My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at a random case of hypertension to see how the NICE guidelines could apply to it. By way of disclaimer, I am not giving medical advice; this podcast is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement. 

There is a YouTube version of this and other videos that you can access here: 

·      The NICE GP YouTube Channel: NICE GP - YouTube 

The NICE hypertension flowcharts can be found here: 

·      Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

·      Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn

The full NICE Guideline NG136 can be found here:

·      Website: https://www.nice.org.uk/guidance/NG136

·      Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus

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Transcript

Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.  

In today’s episode I look at a random case of hypertension to see how the NICE guidelines could apply to it, focusing on the pharmacological treatment. By way of disclaimer, I am not giving medical advice; this is for health care professionals and it is only my interpretation of the guidelines so you must use your own clinical judgement.

Remember that there is also a YouTube version of these episodes so have a look in the episode description. 

Right, so let’s generate our random patient.

OK, so we have 85-year-old Caucasian woman presenting in clinic with a BP of 168/83. She is not on treatment and therefore we will assume that she has not been diagnosed with hypertension before. 

So, let’s have a look at the NICE guidelines. 

Firstly, NICE says that if the clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, we need to offer ABPM to confirm the diagnosis and if ABPM is unsuitable or the person is unable to tolerate it, then we will offer HBPM instead.

So, we assess this patient and, because of her vascular dementia, we find that she will not be able to tolerate ABPM so we arrange HBPM instead.  

NICE also say that while waiting for the confirmation we should carry out

1-investigations for target organ damage and

2-a formal assessment of cardiovascular risk 

And we can see that she has been investigated previously and we know that she has several comorbidities such as:

1- Vascular dementia

2- Heart failure, which we will say here that it is HF with reduced ejection fraction and

3- Microalbuminuria, which, for the purpose of this case we will say that there is no evidence of structural renal tract issues so we are going to presume that the working diagnosis is hypertensive nephropathy

And all of these three comorbidities indicate end organ damage. Also, there is no need to assess formally her cardiovascular risk because she already has established CVD. 

Right, so we organise the HBPM and let’s say that we have a HBPM result of also 168/83. Isolated systolic hypertension according to NICE is when the systolic BP is >160 but the diastolic BP is not raised. So, in this patient’s case, we will say that she has ISH.

Does she need treatment? Well, NICE says that we should offer people with isolated systolic hypertension the same treatment as people with both raised systolic and diastolic blood pressure. Stage 2 hypertension is when the BP is 160/100 or higher but less than 180/120. This effectively means that this patient needs to be treated exactly the same as if she had stage 2 hypertension.

And NICE says that we need to offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension but of course, using our clinical judgement for anyone with frailty or multimorbidity. 

We assess this patient and consider that despite of, or even because of her multimorbidities, she needs to be started on treatment to lower her BP. According to NICE, the target clinic BP for those aged 80 and over, is below 150/90 mmHg or below 145/85 if using ambulatory or home BP readings, again using our clinical judgement for people with frailty or multimorbidity.

 Right, so we have decided to start medication. How do we treat her?

 If we look at the visual aid resource from NICE, it says that for people without diabetes and over the age of 55, step 1 treatment should be with a calcium channel blocker, right? Well, yes and no, because it will depend on the case. There is always the small print to worry about, and we find it here:

 NICE says that for people with chronic kidney disease, we should follow the NICE’s guideline on chronic kidney disease and for people with heart failure, we should follow the NICE’s guideline on chronic heart failure.

 To be fair, although we know that she has microalbuminuria, presumed to be due to hypertensive nephropathy, the history does not really say that this patient has CKD. But it does say that she has heart failure with reduced ejection fraction. The chronic heart failure NICE guidelines say that in order to reduce morbidity and mortality, we should prescribe both an ACE inhibitor and a beta-blocker escalating to adding Spironolactone and more if necessary. One drug should be introduced at a time, adding the second drug once the person is stable on the first drug and we will use our clinical judgement as to which drug we will start first.

 So, my interpretation in this case is that I would start an ACEI, for example lisinopril 2.5 mg daily, for both her heart failure and hypertension, titrating it up to the target or maximal tolerated dose and, as soon as possible after that, I would also start a betablocker licensed for the treatment of HF, for example bisoprolol 1.25mg OD, also titrating it up also to the target or maximal tolerated dose. And I would do that for her CHF only. However, although betablockers do not appear as an option in the management of hypertension but we do know that they can also have a BP lowering effect so it is likely to be beneficial for her HTA too.

 Remember that she already has vascular dementia so it is likely that she has a degree of widespread atherosclerosis and we should start the ACEI cautiously and watching her renal function closely in case that she has already developed renal artery stenosis.

 And of course, remember that, because she is over 80, we should regularly measure both her sitting and standing BP. And, if there is a significant postural drop or symptoms of postural hypotension, we will base the blood pressure target on the standing blood pressure value. 

 But remember that this is only my interpretation so it is not necessarily the best option. 

 We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye