Hypertension management in adult part 2

-

 Hypertension 

Part 2


Treatment::

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity 

 Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:

• target organ damage 

• established cardiovascular disease • renal disease 

• diabetes •an estimated 10-year risk of cardiovascular disease of 10% or more.

Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with stage 1 hypertension if their clinic blood pressure is over 150/90 mmHg

 For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks


Measure standing as well as seated blood pressure in people with hypertension and:

• with type 2 diabetes or • with symptoms of postural hypotension or • aged 80 and over.

In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure


Reduce clinic blood pressure to below 140/90 mmHg and maintain that level in adults with hypertension aged under 80. Reduce clinic blood pressure to below 150/90 mmHg and maintain that level in adults with hypertension aged 80 and over.


Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure


Drug::

Step 1 treatment 

 Offer an ACE inhibitor or an ARB treatment who:

• have type 2 diabetes and are of any age or family origin or

• are aged under 55 but not of black African or African – Caribbean family origin. If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB.

 Do not combine an ACE inhibitor with an ARB to treat hypertension.

 Offer a calcium-channel blocker (CCB) to adults starting step 1 antihypertension to adults starting step 1 antihypertensive

treatment who: • are aged 55 or over and do not have type 2 diabetes or • are of black African or African–Caribbean family origin and do not have type 2 diabetes (of any age)

 If a CCB is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension.

 If there is evidence of heart failure, offer a thiazide-like diuretic and follow NICE's guideline on chronic heart failure. 

If starting or changing diuretic treatment for hypertension, offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.

 For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment.


Step 2 treatment

 Before considering next step treatment for hypertension discuss with the person if they are taking their medicine as prescribed

 If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step 1 treatment:

• a CCB or • a thiazide-like diuretic

 If hypertension is not controlled in adults taking step 1 treatment of a CCB, offer the choice of 1 of the following drugs in addition to step 1 treatment:an ACE inhibitor or • an ARB or • a thiazide-like diuretic.

 If hypertension is not controlled in adults of black African or African–Caribbean family origin who do not have type 2 diabetes taking step 1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step 1 treatment.


Step 3 treatment 

 Before considering next step treatment for hypertension:

• review the person's medications to ensure they are being taken at the optimal tolerated doses and

• discuss adherence

 If hypertension is not controlled in adults taking step 2 treatment , offer a combination of:

• an ACE inhibitor or ARB and

• a CCB and • a thiazide-like diuretic.

 If hypertension is not controlled in adults taking the optimal tolerated doses of an ACE inhibitor or an ARB plus a CCB and a thiazide-like diuretic, regard them as having resistant hypertension.

For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment (see recommendations.

Consider further diuretic therapy with low-dose spironolactone for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of 4.5 mmol/l or less. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia. When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium and potassium and renal function within 1 month of starting treatment and repeat as needed thereafter.

 Consider an alpha-blocker or beta-blocker for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4.5 mmol/L. If blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4 drugs, seek specialist advice.


Identifying who to refer for same-day specialist review::

If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral ,carry out investigations for target organ damage as soon as possible:


• If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

• If no target organ damage is identified, repeat clinic blood pressure measurement within 7 days.

Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

• signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

• life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.

Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis


Source:: NICE guidance


By: Dr. Manilal Biswas

SSMC (২০১২-১৩)

Comments

Post a Comment

Popular posts from this blog

Withdrawal, absence and cancellation of MRCP UK EXAM

-
Withdrawal, absence and cancellation of examinations 5.1 Withdrawal from the examination and refund of examination fees Notice of withdrawal from any part of the examination must be given in writing (by email) to the appropriate Administration Office, (or MRCP(UK) if the examination is to be taken outside the UK). Candidates should give their RCP Code Number, full name and date of birth in their request to withdraw to allow College staff to identify candidates easily. Examination applications and/or fees cannot be transferred from one examination to another. Candidates whose withdrawal request is received on or before the application closing date will be refunded 90% of the examination fee paid (10% of the fee is retained as an administrative charge). Refunds will not be made where candidates submit their withdrawal request after the closing date unless there are circumstances deemed exceptional that can be substantiated. (This does not apply to PACES candidates who are allocated place...
Read more

এমবিবিএস বাংলাদেশ, খরচ,সময় , বিষয়

-
 MBBS অনেকেই জিজ্ঞাসা করে এমবিবিএস কোন সাবজেক্ট,কোন বিষয়ে বিশেষজ্ঞ হচ্ছি,কত দিন পড়া,কি কি পড়া লাগে ইত্যাদি। সেগুলা নিয়ে কিছু কথা বলি। এমবিবিএস এ কখন ভর্তি হয়? HSC pass করার পর,সাইন্স থেকে অবশ্যই , এমবিবিএস ভর্তি পরীক্ষার জন্য সময় মত ফরম পূরণ করতে হয়।এরপর নির্দিষ্ট দিনে সারাদেশে একই প্রশ্নে একই সাথে পরীক্ষা অনুষ্ঠিত হয়। পরীক্ষায় মার্ক অনুযায়ী মেডিক্যাল কলেজের সিরিয়াল আসে।অর্থাৎ যার মার্ক বেশি সে উপরের দিকে সিরিয়াল এর মেডিক্যাল এ।এই সিরিয়াল কোন মেডিক্যাল আগে বা পরে এগুলা website e দেওয়া আছে। 2 বার পরীক্ষা দিতে পারে মোট।যে বছর এসএসসি পাস করে সেখান থেকে দ্বিতীয় ও তৃতীয় বছর। এমবিবিএস কোর্সে কত সময় লাগে? 5 বছরের কোর্স, শেষ বছরের শেষ দিকে ফাইনাল পরীক্ষা অনুষ্ঠিত হয়।রেজাল্ট দিতে আরো 3 - 4 মাস লাগে। মোট সময় লাগে 5 বছর 3 মাস প্রায়। এরপর 1 বছর ইন্টার্নশিপ। ইন্টার্নশিপ শেষ হলে BMDC কর্তৃক দেশে প্রাক্টিস করতে রেজিস্ট্রেসন নম্বর দেওয়া হয়।তখন সে রেজিস্ট্রার্ড ডক্টর। কি কি সাবজেক্ট পড়তে হয়?  এখানে যতগুলো বড় পরীক্ষা হয় সেগুলা প্রফেশনাল এক্সাম,প্রফ বা পেশাগত পরীক্ষা বল...
Read more

MRCP UK, when you get the degree

-
Progress through the diploma 8.1 On passing Part 1 Examination Once they have received confirmation that they have passed the Part 1 examination, candidates can apply for the MRCP(UK) Part 2 Written and/or the Part 2 Clinical (PACES) Examination (in accordance with the recommendations for necessary clinical experience detailed in MRCP advice and guidance). Candidates will be permitted seven years from the date of the Part 1 Examination at which they were successful to pass the remaining parts of the diploma. Candidates who have passed Part 1 cannot re-sit the Part 1 Examination until the seven-year period has expired. 8.2 On passing Part 2 Written Examination Candidates who have not yet passed MRCP(UK) Part 2 Clinical Examination must pass PACES before they can complete the MRCP(UK) diploma and be elected to Membership of the Royal Colleges of Physicians of the United Kingdom. Candidates do not need to wait until their result for MRCP(UK) Part 2 Written is confirmed before applying for...
Read more