Key learning points:
– How to recognise hypertension and heart disease (coronary heart disease, heart failure) early in patients
– The key symptoms, signs and main causes of hypertension and heart disease
– How to treat early signs of hypertension and heart disease
The National Institute for Health and Care Excellence (NICE) published CG 127 entitled clinical management of primary hypertension in adults, in August 2011. (1) The guideline states “hypertension is one of the most preventable causes of premature morbidity and mortality in the UK. It is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension is usually associated with a progressive increase in blood pressure. The vascular and renal damage this may cause can cumulate in a treatment resistant state”.
An article published in The Lancet discussed the underlying causes and associated risk factors of hypertension. (2) It warned that people living in the developed world were facing a substantial (>90%) risk of developing hypertension (BP >140/90) at some stage during their lives. It predicted that the number of adults with hypertension worldwide would increase from 972 million in 2000 to 1.56 billion by 2025. The editorial that accompanied the article highlighted that hypertension, along with a selection of other cardiovascular risk factors such as obesity, diabetes, metabolic syndrome and hyperlipidaemia, if left untreated would ultimately lead to cardiovascular disease, cerebrovascular disease, renal failure, ocular complications, dementia and premature death. Lifestyle factors such as a lack of physical exercise, a diet containing salt rich, fatty or processed foods, alcohol consumption and smoking also contribute to this worrying scenario.
NICE has identified its key priorities as: diagnosing hypertension, measuring blood pressure (BP), initiating and monitoring anti hypertensive drug treatment, lifestyle interventions, identifying cardiovascular risk and target organ damage, drug interventions, continuing treatment and patient education. The guideline includes a step-by-step algorithm for choosing drugs that will be appropriate for newly diagnosed hypertensive patients.
Causes of hypertension
In more than 90% of patients the cause of hypertension is unknown and usually has no obvious symptoms. In the remaining 10%, ‘secondary hypertension’ can be due to kidney disease, diabetes, endocrine causes (Cushing’s, thyroid disorders, acromegaly), congenital causes (coarctation of the aorta) and drugs (oral contraceptive pill, recreational drugs, steroids, non steroidal anti inflammatory drugs), obstructive sleep apnoea and pregnancy.
Practice nurses play a key role in opportunistic screening for hypertension before target organ damage has already occurred.
The NICE recommends that health care professionals who are measuring BP should receive training and have regular performance reviews. Devices for measuring BP must be validated, re-calibrated and functionally maintained. The patient should be relaxed, warm and seated with their arm outstretched and supported. If the first reading exceeds 140/90, a second reading should be taken, the lower measurement should be recorded. The BP on both arms should be checked and the arm with the higher value should be used as the reference arm for future measurements. If the patient has symptoms of postural hypotension (falls, dizziness in standing up), also take a standing BP measurement.
Ambulatory blood pressure monitoring (ABPM) should be offered if the clinic BP is more than 140/90mmHg. Two measurements per hour during the person’s usual waking hours should be taken using the average value of 14 measurements to confirm hypertension. Home blood pressure monitoring (HBPM) can also be used if a person is unable to tolerate ABPM.
NICE recommend that “while waiting for confirmation of a diagnosis of hypertension, carry out investigations for target organ damage and a formal assessment of cardiovascular risk”. Hypertension, if inadequately controlled, will result in target organ damage. Left ventricular hypertrophy can be seen on the electrocardiogram (ECG), reflecting an over worked and pressure loaded left ventricle. Renal damage causes leakage of protein into the urine and a consequent elevation in the urinary albumin/creatinine ratio (ACR). Subtle memory changes can occur early on in the disease process. Hypertensive retinopathy should also be screened for.
To diagnose hypertension healthcare professionals should:
– Test urine – send the dipstick and sample for ACR (with a reagent test strip) for blood.
– Take bloods for plasma glucose, electrolytes, creatinine, eGFR and lipid profile.
– Examine fundi for changes suggestive of hypertensive retinopathy.
– Arrange a 12 lead ECG.
