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High blood pressure increases the risk of other cardiovascular complications such as coronary heart disease, stroke, heart failure, chronic kidney disease, aortic aneurysm, peripheral vascular disease, and retinal disease. The Scottish Intercollegiate Guidelines Network (SIGN) has developed guidance, which refers to the British Hypertension Society clinical practice guidelines, for the Scottish National Health Service.[1]
History
[edit]Epidemiology
[edit]Prevalence
[edit]Current estimates suggest that nearly one-third of the Scottish population, age 16 years and above, has an elevated blood pressure or a history of high blood pressure. The prevalence of high blood pressure increases sharply with age and more than three-quarters of Scottish age 75 years and above have high blood pressure. The table below depicts the prevalence of high blood pressure in Scotland by gender from 2003 to 2010:[2]
| Men (%) | Women (%) | All adults (%) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2003 | 2008 | 2009 | 2010 | 2003 | 2008 | 2009 | 2010 | 2003 | 2008 | 2009 | 2010 | |
| All with high blood pressure | 33.0 | 33.9 | 35.4 | 37.9 | 32.7 | 31.4 | 30.9 | 33.3 | 32.8 | 32.6 | 33.0 | 35.5 |
| Hypertensive untreated | 20.7 | 20.1 | 19.3 | 22.6 | 16.6 | 14.6 | 14.9 | 17.4 | 18.5 | 17.2 | 17.0 | 19.9 |
| Hypertensive controlled | 5.9 | 8.6 | 8.1 | 8.7 | 7.2 | 9.0 | 7.9 | 6.6 | 6.6 | 8.8 | 8.0 | 7.6 |
| Hypertensive uncontrolled | 6.3 | 5.3 | 7.9 | 6.7 | 9.0 | 7.7 | 8.0 | 9.2 | 7.8 | 6.6 | 8.0 | 8.0 |
Growth rate
[edit]The prevalence of high blood pressure of all adults, aged 16 years and above, rose from 32.8% in 2003 to 35.5% in 2010. In 2003, 18.5% of patients were untreated and in 2010, 19.9% of patients were untreated for high blood pressure.[2]
Diagnosis
[edit]Practices are required to complete a cardiovascular disease (CVD) risk assessment in people who have been diagnosed with hypertension without confirmed CVD, after April 1, 2009. Some NHS Boards have local initiatives that allow for pharmacies to provide blood pressure monitoring services. The action to extend contracts for blood pressure monitoring services in pharmacies is being called into action. [3]
Techniques
[edit]- Ambulatory blood pressure monitoring (ABPM)
- Home blood pressure monitoring (HBPM)
Thresholds
[edit]People with a persistent blood pressure ≥140/90 mm Hg or those with a family history of high blood pressure should be given lifestyle advice that is continued even if drug therapy is started. Individuals with a systolic blood pressures >140 and/or a diastolic blood pressure >90 mm Hg, with cardiovascular disease, should be considered for a drug therapy that will reduce the blood pressure.
Management
[edit]Medications
[edit]The British Hypertension Society AB/CD algorithm has been widely adopted for deciding drug therapy for an individual.38 The algorithm was substantially ratified by the ASCOT trial and AB/ CD has now been accepted by JBS2 as the best method of defining combination drug therapy. The AB/CD algorithm was designed to improve blood pressure control based on age-related renin levels and appropriate combinations. In June 2006 the National Institute for Clinical Health and Excellence (NICE) and the BHS jointly released a revised guideline that updated the clinical evidence base to include recent meta-analyses and RCTs and included a cost effectiveness analysis comparing the various blood pressure lowering drug classes.270 The results showed that:[4]
- beta blockers were the least clinically and cost effective drug at preventing major cardiovascular events
- calcium channel blockers and thiazide-type diuretics were the most clinically and cost effective choice for the majority of cases
- for people under the age of 55, drugs affecting the renin-angiotensin system are likely to be most effective.
