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West Yorkshire and Harrogate Healthy Hearts

    • Important instructions and notes - please click to read.

      Instructions: Click the links (blue text), icons () and drop-downs (▶) for further information. Select the appropriate clinical scenario to adjust the pathway.

      This is an adapted version of the source material referenced/linked below. Please see the original source for full details.

      Please read our medical disclaimer - this pathway may not be suitable for your particular patient or healthcare setting/system.
      If you would like to commission a more appropriate localised pathway please get in touch.

      This pathway is adapted from WYHHH: Treatment Guidance Uncomplicated Hypertension

    • Important instructions and notes - please click to read.

      Instructions: Click the links (blue text), icons () and drop-downs (▶) for further information. Select the appropriate clinical scenario to adjust the pathway.

      This is an adapted version of the source material referenced/linked below. Please see the original source for full details.

      Please read our medical disclaimer - this pathway may not be suitable for your particular patient or healthcare setting/system.
      If you would like to commission a more appropriate localised pathway please get in touch.

      This pathway is adapted from WYHHH: Lipid Treatment Guidance

    • Treatment Guidance Uncomplicated Hypertension

      This treatment guidance is for uncomplicated hypertension (in patients under 80 years of age) and is not applicable to patients over 80 years OR patients with Diabetes / CKD 3B+ / Heart Failure / IHD / CVA / PAD.The guidance is also not suitable for the treatment of hypertension in pregnancy.
      Management of hypertension for patients outside of this local guidance: Hypertension in Adults [NG136] | Hypertension in Pregnancy [NG133]
      When assessing CVD risk use QRISK 3 where available www.qrisk.org/three

    • Recommend use of ABPM for diagnosis.
      (HBPM if not available/tolerated).
      If Clinic BP >=140/90 confirm diagnosis with ABPM/HBPM.
      If Clinic BP >=180/120 consider immediate treatment.

    • ↓

      NOT Hypertensive

      Offer lifestyle advice and signposting as required

    • Lipids • U&Es • LFTs • TFT • HbA1c • ECG • Urine Dip • ACR

      ↓

      STAGE 1
      Hypertension

      ↓

      Hypertensive and if < 10% CVD risk* and no target organ damage

      Offer lifestyle advice and signposting
      (one year review)

      ↓

      Hypertensive and if ≥ 10% CVD risk* or target organ damage

      Lifestyle advice + Treat

      *Amlodipine 5mg

      ↓
      If not controlled < 135/85 HBPM or ABPM

      + Indapamide 2.5mg

      ↘

    • Lipids • U&Es • LFTs • TFT • HbA1c • ECG • Urine Dip • ACR

      ↓

      STAGE 2
      Hypertension

      Lifestyle advice + Treat

      *Amlodipine 5mg
      +
      Indapamide 2.5mg

      Consideration can be given to a phased approach when initiating dual therapy at diagnosis
      e.g. start Amlodipine and then commence Indapamide one week later

      ↓

    • Lipids • U&Es • LFTs • TFT • HbA1c • ECG • Urine Dip • ACR

      ↓

      STAGE 3
      Severe Hypertension

      Lifestyle advice + Treat.
      Consider referral if accelerated

      *Amlodipine 5mg
      +
      Indapamide 2.5mg

      Consideration can be given to a phased approach when initiating dual therapy at diagnosis
      e.g. start Amlodipine and then commence Indapamide one week later

      ↓

    • If not controlled check non-adherence, alcohol and lifestyle. Provide signposting to community pharmacy for medication support (MUR/NMS).

      Check U&Es at various stages e.g. when changing dose/medication.

      Check potassium at regular intervals. If low K+ thought due to indapamide:

      • Mild 3.0 - 3.4 <div class="navybox"> <p style="color:green;"><b>Mild (3.0 - 3.4 mmol/l)</b></p> <p><b>When to repeat</b></p> <ul> <li>Compare with previous results. If no change in medication, may be one-off. <b>Change in K+ &lt; 0.5 mmol/L can be just standard lab variation from sample to sample (i.e. “lab error”)</b></li> <li>Continue indapamide and Repeat U&Es routinely (e.g. 4 weeks) then reassess</li> </ul> <p><b>Management</b></p> <ul> <li>If potassium still newly low on repeat and timeline fits with indapamide, can usually continue indapamide. Encourage bananas and tomatoes. Recheck U&Es periodically</li> <li>If due to D&V, use sick day rules: temporarily stop indapamide and restart when better</li> <li>If unrelated to indapamide and is chronic, assess for reversible causes including check magnesium. Low magnesium will make the hypokalaemia resistant to treatment. Correct any magnesium deficiency** which may sometimes correct potassium. If on digoxin, give potassium supplements and aim for K+ ≥ 4.5 long term since lower K+ levels increase the risk of digitoxicity (even at normal serum digoxin levels)</li> <li>If no reversible causes and no concerning underlying cause, advise dietary supplementation (e.g. bananas, tomatoes, avocados, potatoes)</li> <li>Recheck U&Es periodically</li> </ul> <div class="redbutton" style="font-size:12px; font-weight:normal; width: -webkit-fill-available; text-align:left; background-color:#1f4395;"> <p><b>**How to correct low magnesium</b> <br>Oral Supplementation: </p> <ol> <li>First Line: Magnesium aspartate dehydrate – Magnaspartate®. 1-2 sachets daily (= 10-20mmol Mg) for 3 days</li> <li>Second Line: Magnesium glycerophosphate – YourMag®. 2 x 4mmol tablet three times a day (= 24mmol Mg) for 3 days</li> </ol> <p>Recheck Magnesium blood levels after 1-2 weeks. Repeat 3 day course if still low.</p> </div> </div> – recheck K+ in 4 weeks. If still low but mild, continue indapamide.
      • Moderate 2.5 - 2.9 <div class="navybox"> <p style="color:orange;"><b>Moderate (2.5 - 2.9 mmol/l)</b></p> <p><b>When to repeat</b></p> <ul> <li>Compare with previous results - if new change, repeat U&Es within 24 hours.</li> <li>If persistent on recheck and due to starting indapamide / thiazide, switch to ARB instead (e.g. losartan 50mg OD [25mg in elderly]).</li> <li>If due to D&V, use sick day rules: temporarily stop indapamide and restart when better</li> <li>If no reversible causes, advise dietary supplementation (e.g bananas, tomatoes, avocados, potatoes) AND oral supplements (e.g. SandoK one TDS).</li> <li>Recheck U&Es in 1 week</li> </ul> <p><b>Management</b></p> </div> – recheck K+ in 24 hours. If still moderately low, switch to losartan.
      • Severe < 2.5 <div class="navybox"> <p style="color:red;"><b>Severe ( &lt; 2.5 mmol/l)</b></p> <p><b>When to repeat</b></p> <ul> <li>Admit</li> </ul> <p><b>Management</b></p> <ul> <li>Admit</li> </ul> </div> – Admit


      REMEMBER AKI SICK DAY RULES

      AKI SICK DAY RULES

      When unwell with any of the following: Vomiting, diarrhoea, or general dehydration due to intercurrent illness, then STOP taking the medicines listed below (restart after feeling well/after 24-48hrs of eating and drinking normally):

      • ACE Inhibitors, ARBs, NSAIDs, Diuretics, Metformin, Sulfonylureas, SGLT2 inhibitors (e.g. Empagliflozin)

      For further details, see: www.nice.org.uk/advice/KTT17/chapter/Evidence-context



      If still resistant hypertension consider repeat HBPM/ABPM and then consider referral for A&G.

      Titrate up Amlodipine and Losartan to maximum tolerated before referral to A&G.


      * Supporting Clinical Information

      Check U&Es, if indicated, as per usual practice e.g. when starting or up-titrating ACEi / ARB or diuretics.

      If a patient has a ADR then consider another drug from the same group e.g. patient suffering from ankle oedema with Amlodipine can be switched to Lercanidipine.

      Benefits of phased dual therapy - Reduces risk of side effects e.g. sudden symptomatic drop in BP and allows identification of any agent specific side effects.

      When patients commence 4th line Spironolactone, the recommended potassium checks are at 2 week, 6 week and then 6 monthly long-term.

      Preferred first line drugs if other comorbidities:

      • Diabetes / Heart Failure / Previous MI = ACEI or ARB
      • Symptomatic Angina = Betablocker
      • CKD with Proteinuria = ACEI or ARB

      Shared Decision Making & Lifestyle

      Treatment and care should take into account people’s needs and preferences. People with hypertension should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.

      Shared decision making with patients and lifestyle advice should be considered at every stage of the treatment protocol. Encourage as many patients as possible to use self BP monitoring at home.

      Signpost to website for further advice on where to purchase Home BP monitors and how to use guides.

      Medication adherence should be considered at every stage of the treatment protocol.