Ischaemic (coronary) heart disease
The British Heart Foundation revealed that coronary heart disease (CHD) is the UK's single biggest killer, causing the death from heart attack of one-in-six men and one-in-10 women, (3) an average of one person every seven minutes.
Atherosclerosis is where atheroma, a build up of fatty deposits, develops inside the lining of blood vessels. This causes them to narrow and the flow of blood through the affected blood vessel is subsequently reduced. This reduction in blood supply can lead to symptoms such as chest pain (angina) – which is often felt in the central chest and can radiate into the shoulder, left arm neck or jaw, shortness of breath and heart failure. Symptoms are often triggered by exercise, stress or after eating and can ease with rest. Heart attacks occur when blood clots form on top of patches of atheroma and block the blood vessel. Risk factors include smoking, physical inactivity, being overweight, eating a diet rich in salt and fatty or processed foods, excess alcohol consumption, hypertension, raised cholesterol or triglycerides, diabetes, kidney disease, family history (a first degree male relative who had heart disease or a stroke aged below 55 years, or a first degree female relative who had heart disease or a stroke aged below 65 years, male gender, increasing age and ethnicity (people from India, Pakistan, Sri Lanka or Bangladesh are at increased risk).
Diagnosing coronary heart disease
A history should be taken along with a clinical examination. Blood tests (fasting glucose and lipid profile, electrolytes, renal function, liver function, full blood count), electrocardiogram (this can be normal even in the presence of CHD), echocardiogram and a chest x-ray should be performed. If a referral to a cardiologist is made, they may recommend other investigations such as a radio nucleotide scan (which assesses blood flow through the heart), a stress echocardiogram (with exercise to stress the heart) a coronary angiogram or a cardiac CT / MRI scan (to examine the coronary arteries in detail).
Treatment involves correcting the risk factors and medication such as aspirin, statins (to lower cholesterol and aim to slow down the atherosclerotic process), beta blockers (to slow the heart rate and reduce the workload of the heart muscle), ACE inhibitors (to lower blood pressure), calcium channel blockers (to vasodilate the coronary arteries allowing an increase in blood flow) and short acting nitrates (to relax the coronary arteries). Procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) may also be required.
NICE published a guideline regarding chronic heart failure and its management in primary care in August 2010. (4)
It’s a reminder that “heart failure is a complex clinical syndrome of symptoms and signs that suggest the efficiency of the heart as a pump is impaired. It is caused by structural or functional abnormalities of the heart.
"Some patients have heart failure due to left ventricular systolic dysfunction (LVSD). Others have heart failure with a preserved ejection fraction or even reduced long axis function”.
Causes of heart failure
– Ischaemic (coronary) heart disease – the most common cause. The blood flow to the heart muscle is impaired as the coronary arteries that provide the heart muscle with blood and oxygen, are narrowed.
– Following myocardial infarction.
– Cardiomyopathy (diseases affecting the heart muscle).
– Heart valve disorders.
– Diseases of the pericardium (the tissue that surrounds the heart).
– Abnormal heart rhythms (arrhythmias).
– Drugs or chemicals that can cause damage to the heart muscle (alcohol excess, chemotherapy, cocaine).
– Some systemic conditions that also put a strain on heart function (thyroid disease, Paget's disease and profound anaemia).
– Congenital heart disease.
Heart failure has a poor prognosis with up to 40% of patients dying within 12 months. (5) NICE has outlined its key priorities as: diagnosis, treatment, rehabilitation, monitoring and discharge planning.
Diagnosis of heart failure
Patients can present with symptoms and signs such as fluid retention (swollen ankles, enlarged liver, bilateral basal chest crackles, elevated jugular venous pressure), breathlessness (at rest, on exertion or when lying flat in bed at night), tiredness, cough, nausea and loss of appetite. Patients who have had a previous heart attack and have suspected heart failure or who have serum brain natriuretic peptide (BNP) more than 400, or the NT proBNP level is more than 2000, should be referred urgently for an ECG and cardiology assessment within two weeks. All patients should have an ECG, chest x-ray, blood tests for electrolytes, urea and creatinine, eGFR, thyroid function, liver function, fasting lipids, fasting glucose and full blood count, urinalysis and peak flow or spirometry to evaluate possible aggravating factors or alternative diagnoses.