The recommendations based on this evidence are summarized below. It incorporates all classes of antihypertensive drugs. Although not specifically validated by a clinical trial, the recommended drug combinations and sequencing are similar to those used in many clinical trials of blood pressure lowering drugs.[4]
First-line treatment
[edit]First-line therapy for people <55 years of age is an angiotensin converting enzyme inhibitor (ACE-I) or an angiotensin II receptor blocker (ARB) if the patient is intolerant to the ACE-I. People who are ≥55 years of age or black people of African or Caribbean origin of any age, calcium channel blockers or thiazide-type diuretics are the first-line therapy.[4]
Second-line treatment
[edit]If first-line therapy fails, second-line therapy consists of adding a CCB or a thiazide-type diuretic for patient who initially started an ACE-I or ARB as first-line treatment. For patients who were started on a calcium channel blocker or a thiazide-type diuretic should also be given an ACE-I or and ARB.[4]
Third-line treatment
[edit]When blood pressure goal is not reached after introducing a second-line treatment option, patient should be on three medications: an ACE-I or ARB (not both), a CCB, and a thiazide-type diuretic.[4]
Fourth-line treatment
[edit]Patients who fail third-line treatment can further add diuretic therapy, an alpha blocker, or a beta blocker and should consider seeking the advice of a specialist. However, beta blockers are not a preferred initial therapy for hypertension but are an alternative to ACE inhibitors in patients <55 years in whom ACE inhibitors or ARBs are not tolerated, or contraindicated (includes women of childbearing potential). Black patients are only those of African or Caribbean descent. In the absence of evidence, all other patients should be treated according to the algorithm as non-black.[4]
Most Readily Prescribed
[edit]The following table depicts the most readily prescribed medications to treat high blood pressure in Scotland.
| Rank | Medication | Class |
|---|---|---|
| 1 | amlodipine | CCB |
| 2 | ||
| 3 |
Amlodipine was the most dispensed medication used to treat angina and high blood pressure, and the 9th most dispensed medication overall, during the fiscal year of 2011/2012 in Scotland.[5]
Invasive treatments
[edit]Traditional medicines
[edit]Accessibility to treatment
[edit]Treatment programs
[edit]Socioeconomic impact
[edit]The estimated cost burden of high blood pressure in the U.K. has been estimated to be over £7 billion.[6]
Government policies
[edit]The following current national waiting time standards have been developed for patients who have developed cardiac conditions requiring intervention: no patient will wait more than 16 weeks for cardiac intervention following General Practice (GP) referral through a rapid access chest pain clinic (RACPC) and no patient will wait more than 16 weeks for treatment after they have been seen as an outpatient by a heart specialist who has recommended treatment. Currently, the NHS Scotland lacks systems that capture the total patient journey and have relied on an interim solution, which is to monitor the progress of wait times using component parts of the journey.[7]Additionally, practices are required to complete a CVD risk assessment in people who have been diagnosed with hypertension without confirmed CVD, after April 1, 2009. [8]
Challenges ahead
[edit]References
[edit]- ^ Faculty of Public Health. Easing the Pressure: Tackling Hypertension. A toolkit for developing a local strategy to tackle high blood pressure (2005). http://www.fph.org.uk/uploads/hypertension_all.pdf
- ^ a b Scottish Public Health Observatory. High Blood Pressure: prevalence (2010). http://www.scotpho.org.uk/clinical-risk-factors/high-blood-pressure/data/prevalence
- ^ NHS Scotland. Better Heart Disease and Stroke Care Action Plan, (2009). http://www.scotland.gov.uk/Resource/Doc/277650/0083350.pdf
- ^ a b c d e f Scottish Intercollegiate Guidelines Netowrk. Risk estimation and the prevention of cardiovascular disease: A National Clinical Guideline. Edinburgh: SIGN, 2007. (SIGN publication no. 97). http://www.sign.ac.uk/pdf/sign97.pdf Cite error: The named reference "Tx" was defined multiple times with different content (see the help page).
- ^ ISD Scotland. Prescribing & Medicines: Prescription Cost Analysis (2012). http://www.isdscotland.org/Health-Topics/Prescribing-and-Medicines/Publications/2012-06-26/2012-06-26-Prescribing-PrescriptionCostAnalysis-Report.pdf
- ^ Public Health Information for Scotland (2005). http://www.scotpho.org.uk/clinical-risk-factors/high-blood-pressure/introduction
- ^ ISD Scotland. Inpatient, Day case and Outpatient stage of treatment waiting times (2011). http://www.isdscotland.org/Health-Topics/Waiting-Times/Publications/2011-02-22/2011-02-22-WTIPDCOP-Report.pdf
- ^ NHS Scotland. Better Heart Disease and Stroke Care Action Plan, (2009). http://www.scotland.gov.uk/Resource/Doc/277650/0083350.pdf
External Links
[edit]- The Scottish Public Health Observatory - provides public health information for Scotland
- Scottish Health Survey - provides health survey information for Scotland
- British National Formulary - provides prescribers, pharmacists, and other healthcare professionals with sound up-to-date info about the use of medicines (access available to UK residents or HINARI group of developing nations).
- ISD Scotland General Practice - provides information on face-to-face consultations between patients and members of the practice team.
- ISD Scotland Waiting Times - provides information on wait time standards for cardiac interventions.
- ISD Scotland Quality and Outcomes Framework - measures achievement against a range of evidence-based indicators, with points and payments awarded according to the level of achievement.