Management Of Hypertension In Adults Research Articles

Chronic kidney disease in the primary care setting

Practice NursingVol. 22, No. 4 Clinical Renal DiseaseChronic kidney disease in the primary care settingFiona MurphyFiona MurphySearch for more papers by this authorFiona MurphyPublished Online:29 Sep 2013https://doi.org/10.12968/pnur.2011.22.4.184AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleReferencesAdil M, Aslam S (2009) Prevention of progression of chronic kidney disease and its cardiovascular complications. In: Wilcox CS, Tisher CC, eds. (2009) Handbook of Nephrology and Hypertension. 6th edn. Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia: PA Google ScholarDepartment of Health (2005) National Service Framework for Renal Services. Part Two: Chronic kidney disease, acute renal failure and end of life Care. http://tiny.cc/ztd61 (accessed 14 March 2011) Google ScholarLevey AS, Coresh J, Greene Tet al. (2006) Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med 145(4): 247–54 Crossref, Google ScholarMacGregor MS, Taal M W (2011) Detection, Monitoring and Care of Patients with Chronic Kidney Disease. Final Draft. UK Renal Association Clinical Practice Guidelines. 5th edn. http://tiny.cc/y9vkv (accessed 14 March 2011) Google ScholarMartin S. (2011) World Kidney Day 2011: Protect Your Kidneys, Save Your Heart. Am J Kid Dis 57(3): 371–4 Crossref, Google ScholarMobley A (2009) Slowing the progression of chronic kidney disease. The Journal for Nurs Practitioners 5(3): 188–94 Crossref, Google ScholarMurphy F, Bennett L, Jenkins K. (2010) Managing anaemia of chronic kidney disease. Br J Nurs 19(20): 1281–6 Link, Google ScholarMurphy F, Jenkins K, Chamney Met al. (2008a) Patient Management in CKD Stages 1 to 3. J Ren Care 34(3): 127–35 Crossref, Google ScholarMurphy F, Jenkins K, McCann Met al. (2008b) Patient Management in CKD Stages 4 to 5. J Ren Care 34(4): 191–8 Crossref, Google ScholarNational Collaborating Centre for Chronic Conditions (2008) Chronic Kidney Disease. Early Identification and Management in Adults in Primary and Secondary Care. Clinical guideline 73. http://tiny.cc/69tvq (accessed 15 March 2011) Google ScholarNHS Information Centre (2009) QOF prevalence data. http://tiny.cc/l351k (accessed 15 March 2011) Google ScholarNational Institute for Health and Clinical Excellence (2006) Hypertension: Management of Hypertension in Adults in Primary Care. Clinical guideline 34. http://www.nice.org.uk/CG034 (accessed 16 March 2011) Google ScholarNational Kidney Federation Kidney Dialysis Outcome Quality Initiative (2002) Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. http://tiny.cc/p0in0 (accessed 16 March 2011) Google ScholarNational Kidney Federation Kidney Dialysis Outcome Quality Initiative (2007) Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes for Chronic Kidney Disease. Am J Kidney Dis 49(2; Suppl 2): S12–154 Crossref, Google ScholarScottish Intercollegiate Guidelines Network (SIGN) (2008) Diagnosis and Management of Chronic Kidney Disease. A National Clinical Guideline. http://tiny.cc/b0pcd (accessed 17 March 2011) Google ScholarThomas N (2007) Recent developments in the care and management of chronic kidney disease. Prim Health Care 17(6): 41–5 Crossref, Google ScholarThomas N (2011) The management of chronic kidney disease. Nurs Prescribing 9(2): 76–81 Link, Google ScholarWorld Health Organization (2008) WHO 2008–13 action plan for the global strategy for the prevention and control of non communicable diseases. http://tiny.cc/ua93e (accessed 16 March 2011) Google Scholar FiguresReferencesRelatedDetailsCited ByManaging post-transplant patients in primary care29 September 2013 | Practice Nursing, Vol. 22, No. 6 1 April 2011Volume 22Issue 4ISSN (print): 0964-9271ISSN (online): 2052-2940 Metrics Downloaded 15 times History Received 22 March 2011 Accepted 24 March 2011 Published online 29 September 2013 Published in print 1 April 2011 Information© MA Healthcare LimitedKeywordsChronic kidney diseaseprimary carepreventionmanagementPDF download

