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Key points
- Up to a third of adults in the UK have hypertension – defined as clinic blood pressure sustained at or above 140/90mmHg
- As many as 14 per cent of adults have hypertension that is untreated
- Hypertension is the most important risk factor for cardiovascular disease – particularly stroke and coronary heart disease – which causes 25 per cent of deaths in the UK
- The pharmacist-run advanced service for hypertension case-finding in England is an opportunity to screen for and identify previously undiagnosed hypertension, primarily in those over the age of 40 years
- People in deprived areas are more likely to have hypertension and are more likely to be undiagnosed. It is hoped that the service may go some way to address inequalities related to diagnosing hypertension and improve access to this important aspect of preventative care
- The whole of the pharmacy team can be involved in engaging and involving patients in BP checks
- The service depends on good working relationships and communication with local general practices
By June 2022 it was estimated that over 115,000 BP checks had been carried out by the 7,200 pharmacies registered for the service.2
Through hypertension case-finding, pharmacists can suggest or make interventions (primary prevention) to help people who may be largely symptom-free but are at increased risk of developing cardiovascular disease in the future. They can offer lifestyle advice and refer for treatment, where indicated.
How big is the problem?
Hypertension is persistently raised arterial blood pressure. The prevalence increases with age and it affects as many as a third of adults. Unless blood pressure is very high it is not classed as a disease but one of the main risk factors for coronary heart disease, stroke, heart failure and chronic kidney disease. It is estimated that high blood pressure is causally associated with 50 per cent of all strokes and heart attacks.3
In the 2019 Health Survey for England, 28 per cent of adults had blood pressure greater than 140/90mmHg. Overall, 14 per cent of men and 11 per cent of women had hypertension that was untreated.4 Untreated hypertension was higher in men at a younger age (22 per cent of 55 to 64 year-olds) than in women of the same age (13 per cent) and case-finding in men indicates a high area of unmet need.
Although this is based on a survey, other studies using GP clinical records support these findings. From studies such as these it has been estimated that there are at least 5 million people in England who have hypertension that remains undiagnosed. Case-finding by pharmacists can help to find these people and start to manage the most serious risk factor for cardiovascular disease.
Inequalities and the role of pharmacy teams
It is important to note that the need for detection is greater in areas where deprivation is more common, as people in these areas get hypertension at an earlier age and are less likely to be diagnosed or treated.
For example, it has been estimated that residents of deprived areas are 30 per cent more likely to have hypertension than those in more affluent areas. In the Health Survey for England, the prevalence of untreated hypertension was highest in the North West (17 per cent) and North East (16 per cent), and lowest in London, Yorkshire and the Humber, and the South East (10 per cent).4
Heart and circulatory diseases are a leading cause of morbidity and mortality in England (and in the UK as a whole). In 2019 they caused 24 per cent of all deaths in England (a similar proportion in both women and men).3 More than half of the population will get circulatory disease in their lifetime.
Of major concern are premature deaths from CVD (defined as deaths occurring before the age of 75 years). More than 37,000 people under the age of 75 in England die from circulatory disease each year. These premature deaths are more common in men (women get the disease later in life); 25 per cent of all premature deaths in men and 17 per cent in women are from cardiovascular disease.
As with hypertension, there is a strong link to deprivation and where people live. Those aged between 25-44 years in the North of England are 47 per cent more likely to die from heart and circulatory diseases than those in the South.3
The inverse-care law was a phrase coined over 50 years ago to describe how people living in deprived areas were less likely to seek care or have access to care and were more likely to go untreated. This still applies today and it is hoped that the hypertension case-finding service provided by pharmacists in England can go at least some way to redress this balance.5
Hypertension case-finding service criteria
- An adult over the age of 40 years who has not previously been diagnosed with hypertension
- An adult under the age of 40 years who has a recognised family history of hypertension and requests the BP check
- An adult aged between 35-39 years and assessed as eligible for the service by the pharmacist
- Those referred by a GP for a blood pressure check or ambulatory blood pressure measurement (as agreed locally with general practices).
