Rod Tucker discusses the role of pharmacists in supporting hypertensive patients and those prescribed antihypertensive therapy.
The decision to treat hypertension is influenced by:
- Blood pressure reading
- The presence of existing cardiovascular disease
- Evidence of end organ damage
- Evidence of diabetes
- An estimated 10-year CVD risk of 10%
Lifestyle modification (see Table 2) is recommended for patients with all stages of hypertension. Furthermore, there is evidence that treatment of patients with a systolic blood pressure of between 140 to 159mmHg is associated with a reduction in mortality.
Consequently, NICE has suggested the following for all patients with stage 1 disease:
- If aged > 80 and with BP > 150/90mmHg: consider antihypertensive therapy
- If aged < 80 but with one or more of: end organ damage, CVD, renal disease, diabetes or 10-year risk of CVD 10%: consider antihypertensive therapy
- If aged < 60 and with a 10-year risk of CVD < 10%: consider antihypertensive therapy
- If < 40: consider specialist referral to identify secondary causes
Antihypertensive therapy is recommended for all patients with stage 2 hypertension.
In addition, for patients with severe hypertension recorded at a clinic visit (i.e., 180/120 mmHg), an assessment of end organ damage should be performed, and treatment commenced if present. In addition, where there is evidence of retinal haemorrhage or papilloedema or life-threatening symptoms such as new-onset confusion, chest pain, signs or heart failure or acute kidney injury, patients should be referred the same day to a specialist.
If severe hypertension is present, but without end organ damage, measurements should be repeated after 7 days.
Since poor lifestyle choices can contribute to the development of hypertension, modification of the choices can help to lower blood pressure. In fact, lifestyle changes are recommended for all hypertensive patients, irrespective of their stage. The most commonly recommended approaches to lifestyle modification are described in Table 2.
Although lifestyle modifications can be effective at controlling blood pressure, for many patients, drug therapy is required to control hypertension. In its guidance, NICE has produced a flow chart for the treatment of hypertension. Treatment decisions are guided by factors including age, ethnicity and the presence of type 2 diabetes as shown in Figure 1.
Although, as described earlier, most elderly patients have isolated systolic hypertension, NICE suggested that such patients should be treated in the same way as those with raised systolic and diastolic pressures.
Role for pharmacists
Adherence is a major problem in hypertension, with estimates suggesting that it is typically lower than 50% after 12 months. In fact, the NICE guidance has recommended that health professionals discuss treatment adherence before moving to the second or third step.
Furthermore, studies suggest that reductions in systolic pressure of 10mmHg or 5mmHg diastolic can reduce the risk of coronary heart disease events and stroke by 22% and 41%, respectively. Thus, small changes in blood pressures have a huge impact on disease-related effects, and one systemic review of trials found that pharmacist input to the care of those with hypertension led to significant reductions in systolic pressure (6.1mmHg) and diastolic (2.5mmgHg) pressures.
In recent years, the introduction of the New Medicine Service (NMS) has also provided pharmacists with an opportunity to support hypertensive patients. In fact, a recent study found that within the first two weeks of starting their antihypertensives, 95.5% of patents were supported by community pharmacists without the need to see their GP. Interestingly, this study also identified that patients receiving advice about their treatment from the pharmacist were much less likely to be referred to their GP and that most patients were referred after the pharmacist identified possible side-effects.
Currently, there are no financed hypertensive services in community pharmacies. However, there is clear evidence that community pharmacy advice to hypertensive patients, combined with blood pressure screening to identify undiagnosed disease, has the potential to highlight the value of such a role in supporting those prescribed antihypertensive therapy.