10 top tips - Treating BP to target
GP Dr Terry McCormack’s pointers on how to get as many hypertensive patients as possible down to target
GP Dr Terry McCormack's pointers on how to get as many hypertensive patients as possible down to target
1 Make sure you have a correct rested blood pressure measurement. If the blood pressure is raised initially this measurement should be ignored. The patient should remain sitting for 10 minutes with the cuff on and then have two measurements, one minute apart, to give an average reading. This is ideally performed by the practice nurse or health care assistant.
2 Consider lending the patient an automated sphygmomanometer to take home. Home measurement might rule out white coat hypertension. You should give the patient a printed sheet instructing them to measure their BP eight to 12 times over 48 hours. The home measurement needs to be corrected to equate to an office measurement by adding 10/5 to the average measurement. Ambulatory blood pressure monitoring is usually impractical for dealing with the large numbers of patients in general practice.
3 Automated sphygmomanometers are inaccurate in atrial fibrillation. All the manufacturers of British Hypertension Society validated automatic sphygmomanometers recommend that they are not used in patients with dysrhythmias. Mercury sphygmomanometers are legal and are not being phased out. Aneroid sphygmos are inaccurate unless very regularly calibrated. Tell the patient to remind all clinical staff how to measure their BP in consideration of their individual circumstances.
4 Use standing blood pressure only in patients with postural hypotension. The very elderly and diabetic patients are at high risk of postural hypotension – a drop of 20mmHg on standing BP. Once this is established, only use standing blood pressure in future and enter that measurement into the computer as if it is the sitting measurement. Again, tell the patient to remind anyone measuring their BP to consider their individual circumstances.
5 Warn the patient that you will need to use at least two if not three medications to control their blood pressure. All the trials have shown the majority of patients need at least two medications to adequately control blood pressure. The NICE/BHS guideline indicates the logical way to combine medications.
6 ß- blockers still have a place in hypertension. The NICE/BHS guideline recommends that
ß-blockers are relegated to a fourth-line treatment. However, this is only in uncomplicated hypertension and patients with ischaemic heart disease (IHD) will still need
ß-blockers. Furthermore the guidelines recommend that a well-controlled patient taking a ß-blocker should not have their therapy changed.
7 Make sure you're applying the correct QOF target. QOF targets vary for different disease groups. The chronic kidney disease target is 140/85, diabetes is 145/85 and for stroke, IHD and uncomplicated hypertension it is 150/90. These targets may alter in the future.
8 Use a resistance checklist for people who fail to reach target. Your checklist should include:
• ensuring the measurement is correct
• a concordance/compliance check
• establishing that the correct combinations are being used at their maximum tolerated doses
• check that secondary hypertension has been ruled out.
It is particularly important that you establish that the patient understands their need for treatment, is in agreement that they should take the medication and is not hiding their non-compliance because of feeling guilty that they are letting you down.
9 Consider using spiranolactone if the patient has resistant hypertension and a low potassium. Primary aldosteronism is the commonest form of secondary hypertension and responds well to spironolactone. This drug should be used in low doses, 12.5 or 25mg. It is licensed for use in primary aldosteronism but not hypertension and careful monitoring of the patient is required. Other common secondary causes are obesity and sleep apnoea. Bilateral renal artery stenosis and phaeochromocytomas are rare causes.
10 Have written practice rules on how to use exception codes ethically. In the event of a QOF inspection you will be better able to justify your use of exceptions codes if you can show you have rules and follow them. The rules are up to you but would ideally include discussing the decision with the patient and making a written statement in the notes to justify your joint decision. They might also state the minimum number of drug classes you would try in patients before giving up.
Dr Terry McCormack is a GP in Whitby and chair of the Primary Care Cardiovascular Society – he is author of Blood Pressure Management in Primary Care
Competing interests Dr McCormack has received grants and honoraria from Boehringer Ingleheim, Daiichi-Sankyo, Novartis, Recordati, Sanofi Aventis and Servier in regards to hypertension managementMake sure you are using a mercury spygmo on a patient with dysrhythmia Make sure you are using a mercury spygmo on a patient with dysrhythmia