VOL: 103, ISSUE: 35, PAGE NO: 21
An editorial in The Lancet this month warns of a massive increase worldwide in the number of adults with hypertensi…
An editorial in The Lancet this month warns of a massive increase worldwide in the number of adults with hypertension (The Lancet, 2007). This editorial accompanies an article (Messerli et al, 2007), which examines in detail hypertension, its underlying causes and risk factors. Nurses have a major role in detecting, monitoring and preventing hypertension, which will affect the incidence of related diseases and conditions.
People in developed countries are at over 90% risk of developing hypertension at some point in their lives. It is predicted that the number of adults with the condition worldwide will increase to 1.56 billion by 2025 compared with around 972 million in 2000 (The Lancet, 2007; Messerli et al, 2007).
The editorial warns that the increasingly common combination and interaction of obesity, diabetes, hyperlipidaemia and hypertension, if left untreated leads to cardiovascular disease, stroke, renal failure, dementia and ultimately death. It says that lifestyle factors, such as physical inactivity, a salt-rich diet with processed and fatty foods, and alcohol and tobacco use are at the heart of this disease burden. It adds that the problem is also spreading to emerging economies such as India and China.
The Lancet argues that the biggest problem is compliance with treatment. The editorial states: ‘Despite very effective and cost-effective treatments, target blood pressure levels are rarely reached. Many people still believe that hypertension is a disease that can be cured, and stop or reduce medication when blood pressure levels fall.’
The editorial also points out that screening is not done systematically, and diagnosis is often made at a late stage when organ damage has occurred. It acknowledges that the optimum time to start treatment remains under discussion and outlines the emergence of the notions of ‘high normal’ blood pressure (BP) in Europe or ‘pre-hypertension’ in the US, adding that people in this category are advised to modify their lifestyle, an approach that has had ‘very limited success’.
A study published by the British Medical Journal this month compares cardiovascular risk among women with high normal BP against those with normal BP and those with baseline hypertension (Conen et al, 2007). The women were classified into four BP categories: optimal BP, normal BP, high normal BP and established hypertension. The study explores the classification of pre-hypertension in detail and makes recommendations (see www.bmj.com).
NICE partially updated its clinical guideline on the management of hypertension in adults last year to take account of new evidence on drug treatment (NICE, 2006). The British Hypertension Society collaborated with NICE to review these guidelines (BHS, 2006). NICE outlined the key priorities as follows: measuring BP, lifestyle interventions, cardiovascular risk, pharmacological interventions and continuing treatment. For advice on lifestyle interventions to reduce BP see box, p22. The guidance includes a detailed care pathway for hypertension and an algorithm for choosing drugs for newly diagnosed patients.
The recommendations apply to primary care. NICE is currently developing guidance on managing hypertension in pregnancy (see www.nice.org.uk).
The guidance outlines recommendations for taking BP. It recommends that professionals undertaking the procedure need initial training and should have their performance reviewed periodically. Devices for measuring BP must be properly validated, maintained and regularly recalibrated according to manufacturers’ instructions.
When taking measurements, NICE recommends the following:
- Where possible, standardise the environment. This should be relaxed, quiet and warm, with the patient seated with their arm outstretched and supported;
- If the first measurement exceeds 140/90mmHg, take a second reading at the end of the consultation if possible;
- Measure BP on both of the patient’s arms and use the arm with the higher value as the reference arm for future measurements;
- If the patient has symptoms of postural hypotension (falls or postural dizziness), take a standing BP measurement;
- To identify hypertension (BP persistently above 140/90mmHg), ask the patient to return for at least two appointments; check BP twice on each occasion;
- Take measurements at monthly intervals, but patients with severe hypertension should be re-evaluated earlier;
- The routine use of automated ambulatory BP monitoring or home monitoring devices in primary care is not recommended.
The NICE guidance recommends immediate referral if the patient has signs of:
- Accelerated (malignant) hypertension (BP over 180/110mmHg with signs of papilloedema and/or retinal haemorrhage);
- Suspected phaeochromocytoma (signs include labile or postural hypotension, pallor, headache, palpitations and diaphoresis).
Referral should be considered if:
- There are unusual signs and symptoms;
- The patient has signs or symptoms suggesting a secondary cause;
- The patient’s management depends critically on the accurate estimation of BP;
- The patient has symptoms of postural hypotension, or a fall in systolic BP when standing of 20mmHg or more.
NICE advises that if raised BP persists and the patient does not have established cardiovascular disease, practitioners should discuss the need to assess cardiovascular risk. The CV risk assessment should be used to discuss prognosis and options for managing raised BP and other modifiable risk factors. Practitioners should consider specialist referral. The tests to assess risk are:l Urine test for protein (using test strip);
- Plasma glucose, electrolytes, creatinine, serum total cholesterol and HDL cholesterol;
- 12-lead ECG.
The NICE guidance says continuing treatment is a priority. It stresses that drug treatment to lower BP is worthwhile even if BP does not fall to 140/90mmHg or below on treatment with several drugs or if the use of more drugs is inappropriate or declined.
It explains that some patients want to make lifestyle changes and reduce or stop using antihypertensive drugs. If they are at low cardiovascular risk and their BP is well controlled, they may be offered a trial reduction or withdrawal of therapy. They should be advised on lifestyle modifications and have regular reviews. Healthcare staff should consider offering details of organisations where patients can share views and information.
In addition, the guidance recommends offering patients an annual review to: monitor BP, provide support, and discuss lifestyle, symptoms and drugs.
The Lancet editorial concludes: ‘Physicians need to convey the message that hypertension is the first, and easily measurable, irreversible sign that many organs in the body are under attack. Perhaps this message will also make people think more carefully about the consequences of an unhealthy lifestyle and help to give preventive measures a real chance of success.’
Nurses clearly have a key role to play in the detection, management, monitoring and prevention of hypertension.
Lifestyle Interventions to reduce BP
Healthcare professionals should:
- Ask patients about diet and exercise, and offer guidance and written or audiovisual information;
- Ask about alcohol consumption and encourage patients to cut down if they drink excessively;
- Discourage excessive consumption of coffee and other caffeine-rich products;
- Encourage patients to reduce their salt intake or use a substitute;
- Offer smokers advice and help to stop smoking;
- Tell patients about local initiatives that provide support and promote lifestyle change.
- Do not offer calcium, magnesium or potassium supplements to lower BP;
- Relaxation therapies can reduce BP and patients may wish to try them. However, it is not recommended that primary care teams should provide them routinely.
Source: NICE (2006)