The 2009 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 2 – therapy

To update the evidence-based recommendations for the prevention and management of hypertension in adults for 2009. For lifestyle and pharmacological interventions, evidence from randomized controlled trials and systematic reviews of trials was preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease. A Cochrane collaboration librarian conducted an independent MEDLINE search from 2007 to August 2008 to update the 2008 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence. For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to less than 2300 mg (100 mmol)/day (and 1500 mg to 2300 mg [65 mmol to 100 mmol]/day in hypertensive patients); perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as the initial treatment of hypertension if the systolic blood pressure is 20 mmHg above the target or if the diastolic blood pressure is 10 mmHg above the target. The combination of ACE inhibitors and ARBs should not be used. Other agents appropriate for first-line therapy for isolated systolic hypertension include long- acting dihydropyridine CCBs or ARBs. In patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered. All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

Hypertension guidelines: thresholds, targets, and teratogenicity

The current British Hypertension Society (BHS) Guidelines for the management of Hypertension run to an impressive 46 pages.1 The Quick Reference Guide on management of hypertension in adults in primary care published by the National Institute of Health and Clinical Excellence (NICE) in June 2006 is shorter at 11 pages.2 Both documents give essentially the same message about thresholds, treatments, and targets for hypertensive patients with the NICE guide providing easy to follow, colourful flow diagrams. By definition clinical guidelines need to be clear and user-friendly but I worry that important and subtle messages may be lost completely in the process. A case in point is the management of hypertension in young women of childbearing age. In the NICE Quick Reference Guide only one line mentions this group saying that beta blockers should be avoided in women of childbearing age. There is no mention of why and no reference to the potential dangers of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should these women become pregnant. Research emerging in the early 1990s indicated a causative association between the use of ACE inhibitors during pregnancy and the development of severe fetal abnormalities. A significantly increased incidence of oligohydramnios, neonatal renal failure, pulmonary hypoplasia, calvarial hypoplasia, and fetal death were reported. These effects are thought to be the result of hypoperfusion of the fetal kidneys during development.3 The increased risk of fetal abnormalities was initially thought to be limited to women receiving ACE inhibitor therapy in the second and third trimesters of pregnancy. However, a more recent study has suggested a significantly increased risk (>2.7) of major congenital malformations in women receiving ACE inhibitor therapy in the first trimester of pregnancy.4 A higher incidence of fetal abnormalities in the offspring of women taking ARBs during pregnancy has also been noted.5 Current BHS guidelines recommend ACE inhibitors as first-line agents for younger, non-black patients but advise that these agents should be avoided in women who wish to become pregnant. The recommendations also state that ACE inhibitors and ARBs should be discontinued immediately if a woman were to become pregnant while receiving treatment with either agent. The Quick Reference NICE guidelines suggest beta blockers may have a role in younger women but do not specify why.2 Despite their known adverse effects, recent US data shows that 4.4% of women of childbearing age (15–44 years) take ACE inhibitors, reflecting an 83% increase in use from 1995–2002.6 In addition, a UK poll suggests that 40% of pregnancies are unplanned, with over half of these due to lack of contraception.7 At the Hypertension Clinic, University Hospital Birmingham we recently investigated the number of women of childbearing age (16–45 years), who had been prescribed ACE inhibitors or ARBs in primary care before referral.8 In addition, contraceptive use by these women was evaluated to assess whether adequate precautions were being taken to prevent pregnancy in these at-risk patients. A cohort of female patients aged 16–45 years was identified from approximately 1500 new referrals from January 2004 to October 2006, excluding those not taking antihypertensive medication. Contraceptive status was established where possible. Forty-seven of 101 (47%) women aged 16–45 years were taking an ACE inhibitor (n = 35) an ARB (n = 11) or both (n = 1) of whom 26 (55%) were aged 16–40 years. In this younger group, eight were using no contraception and three were using barrier methods only. In other words, one-quarter of women in the study were taking these agents and were aged 40 years or less; of these, many were not using reliable contraception. The study identifies a worrying trend to use ACE inhibitors or ARBs in younger women who are at risk of poor perinatal outcomes if they become pregnant. On the basis of this small study and my own clinical experience I feel that the BHS and NICE guidelines may put younger women at risk if doctors are unaware of potential fetotoxic and teratogenic consequences of prescribing ACE inhibitors and ARBs. When I give talks to GPs and hospital doctors, several colleagues confirm that they were previously unaware of such an association. A final point that the study highlighted was the surprising number of young women who were taking antihypertensives in the first place. This brings me on to thresholds for intervention, white coat hypertension, and appropriateness of treatment in this very low-risk group: important subjects for another Viewpoint, perhaps.

