A=ACEI  e.g. enalapril -20mg once dly  lisinopril 10-20mg once dly        perindopril -8mg once dly        or AIIRB e.g. candesartan 8-16mg once dly  (if intolerant)  eprosartan 600-800mg once dly       losartan 0-100mg once dly        telmisartan 0-80mg once dly        valsartan 80-160mg once dly  C=calcium channel blocker e.g. amlodipine -10mg once dly    D=thiazide-type diuretic e.g. bendroflumethiazide 2.mg once dly indapamide 1.mg once dly     β-blocker e.g. atenolol 0mg once dlyα-blocker e.g. doxazosin -8mg once dly, terazosin 2-10mg once dly    usual maintenance doses; lower dose may be required in elderly and in renal or liver impairmentFigure	1:	NICE	algorithm	for	the	drug	treatment		 of	patients	with	newly	diagnosed	hypertension1,3	 	If BP is controlled, consider long-term management at a routine review. There is no absolute need to replace the β-blocker with an alternative agent.         If BP is not controlled, revise treatment according to the treatment algorithm (see Figure 1).         When a β-blocker is withdrawn, step the dose down gradually.         Do not withdraw the β-blocker if there is a compelling indication for being treated with one, such as symptomatic angina or a previous myocardial infarction.Panel	1:		NICE	recommendations	for	patients	already	receiving	 a	regimen	that	includes	a	β-blocker1	with diabetes. In these patients, a thiazide diuretic or an ACEI is an appropriate first-line choice, with a combination of these two drugs being used should BP control not be achieved. An ACEI should be used first-line where there is evidence of nephropathy.10Patient	perspective	Decision on treatment goals should be reached in full discussion with patients, since the trial evidence does not support one target BP. The aim should be to achieve as great a reduction in BP toward the target as is acceptable to the patient.Patients have reservations about taking their antihypertensive medication (e.g. preference for non-drug measures to lower BP, anxiety about potential side effects of treatment, doubt whether treatment continues to be necessary).12 NICE guidelines recommend that all patients should have an annual review of care to monitor BP, provide support, and discuss lifestyle, symptoms and medication.1It is estimated that 0–80% of patients with hypertension do not take all of their prescribed medication.9 Reasons include the asymptomatic nature of hypertension, the need for long-term treatment, complex drug regimens, poor instructions, and disagreement about the need for treatment.9 Non-adherence to medication should be considered when evaluating a patient with poor BP control.13 Understanding a patient’s reasons for not taking their medication is important for implementing effective strategies to improve the management of their hypertension.9ConclusionManaging hypertension is a challenge for both health professional and the patient. Updated guidelines should be utilised so as to provide optimal treatment and improve patient outcomes. Full involvement of patients in treatment decisions and regular review are essential for effective management.10           Journal of the Malta College of Pharmacy Practice      Issue 13 Summer 2007References1. National Institute for Health and Clinical Excellence. Hypertension: management of hypertension in adults in primary care (partial update of NICE clinical guideline 18). Clinical Guideline 3. June 2006. Available from: http://www.nice.org.uk 2. Guidelines Subcommittee. 1999 World Health Organization - International Society of Hypertension guidelines for the m anagement of hypertension. J Hypertension 1999; 17:11–83.3. BMJ Publishing Group Ltd and Royal Pharmaceutical Society of Great Britain. British National Formulary. Edition 3 UK: Pharmaceutical Press; 2007.. National Institute for Health and Clinical Excellence. Statins for the prevention of cardiovascular events. Technology Appraisal 9. January 2006. Available from: http://www.nice.org.uk . British Cardiac Society, British Hypertension Society, Diabetes UK, HEART UK, Primary Care Cardiovascular Society, The Stroke Association. JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 200;  91(Suppl V): v1–v2.6. Williams B, Poulter NR, Brown MJ, et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 200—BHS IV. J Hum Hypertens 200; 18:139–8.7. National Institute for Clinical Excellence. Management of type 2 diabetes: management of blood pressure and blood lipids. Inherited Clinical Guideline H. October 2002. Available from: http://www.nice.org.uk 8. National Institute for Clinical Excellence. Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults. Clinical Guideline 1. July 200. Available from: http://www.nice.org.uk 9. North of England Hypertension Guideline Development Group. Essential hypertension: managing adult patients in primary care. Evidence-based Clinical Practice Guideline; August 200. Available from: http://www.nice.org.uk 10. National Prescribing Centre. The management of hypertension in primary care: updated guidance from NICE – Part 2. MeReC Bulletin 2006; Issue no 1:3-13. Available from: http://www.npc.co.uk11. National Collaborating Centre for Chronic Conditions. Hypertension: management of hypertension in adults in primary care: partial update. June 2006. Available from: http://www.nice.org.uk12. Benson J, Britten N. Keep taking the tablets: balancing the pros and cons when deciding to take blood pressure treatment. BMJ 2003; 326:131–.13. Krousel-Wood M, Hyre A, Muntner P, et al. Methods to improve medication adherence in patients with hypertension: current status and future directions. Curr Opin Cardiol 200; 20:296–300.•	 Hypertension is a major modifiable risk factor for cardiovascular disease.•	 The co-existence of other modifiable risk factors has a bearing on the management strategy for the patient (CVD risk assessment).•	 Drug therapy should be offered to patients with persistently high BP of 160/100mmHg or more, and patients at raised CVD risk (10-year risk of CVD of 20% or more, or existing CVD or target organ damage) with persistent BP of >10/90mmHg.•	 BBs are no longer considered by NICE as an appropriate choice for initial treatment of hypertension unless there are compelling reasons to use them (e.g. coronary artery disease).•	 Patients should be involved in treatment decisions on an on-going basis.Practice	Points

An update on the management of hypertension

https://www.um.edu.mt/library/oar//bitstream/123456789/13786/1/2007-13-1.pdf

An update on the management of hypertension

Abstract

Similar works

Full text

Available Versions

OAR@UM