My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I do a quick review of a mind map that I have created based on the NICE Guideline: Hypertension in adults: diagnosis and management (NG136 guideline), updated on 18th March 2022. I have summarised the guidance from a Primary Care perspective, and I have created an e-book on this too. You are welcome to download both the mind map and both versions of the e-book here:

·      Mind map: https://1drv.ms/b/s!AiVFJ_Uoigq0l2boZjh4biBJ5WGv?e=7YqdBn

·      Condensed and easy to print e-book: https://1drv.ms/b/s!AiVFJ_Uoigq0l2cepU4PPQoY_0NQ?e=xymSS3

·      Digital and fully “clickable” e-book: https://1drv.ms/b/s!AiVFJ_Uoigq0l2iI6yHrZAU0VsWg?e=VtaO9N

By way of disclaimer, nothing that I say either in the video or the downloads is medical advice; this video 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 

NICE Guideline NG136 can be found here:

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

Other links relevant to this episode:

·     guideline on hypertension in pregnancy

·     NICE's guideline on cardiovascular disease

·     patient decision aid on treatment options for hypertension

·     NICE's guideline on multimorbidity

·     NICE guidelines on chronic kidney disease

·     type 1 diabetes 

·     MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, recommendations on how to use for breastfeeding and the related clarification on breastfeeding

·      drug therapy for secondary prevention in the NICE guideline on acute coronary syndromes

·      treatment after stabilisation in the NICE guideline on acute heart failure

·      treating heart failure with reduced ejection fraction in the NICE guideline on chronic heart failure

·      drugs for secondary prevention of cardiovascular disease in the NICE guideline on stable angina

·      blood pressure management in the NICE guideline on type 1 diabetes in adults.

·     NICE's guideline on chronic heart failure

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Script

Hello everyone and welcome. My name is Fernando, a GP in the United Kingdom.

Today, we'll be doing a quick revision on hypertension and we will do it by reviewing a mind map that I have made based on the NICE Guideline on hypertension. Therefore, this episode will be fairly short but make sure that you stay for its entirety because, at the end, I am going to tell you how you can download the mind map and I will also tell you about a mini e-book that I have created that summarises the guidance, as always, from a Primary Care perspective.

Please note that this is my interpretation of the guidelines, not medical advice. Always use your clinical judgement when treating your patients.

There is also a YouTube version which you can find in the episode description.

So, with that said, let's dive in! I hope that you enjoy this episode.

So let me introduce the mind map, and here it is. We are going to quickly navigate through it.

So we’re going to start in the centre of the mind map where it tells us about the guideline NG136. And here we see that it applies to people aged 18 and over, including those with type two diabetes. It also tells us that the updated guideline in March 2022, gives us new targets and new advice on drug treatment for cardiovascular disease. It also reminds us that when measuring the blood pressure we need to consider pulse irregularity when using automated devices, and also we should consider postural hypotension as well as the need to measure the blood pressure in both arms and to repeat the measurement if the difference is greater than 15 mmHg. 

When it comes to diagnosis if the clinic blood pressure is over 140/90 then we will need to arrange ambulatory blood pressure monitoring or alternatively home Blood pressure monitoring and if the average is above 135/85, then we will confirm the diagnosis.

In terms of lifestyle interventions, we will recommend a healthy diet, regular exercise, reduced alcohol, avoid excessive caffeine, as well as low dietary sodium and smoking cessation.

With monitoring we will remember that we need to use the clinic Blood pressure for monitoring purposes although in specific situations ambulatory home blood pressure monitoring may be used and we will base the blood pressure targets on age and comorbidities as well as remembering the need for an annual review of these patients.

When it comes to investigations we will assess for secondary causes, we will estimate the cardiovascular risk and we will assess for target organ damage. This assessment will comprise of at least a urine sample for albumin creatinine ratio, a number of blood tests, fundoscopy and an ECG

For urgent, same day referral we will consider patients with a clinic blood pressure of 180/120 or more with one of the following, either life-threatening symptoms, retinal, haemorrhage, or papilloedema as well as if we suspect pheochromocytoma (pause)

We are now going to focus on the antihypertensive drug treatment and we need to remember that we need to review the treatment when type two diabetes is diagnosed, as well as considering individual factors and medication safety when treating patients and this treatment will follow a stepwise approach. Step one is when we give one drug and this can be an ace inhibitor or ARB if the patient has diabetes, regardless of age and ethnicity. Or if the patient is less than 55 and not of Afro Caribbean family origin or, alternatively we can give a calcium channel blocker is the patient is of Afro-Caribbean family origin and has no diabetes or if the patient is over 55 and has no diabetes

Step two is one we give two drugs and it could be anyone of these combinations, an ace inhibitor or ARB and a calcium channel blocker; an ace inhibitor or arb and a thiazide like diuretic, or a calcium channel blocker, and a thiazide diuretic. Step three is when we give three drugs, and this would be an ace inhibitor, a calcium channel blocker, and a thiazide like diuretic. And step 4 is when we give four drugs. If this happens, we will say that the patient has resistant hypertension and we will consider specialist referral. But if we decide to treat ourselves, we will give triple therapy with an ace inhibitor or arb, a calcium channel blocker, a thiazide like diuretic, and we will check the potassium if the potassium is less than 4.5 we will give. Spironolactone and if potassium is more than 4.5 we will give an alpha blocker or a beta blocker.

And finally, we have a section giving definitions and terms used such as accelerated hypertension, which is when the blood pressure is over 180/120 with retinal involvement, masked hypertension, as well as the three stages of hypertension. 

Right, so this is it, this is the end of the mind map tour. As promised, let me tell you about the downloads. Just click in the episode description and there you will be find a link to download the mind map for free, without the need to provide your email address or any other information. You will also find two other links to download the two versions of the mini e-book that I have created. The first one is a printer friendly e-book, for those of you that would want to have a physical copy in your hands. It is more condensed and has therefore fewer pages. It is in black and white text so you will not be wasting ink unnecessarily on pictures or background colours. The second version is a fully digital “clickable” e-book. It has a few more pages as well as photographs and links to further information. Furthermore, under each section of the mind map there is a button that says “more” and if you click on it, you will be taken directly to the section of the summary that refers to it, followed by a button to take you back to the mind map.

Over the next few episodes, I will be producing more material similar to this so make sure to stay tuned.

But please, let me reiterate again that this is only a summary and my interpretation of the guideline.

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