Hypertension: Management of hypertension in adults in primary care: partial update

Hypertension: Management of hypertension in adults in primary care: partial update

The sour taste of cherry-picking

No one could have missed the news this week that β-blockers are to be phased out in the treatment of hypertension. The update of Hypertension: Management of Hypertension in Adults in Primary Care (National Institute of Health and Clinical Excellence (NICE), 2006) comes just two years after the original guidelines were published, and signify major changes in the treatment of high blood pressure.

Drug management of hypertension in primary care

The management of hypertension in primary care continues to represent a significant burden on the NHS, both clinically and financially (Box 1). Recent estimates suggest that around 16 million people in the UK have hypertension (Blood Pressure Association 2005), which accounts for around 37 per cent of men and 34 per cent of women (Department of Health (DH) 2002). According to the World Health Organization (WHO), the global disease burden attributable to a systolic blood pressure of 115 mmHg or above is significant. It accounts for around seven million deaths each year (WHO 2005), 49 per cent of coronary heart disease cases and 62 per cent of strokes (Maryon-Davis et al 2005). A recent study showing that the burden of stroke is greater than that of heart disease highlights the significance of these figures (Rothwell et al 2005). Hypertension is also costly. In 1999 alone, a cost to the NHS of at least £7 billion could be attributed directly or indirectly to hypertension (Maryon-Davis et al 2005). Considerable efforts are being made to improve hypertension management both in primary and secondary care settings. The new GMS contract offers incentives for improving the detection and control of blood pressure with a significant number of the clinical points for additional payments in the Quality and Outcome framework (QOF) being for hypertension (BMA, 2003). The National Service Frameworks (NSFs) for Coronary Heart Disease (DH 2000), Older People (DH 2000) and Diabetes (DH 2001) all highlight the importance of detecting and monitoring high blood pressure and recommend targets for control. With the increasing incidence of conditions such as diabetes and obesity – both of which are strongly linked to high blood pressure – the number of people with hypertension looks set to rise. The review, therefore, of government recommendations for the management of hypertension is both timely and necessary. New joint guidelines on the management of hypertension in adults in primary care are expected Drug management of hypertension in primary care

Section 14: Managing Patients With Hypertension and Heart Failure

Section 14: Managing Patients With Hypertension and Heart Failure

Fatal neonatal renal failure due to maternal enalapril ingestion

ACE inhibitors are commonly used drugs in the management of adult hypertension. However their use in pregnant women can have serious effects on the fetus. In this manuscript we report a case of fatal neonatal renal failure associated with maternal intake of enalapril during third trimester and review the related literature.Case. The index case was born to a mother with PIH which was treated with enalapril (5 mg) once a day for 21 days prior to delivery in addition to other anti-hypertensives. Temporally, use of enalapril was associated with the onset of oligohydramnios. The neonate presented with intrauterine growth retardation, hydrops and oliguric renal failure, which did not respond to furosemide, peritoneal dialysis and exchange transfusion. Autopsy showed macroscopically and microscopically normal kidneys.Conclusion. Use of ACE inhibitors during pregnancy should be avoided.