Management of heart failure
NICE highlights the importance addressing lifestyle factors and of offering both an angiotensin converting enzyme (ACE) inhibitor, aspirin (75-150mg once daily) and beta blockers to all patients with heart failure that is due to LVSD. If a patient remains symptomatic despite optimal therapy, an aldosterone antagonist or hydralazine and a nitrate should be considered. If the patient is stable, a supervised group exercise based rehabilitation programme for patients with heart failure that incorporates educational and psychological support, should be offered.
Patients with heart failure need to be monitored, with a clinical assessment of functional capacity (New York Heart Association status), the presence of ankle oedema and raised jugular venous pressure, heart rhythm (minimum of feeling the pulse), cognitive and nutritional status. Patients also require a medication review to see whether any side effects are present and a blood test for urea, electrolytes, creatinine and eGFR.
Management of hypertension
Assessing a patient's overall cardiac risk, taking into consideration life style factors, age, sex and family history is important, as is the use of risk calculation tools such as the QRisk2, which helps to guide management decisions and facilitates patient counselling.
When considering drug therapies, the indications for treatment, treatment goals and specific choice of treatment should be discussed with the patient in order to highlight the rationale behind treatment decisions and why compliance is of vital importance. The Lancet article stated that “despite very effective and cost-effective treatments, target blood pressure levels are rarely reached. Many people still believe that hypertension is a disease that can be cured, and stop or reduce medication when blood pressure levels fall”. People with hypertension should have the opportunity to make informed decisions about their care and treatment, in partnership with the health care professional. It should be supported by written evidence based information tailored to the patients needs.
The NICE guideline discusses initiating treatment for hypertension and suggests that we “offer anti-hypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following: target organ damage, established cardiovascular disease, renal disease, diabetes, a 10 year cardiovascular risk equivalent to 20% and people of any age with stage 2 hypertension”. It also guides us on choosing anti hypertensive drug treatment, and reminds us to “offer people aged 80 years and over the same anti hypertensive drug treatment as people aged 55-80, taking into account any comorbidities”.
NICE suggests that a person should be referred to secondary care on the same day if they have accelerated hypertension (BP more than 180/110) with signs of papilloedema and/or retinal haemorrhage, or suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor and sweating).
Clinic BP measurements should be used to monitor the response to treatment with lifestyle modifications or drugs. A target BP of less than 140/90 in those aged less than 80 should be aimed for. In those aged more than 80, a target of 150/90 is deemed acceptable.
Practice nurses play a pivotal role in screening for, diagnosing and managing hypertension, heart failure and CHD along with assessing for target organ damage and the initiation of drug therapies and their subsequent monitoring. Annual reviews should be offered to monitor BP, provide support, and discuss lifestyle, the psychological impact of the condition, symptoms and medical therapies.
1. Nice guideline CG 127 2011 Hypertension. 2011. www.nice.org.uk/guidance/cg127/evidence/cg127-hypertension-full-guideline3 (accessed 29 March 2015).
2. Messerli FH, Williams B and Ritz E. Essential hypertension. The Lancet 2007:370;591-603.
3. British Heart Foundation Coronary heart disease leading cause of death for men aged 50 and over. 2013. www.bhf.org.uk/news-from-the-bhf/news-archive/2015/february/coronary-hea... (accessed 29 March 2015).
4. Nice guideline CG 108 Heart failure. 2010 www.nice.org.uk/guidance/cg108/resources/guidance-chronic-heart-failure-pdf (accessed 29 March 2015).
5. Cowie MR, Wood DA, Coats AJ et al. Survival of patients with a new diagnosis of heart failure: a population based study. Heart 2000;83:505-10.
You are currently leaving the Nursing in Practice site. Are you sure you want to proceed?