      There is lots of helpful information including a ‘looking after your heart’ resource booklet to help support conversations with patients. You can find these on the website: www.westyorkshireandharrogatehealthyhearts.co.uk

      Patients should be encouraged to use community pharmacy services, such as: www.nhs.uk/live-well/healthy-body/how-your-pharmacist-can-help

      Patients and clinicians are encouraged to utilise Me and My Medicines resource; a campaign led by patients and supported by clinical staff to help people raise concerns and use their medicines better. www.meandmymedicines.org.uk


    • If not controlled < 135/85 HBPM or ABPM

      ARB - Losartan 50mg OD increase to 100mg if needed

      ↓
      If not controlled < 135/85 HBPM or ABPM

      4th Line Hypertension Therapy

      +
      Spironolactone 25mg daily
      Monitoring Spironolactone: CAN START IF K+ < 4.5 AND GFR > 45
      If K+ > 4.5 then use alpha / beta blockers and titrate up

      ↓
      If not controlled < 135/85 HBPM or ABPM

      Referral for Advice and Guidance:
      Same day: Accelerated Hypertension or suspected Pheochromocytoma
      Routine: Age under 40 with Hypertension / If Secondary Hypertension suspected / unresponsive to 4th line therapy

    • Lipid Treatment Guidance

      Guidance: Lipid management for patients with CVD and risks of CVD (for patients under 85-years-old - excluding frailty and women of child bearing age < 55years)

    • Shared Decision Making

      Outline the risks and benefits of statin treatment, taking into account lifestyle modifications, comorbidities, polypharmacy, general frailty and life expectancy

      Lifestyle

      Lifestyle to be considered fundamental to this guidance. Lifestyle helps to reduce future CVD risk. Statins are effective at reducing cholesterol. Both important

      ↓

    • Show patients the QRISK 2/3 risk assessment tool qrisk.org/three
      and/or
      NICE: Statin patient decision aid

      Signpost to details provided on
      westyorkshireandharrogatehealthyhearts.co.uk /cholesterol
      meandmymedicines.org.uk

      Women of childbearing potential and patients over 85 years old
      • Women of childbearing potential can still have statin dose optimisation, but they should be invited to speak to a health professional about teratogenic risks of statins and precautions that need to be taken. Statins are contraindicated in pregnancy and precautions should be continued for 1 month after stopping a statin. Statins are less commonly routinely prescribed to women under the age of 55 as they tend to have lower 10yr CVD risks.
      • Guidance is aimed at < 84 years. For people 85 years or older consider Atorvastatin 20 mg as statins may be of benefit in reducing the risk of nonfatal myocardial infarction, taking into account patient choice, comorbidities, polypharmacy, general frailty and life expectancy

    • CKD 3 and above (regardless of cholesterol level or risk of CVD)
      QRISK2 > 10% 10 year Cardiovascular Risk
      Diabetes Type 1 who are older than 40 or nephropathy or had T1DM for more than 10 years or other CVD risk factors

      Pre-treatment blood tests and familial hypercholesteroaemia

      Before starting lipid modification therapy take full lipid profile and check ALT

      • Total / (HDL) / Non-HDL / Triglycerides. A fasting sample is not needed

      Please consider

      Familial hypercholesterolaemia and Hyperlipidaemia in anyone with a total cholesterol >7.5mmol/L or LDL >4.9 mmol/ - Talk to patients to get family history

      Familial hypercholesterolaemia affects c.1 in 325. NHS Long Term Plan commitment to improving the genetically confirmed detection of FH from 7% to 25% by 2024 (January 2019)

      Criteria for Specialist Lipid Clinics / Familial Hypercholesterolaemia (FH) - Adults

      ↓

      Usually Atorvastatin 40mg

      Second Line (those intolerant to Atorvastatin)

      Initiate one month of Rosuvastatin 5 mg once daily - doubled to 10 mg daily for primary prevention on repeat prescription after one month if no reported side effects

      Sometimes
      Atorvastatin 20mg

      Scenarios
      Concerns about dosage
      Potential sensitivity of those of South Asian/East Asian (e.g. Chinese & Japanese)

      ↓

      Aim for Total cholestrol < 4mmol/l or > 40% reduction in baseline non-high density lipoprotein (HDL) with up-titration to 80mg Atorvastatin if required

      Target supporting clinical information

      The aim of treatment is to achieve a pragmatic target of < 4 mmol/l of total cholesterol (since many practices are only measuring total cholesterol), or ideally, a more precise target of > 40% reduction in baseline LDL or non-HDL levels. If the clinician prefers to aim for absolute targets in LDL, the European Society of Cardiology (ESC) targets are a great evidence-based choice:

      • LDL-C < 3 mmol/L in moderate risk patients
      • LDL-C < 2.5 mmol/L in high riskpatients
      Post-treatment blood tests monitoring

      Repeat lipid profile and ALT after 3 months

      • Total / (HDL) / Non-HDL / Triglycerides. A fasting sample is not needed
      • Check ALTs at baseline and at 3 months. No further checks required after starting statin unless clinical concern (e.g. liver disease)

      Show patients targets / progress to help behaviour change

      If target not achieved discuss adherence / understanding and timing of dose / diet and lifestyle