Impact of ambulatory blood pressure monitoring on the management of hypertension in children.

Ambulatory blood pressure monitoring (ABPM) is widely utilized for the evaluation and management of hypertension in adults but has not been routinely used in the care of hypertensive children. To examine the potential impact that the routine use of ABPM might have on the evaluation and management of hypertension in children, we reviewed our early experience with this technique, comparing management decisions based on ABPM with those based on casual blood pressure readings. Twenty children (4-17 years old) underwent ABPM for either the initial evaluation of suspected hypertension or the ongoing management of known hypertension. ABPM studies were considered abnormal if over 40% of both systolic and/or diastolic blood pressure readings were above the 95th percentile for the child's age and gender. Of 13 children studied for suspected hypertension, nine had abnormal ABPM studies and were treated, but four had normal results and were therefore not treated. Of seven children with known hypertension studied by ABPM to assess their blood pressure control further, three had normal results and no management changes were made, but four had abnormal studies, prompting a change in therapy or further diagnostic testing. Overall, eight out of 20 ABPM studies led to the initiation of further diagnostic evaluation or a change in planned or ongoing therapy. We conclude that ABPM has the potential to become an important tool in the evaluation and management of childhood hypertension, and suggest that more widespread use of this technique in children is appropriate.

Consultant participation in hospital management

<h3>Objectives</h3> A problem with the approach of Evidence-based Medicine (EBM) is the current ability to only reduce but not prevent overdiagnosis. Overdiagnosis is broadly defined as ‘making people patients unnecessarily, by identifying problems that were never going to cause harm or by medicalising ordinary life experiences through expanded definitions of diseases’. One aspect of overdiagnosis is <i>overdefinition</i>, such as lowering the threshold for treatment for a risk factor. A current example is the UK’s National Institute for Health and Care Excellence (NICE) updated draft guidance for the diagnosis and management of hypertension in adults. The recommendations in the guidance are not evidence based and will increase overdiagnosis. However, EBM would be insufficient to avoid overdiagnosis even if this NICE guidance followed the principles. The objective of this study is to show why EBM is insufficient to avoid over diagnosis. <h3>Method</h3> This study analyse the NICE draft guidance by the principles of following EBM guidance: Users’ Guides to the Medical Literature by (Guyatt et al), Guidance for modifying the definition of diseases: A checklist (Doust et al), and EBM manifesto for better healthcare (Heneghan et al). The principles of these analyses are what the consequences would have been <i>if</i> the NICE guidance had followed these principles. The principles and consequences are then analysed for their epistemological and ontological properties to determine what kind of scientific theory that leads the current EBM. <h3>Results</h3> EBM do not sufficiently assess the ontological aspect of a diagnosis. In the case of the NICE guidance, the ontological status of hypertension is primarily as a risk factor. A risk factor of such is a continuum with no clear boundary between normal (health risk small enough to be accepted) and pathological (health risk unacceptably high). Therefore, the diagnosis of hypertension is subject to the problematic <i>sorites paradox.</i> The original puzzle, from 400 BCE, is: how many times can we remove grains from a heap before we no longer have a heap? In this case, when a risk factor is accepted as a disease, how low a risk is low enough <i>not</i> to be a disease? EBM does not assess this problem. Instead, the present EBM is dominated by an epistemological approach, which legitimise any risk to become a disease, followed by the consequence of overdiagnosis. <h3>Conclusions</h3> Due to lack of ontological awareness and epistemological dominance, the current EBM approach does not sufficiently address overdiagnosis. Increase awareness of ontological aspects is necessary. The NICE guidance for hypertension provides a good basis for a much-needed discussion about what possible ontological solutions could bring us closer to limiting overdiagnosis via EBM.