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Managing hypertension in primary care settings: application of NICE guidelines

 - The prevalence hypertension in the UK and worldwide

- Pathophysiology of atherosclerosis and disorders of chronic hypertension 

- Taking and recording of blood pressure

Hypertension (HTN) places strain on the contractility of the myocardium, increases arterial walls tension and predisposes to coronary artery and renal artery damage, stroke and hyperglycaemia. HTN affects any race, age or gender and is one of the most common conditions seen in primary care settings. The National Institute of Health and Care Excellence (NICE)1 recommends that HTN is better managed in the primary care settings, using a validated self-management diagnostic mechanical device to diagnose HTN, followed by stepwise pharmacological treatment, coupled with lifestyle adjustments. The high prevalence of HTN in the community is due to an aging population and the growing prevalence of obesity,2 high dietary salt intake3 and lack of exercise.4 Primary care specialist nurses, working from HTN clinics with nurse-prescribing powers and enhanced managerial responsibility, can improve blood pressure control and reduce morbidity and mortality.
Over time, the increased pressure of HTN damages arterial walls and enhances vulnerability to atherosclerosis, reduced blood flow, oxygen and nutrients and organ damage, eg. myocardial infarction, stroke, renal damage, vision loss and memory impairment. As the myocardium has to pump blood against the higher pressure, it hypertrophies leading to heart failure. HTN may also cause metabolic syndrome with increasing waist circumference, high triglycerides and low high-density lipoprotein (HDL). The increasing intravascular build-up of these substances reduces tissue insulin receptors' activities and exacerbates hyperglycaemia.
In 2000, 26.4% (329-336 million in economically developed countries and 625-654 million in economically developing countries) of the adult population (26.6% men and 26.1% women) had HTN. The number is predicted to increase by about 60% to a total of 1.56 billion by 2025.5 In 2010, 20.7% of men and 19.4% of women aged 65-74 years had uncontrolled hypertension, of which 17.9% of men and 20.0% of women were untreated.6 Johnson et al7 noted variations in the incidence of undiagnosed HTN with 78% in 18-24 years compared to 71% in 25-31 year olds, 61% in 32-39 year olds, 45% in 40-59 year olds and 32% in over 60 year olds. In England 32% of men and 29% of women have HTN or are being treated for HTN; the lowest proportion of men with HTN is in the West Midlands, the highest proportions in the East Midlands and Yorkshire & the Humber, while for women, the lowest levels is in London and across the south, with the highest levels in the North East.8 The global economic burden of treating HTN was estimated at US$370 billion or 10% of total healthcare expenditures.9 If these trends continue, HTN will cause about 7.5 million deaths,12.8% of the total deaths through coronary heart disease, haemorrhagic stroke, heart failure, peripheral vascular disease and diabetes mellitus.5,10
Primary care specialist nurses are taking on a bigger role in the prevention and clinical management of HTN. Those who regularly take blood pressure measurements benefit from advanced training and periodic review of their performance to update, develop and evidence-base their practice to reflect latest national and local guidelines1 with direct improvement in the clinical management of HTN. Advanced practitioners in nurse-led clinics are assuming greater role, for example independent nurse prescribing, telephone monitoring, evidence-based practice and quality monitoring. There is increasing use of approved automated devices as they are more reliable in measuring blood pressure accurately. However, if pulse irregularity is present, blood pressure should be manually taken using direct auscultation over the radial or brachial artery as advised by NICE,1 which also recommends a relaxed, temperate setting, where the person sits quietly with outstretched and supported arm. It is recommended to measure blood pressure with the person either supine or seated and to allow the person to stand up for at least one minute prior to measurement where postural hypotension (falls or postural dizziness) is suspected. If systolic blood pressure falls by 20 mmHg or more when the person is standing, measure subsequent blood pressures with the person standing and consider referral to specialist care if symptoms of postural hypotension persists, following review of medication. 
To confirm a diagnosis of HTN, (see NICE classification below), NICE1 recommends measuring blood pressure in both arms, 
and if the difference in readings between arms is more than 20 mmHg, repeat the measurements. If the difference in readings between arms remains more than 20 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading. 