To provide the service, community pharmacists in England must:
- Be familiar with the NICE guideline Hypertension in adults: diagnosis and management (NG136)6
- Have read and understood the operational processes to provide the service as described in the service specification
- Have completed the recommended training on how to use the blood pressure monitoring equipment, which should be provided by the equipment manufacturer/supplier.
Pharmacists wanting to undertake further training on hypertension, understanding vascular risk and behavioural change interventions, can do so on an optional basis to support their own continuing professional development. An example of additional learning is the CPPE module on hypertension.7
The whole pharmacy team can promote this service and support the recruitment of patients. Teams should be briefed on the service and coached on how to best approach people. A pharmacy team briefing and guide on how to recruit patients is available to assist contractors to engage and coach their team members.
The service has four main components:
- Identifying people at risk of hypertension and offering them blood pressure measurement (a so-called ‘clinic check’)
- Where clinically indicated, offer 24-hour ambulatory blood pressure monitoring (ABPM). The blood pressure test results will then be shared with the patient’s GP to inform a potential diagnosis of hypertension
- General practices can refer patients to a participating community pharmacy for a clinic blood pressure reading or for 24-hour ambulatory blood pressure monitoring (via locally agreed arrangements). This helps to share the work of managing these patients and may be more convenient for them
- Offering lifestyle advice.
Equipment used in the service must be validated by the British and Irish Hypertension Society (BIHS), so contractors must use a conventional BP meter or an ABPM device that is included on one of the two following BIHS lists:
Stages of hypertension: thresholds and referral
An arbitrary threshold is set to describe hypertension as blood pressure persistently greater than 140mmHg systolic or 90mmHg diastolic when measured in a clinic setting. In people at higher risk of cardiovascular disease, this level of blood pressure is usually treated if it is persistently this high.
Formal risk calculators such as QRISK3 can help to determine the level of risk.9 Diagnosis in the community can involve ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) if the clinic reading is greater than 140/90mmHg after several readings. In these cases a lower level is set (135/85 mmHg) as clinic readings are usually higher.
The revised NICE 2019 blood pressure guideline (NG136) recommends ABPM in preference to HBPM initially (HBPM is indicated if ABPM is unsuitable or the patient cannot tolerate it).6 The pharmacy hypertension case-finding service encourages the use of ABPM, so this should widen access to this diagnostic tool. HBPM remains a useful tool for monitoring blood pressure once a diagnosis has been confirmed.
The threshold for hypertension usually requiring treatment irrespective of CVD risk is greater than 160mmHg systolic or 100mmHg diastolic. One way to think of this is as the threshold at which high blood pressure becomes a disease, rather than simply a risk factor.
Hypertension stages
Clinic blood pressure ranging from 140/90mmHg to 159/99mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85mmHg to 149/94mmHg
Clinic blood pressure of 160/100mmHg or higher but less than 180/120mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95mmHg or higher
Clinic systolic blood pressure of 180mmHg or higher or clinic diastolic blood pressure of 120mmHg or higher.
Damage to organs such as the heart, brain, kidneys and eyes. Examples are left ventricular hypertrophy,
chronic kidney disease, hypertensive retinopathy or increased urine albumin:creatinine ratio
A severe increase in blood pressure to 180/120mmHg or higher (and often over 220/120mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage.
Most cases (90 per cent) are primary, or essential, hypertension, which have no identifiable cause. Secondary hypertension occurs in about 10 per cent of people and has a known underlying cause, such as a renal, endocrine or vascular disorder, or the use of certain drugs (e.g. oral contraceptives). Basic blood tests are usually done to look for secondary hypertension or organ damage before starting drug therapy.
Hypertension occurring in younger people (below the age of 40 years) requires more extensive investigation. These patients are usually referred to a specialist.
Referral criteria
ABPM shows an average blood pressure of 135/85mmHg or higher but lower than 150/95mmHg. Refer to see GP within three weeks.
Average blood pressure of 150/95mmHg or higher. Refer urgently to see GP same day.