      • If commenced on 20mg atorva, consider increase to 40mg

      Provide annual medication reviews for people taking statins. Consider an annual non-fasting full lipid profile to inform the discussion (if needed to assess or support adherence/response)

    • Established CHD/IHD/MI, Ischemic Stroke & TIA, PAD

      Pre-treatment blood tests and familial hypercholesteroaemia

      Before starting lipid modification therapy take full lipid profile and check ALT

      • Total / (HDL) / Non-HDL / Triglycerides. A fasting sample is not needed

      Please consider

      Familial hypercholesterolaemia and Hyperlipidaemia in anyone with a total cholesterol >7.5mmol/L or LDL >4.9 mmol/ - Talk to patients to get family history

      Familial hypercholesterolaemia affects c.1 in 325. NHS Long Term Plan commitment to improving the genetically confirmed detection of FH from 7% to 25% by 2024 (January 2019)

      Criteria for Specialist Lipid Clinics / Familial Hypercholesterolaemia (FH) - Adults

      ↓

      Recommended
      Atorvastatin 80mg

      Second Line (those intolerant to Atorvastatin)

      Initiate one month of Rosuvastatin 5 mg once daily - dose to be increased gradually at intervals of at least 4 weeks up to 20 mg once daily for secondary prevention.

      ↓

      Aim for Total cholestrol < 4mmol/l or > 40% reduction in baseline non-high density lipoprotein (HDL)

      Target supporting clinical information

      The aim of treatment is to achieve a pragmatic target of < 4 mmol/l of total cholesterol (since many practices are only measuring total cholesterol), or ideally, a more precise target of > 40% reduction in baseline LDL or non-HDL levels. If the clinician prefers to aim for absolute targets in LDL, the European Society of Cardiology (ESC) targets are a great evidence-based choice:

      • LDL-C < 1.8 mmol/L in secondary prevention
      Post-treatment blood tests monitoring

      Repeat lipid profile and ALT after 3 months

      • Total / (HDL) / Non-HDL / Triglycerides. A fasting sample is not needed
      • Check ALTs at baseline and at 3 months. No further checks required after starting statin unless clinical concern (e.g. liver disease)

      Show patients targets / progress to help behaviour change

      If target not achieved discuss adherence / understanding and timing of dose / diet and lifestyle

    • What if a patient experiences muscular side effects?
      If muscle pains develop: Check Creatine Kinase
      • If CK normal and pains intolerable, stop statin for 6 weeks and then re-challenge with statin at the same or lower dose
      • If truly intolerant to Atorvastatin, try Rosuvastatin as second line.
      • If still intolerant, reducing to once or twice weekly dosing is worthwhile.
    • Consider if statin-attributed symptoms favour continuation/reinitiation
    • 2 - 4 week washout of statin

      ↓

      Symptoms persist: statin re-challenge

      ↓

      Symptoms improve: Then try second statin: e.g. Rosuvastatin 5mg OD

      ↓

      If symptoms re-occur: Try a third low dose different statin (e.g. Pravastatin, Atorvastatin or Rosuvastatin)

      ↓

      Seek specialist advice if still not tolerated - e.g. referral to a lipidologist or, if available, to an Advanced Cardiology Medicines Optimisation Clinic

    • 6 week washout of statin until normalisation of CK/creatinine and symptoms

      ↓

      Low dose second efficacious statin (e.g. Atorvastatin or Rosuvastatin). If already tried Atorvastatin, second line is Rosuvastatin 5mg OD)

      ↓

      Seek specialist advice if still not tolerated - e.g. referral to a lipidologist or, if available, to an Advanced Cardiology Medicines Optimisation Clinic

      *Consider Rhabdomylosis if there is severe muscle pain, general weakness, sign of myoglobinaemia or Myoglobinuria or CK > 10 x ULN
      Stop statin immediately
      Do not restart that particular statin regimen
      Discuss with hospital specialist urgently to consider admission

    • CK level < 10 x ULN

      ↓

      Continue statin at the same or lower dose
      CK level > 10 x ULN*

      ↓

      Discontinue statin (discuss urgently with hospital to consider admission)

      ↓

      Seek specialist advice if still not tolerated - e.g. referral to a lipidologist or, if available, to an Advanced Cardiology Medicines Optimisation Clinic

      *Consider Rhabdomylosis if there is severe muscle pain, general weakness, sign of myoglobinaemia or Myoglobinuria or CK > 10 x ULN
      Stop statin immediately
      Do not restart that particular statin regimen
      Discuss with hospital specialist urgently to consider admission

    • Diabetes Treatment guidance - COMING SOON

      Diabetes Treatment guidance in development