The NHS Plan: A Plan for Investment11 and Improving Patients' Access to Medicines: A Guide to Implementing Nurse and Pharmacist Independent Prescribing Within the NHS in England12 provide for an enhanced role for nurse prescribing to improve patient's access to medication and makes better use the advanced knowledge and skills of primary care nurses. NICE1 promotes the involvement of primary care specialist nurses to play a more leadership role for improved pharmacological management of HTN. Non-adherence to antihypertensive medication is often a significant factor in poorly controlled HTN. Nurse prescribing based on an approved algorithm (see Figure 1) improves medication adherence and control of HTN.1 However, Clark et al13 cautioned that although nurse led interventions, through an algorithm, improved structured care and clinical outcomes, there is still insufficient research evidence to support widespread nurse prescribing in the management of hypertension. Specialist nurses are trained and better placed to give guidance on improving lifestyle to reduce blood pressure and promote relaxation therapies to reduce blood pressure and to encourage sufferers to join suitable social groups as part of their treatment.1 They should consider offering free prescriptions to older people with HTN to attend a local exercise centre to do exercise as membership fee to some centres are expensive. Primary care nurses should establish people's alcohol consumption and encourage a reduced intake if they drink excessively, as these can reduce blood pressure and also have broader health benefits, discourage excessive consumption of coffee and other caffeine-rich products and advised to keep dietary sodium intake low, either by reducing or substituting sodium salt. Offer advice and help to smokers to stop smoking and inform them of local initiatives by, for example, healthcare teams or self-help organisations that provide support and promote sustained healthy lifestyle change. 
Telemonitoring of home management of HTN produces clinically important reductions in both daytime systolic and diastolic ambulatory blood pressure.14 This requires patients to log on to a website, set up by the nurse, where they record their own blood pressure readings. This is then followed-up with automated SMS texts or emails by the nurse if therapy adjustment is indicated. This offers an improved channel of communication for patients to resolve any immediate concerns regarding their blood pressure level and also promotes better autonomy and control through team working as well as improving compliance with medications.15
The number of people with HTN is increasing worldwide. Uncontrolled HTN leads to various pathologies with increasing morbidity and mortally. The prevention of HTN should start within the primary care settings where specialist primary care nurses can play a more prominent role in reducing HTN. Primary care nurses have unique knowledge and skills to participate in all domains of care, with a primary responsibility for curative and rehabilitative care and service co-ordination. Primary care nurses are ideally placed to deliver comprehensive primary health care through full and effective application of the knowledge and skills including better lifestyle promotion, screening and management of interventions and for providing supportive care. Primary care nurses bring their specialist nursing knowledge and skills to population and individual health promotion by working more closely with professionals and clients to provide supportive and rehabilitative care. 
1. NICE. Hypertension: clinical management of primary hypertension in adults. National Institute for Health and Care Excellence. Clinical Guidelines, CG127. 2011.
2. NICE. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. National Institute for Health and Care Excellence. Clinical guidelines, CG43. 2006.
3. He FJ, Li J, Macgregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. British Medical Journal 2013; 3:346:f1325. 
4. Libonati JR. Cardiac Effects of Exercise Training in Hypertension. International Scholarly Research Notices 2013: ID 980824. 
5. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK,  He J. Global burden of hypertension: analysis of worldwide data. Lancet 2005;5-21;365(9455):217-23.
6. McCormack T, Arden C, Begg A, Caulfield M, Griffith K,  Williams H. Optimising hypertension treatment: NICE/BHS guideline implementation and audit for best practice. British Journal of Cardiology 2013;20(suppl 1):S1-S16.
7. Johnson HM, Thorpe CT, Bartels CM, Pandhi N, Sheehy AM, Smith MA. Predictors of Undiagnosed Hypertension Among Young Adults with Regular Primary Care Use. Circulation 2012;126:A16557.
8. British Heart Foundation. Joint Health Surveys Unit (2010). Health Survey for England 2008: Physical activity and fitness. Leeds: The Information Centre; 2010.
9. Gaziano TA, Bitton A, Anand S, Weinstein MC. The global cost of non-optimal blood pressure. Journal of Hypertension 2009;27:1472-77.
10. WHO. World Health Statistics. Geneva. 2012.
11. Department of Health. 'NHS Plan ' a plan for investment', London: NHS; 2000.
12. Department of Health. Improving patients' access to medicines:  a guide to implementing nurse and pharmacist independent prescribing within the NHS in England. London: NHS; 2006.  
13. Clark CE, Smith LFP, Taylor RS, Campbell JL. Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis. British Medical Journal 2010. 341:c3995. 
14. Kaambwa B, Bryan S, Jowett S,  Mant J,  Bray EP, Hobbs FDR, Holder R, Jones MI, Little P, Williams B. Telemonitoring and self-management in the control of hypertension (TASMINH2): a cost-effectiveness analysis. European Journal of Preventive Cardiology. 2013:29. 
15. McKinstry B, Hanley J, Wild S, Pagliari C, Paterson M, Lewis S, Sheikh A, Krishan A, Stoddart A, Padfield P. Telemonitoring based service redesign for the management of uncontrolled hypertension: multicentre randomised controlled trial. British Medical Journal 2013;346:f3030.