A blood pressure of 180/120mmHg or higher. Urgent same day referral.
Patients with blood pressure lower than 90/60mmHg who experience regular fainting or falls, or feel like they may faint on a daily/near daily basis. Urgent same day referral
Patients with blood pressure lower than 90/60mmHg who experience dizziness, nausea or fatigue will receive advice promoting healthy behaviours and be advised to see their GP within three weeks. If they are at risk of falls, this should be an urgent same day referral
If the blood pressure monitor indicates an irregular pulse, this should be an urgent same day referral to GP.
“Evidence suggests that undertreated hypertension is common with up to half of all people with diagnosed hypertension not reaching recommended BP targets.”
Some GPs have expressed concern that the referral recommendations in the hypertension case-finding service are overcautious and that ‘same day’ assessment is unrealistic given the pressures in primary care.
In other words, if followed to the letter, referrals may overload provision of acute care on a day-to-day basis.
Because of this, it is important that pharmacists engage with local GP services, perhaps involving their primary care network, to decide how best to use these referral pathways and avoid overloading an already-stretched system.
Lifestyle advice
The pharmacy hypertension case-finding service specification advises following NICE guidance on lifestyle interventions:6
- Contributing factors to hypertension should be identified. These include diabetes, obesity, excessive alcohol intake (>3 units/day), high salt intake and physical inactivity
- Ask about diet and exercise patterns. A healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audio-visual materials to promote lifestyle changes
- Ask about alcohol consumption and encourage a reduced intake as this can reduce blood pressure and also has broader health benefits
- Discourage excessive consumption of coffee and other caffeine-rich products
- Encourage keeping dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. Note that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin II receptor blockers
- Do not offer calcium, magnesium or potassium supplements as a means of reducing blood pressure
- Offer advice and help smokers to quit
- Inform patients about local initiatives carried out, for example, by healthcare teams or patient organisations that provide support and promote healthy lifestyle change, especially those that include group work for motivating behavioural changes.
Equipment check
Many patients now purchase blood pressure monitors but some of these devices are of dubious quality – so it is important to ensure that the equipment used by patients is accurate. Here is a list of devices validated for home use.
Medication management
Evidence suggests that undertreated hypertension is common, with up to half of all people with diagnosed hypertension not reaching recommended targets. Pharmacists have a valuable role in following up patients with hypertension and advising them (and their GPs) if they suspect their treatment needs to be altered or intensified.
Another key issue is whether antihypertensive therapies are being taken as prescribed or perhaps only intermittently. Pharmacy teams have a vital role to play in encouraging patient adherence to therapy.
Dr Martin Duerden, FRCGP, is co-author of the book, Symptoms in the Pharmacy (Ninth Edition), to be published in September 2022
Case study
A woman in her 40s is asking for some NRT patches to help her give up cigarettes. She is a heavy smoker on 20-30 cigarettes a day and has smoked for 25 years. She is overweight and struggles to keep her weight down. She managed to stop smoking once for about three months but put on weight.
She has a family history of diabetes, two of her grandparents died of a heart attack in their 70s and her 60-year-old uncle has angina. She saw her GP about a year ago, who said her blood pressure was “borderline”. She was supposed to go back for a review but has not been yet.
Discussion
The patient should be asked to describe her previous attempts to quit, including whether she used any NRT products bought OTC or provided on the NHS.
Community pharmacies can provide support and NRT either sold over the counter or at no cost to the patient as part of local NHS smoking cessation services.
Many people are concerned that they will put on weight when they stop smoking and this should be discussed. The health benefits of stopping smoking far outweigh any added risk from additional weight gain.
As the pharmacy provides the NHS Blood Pressure Check Service, this can also be offered. If her blood pressure is over 140/90 mmHg on several readings, then ambulatory blood pressure monitoring is advised. If it remains high a referral to the GP surgery is indicated – perhaps to see the practice nurse or pharmacist in the first instance.
However, because of her other issues with being overweight and the family history, alongside checking for hypertension she should also be encouraged to attend the GP surgery – possibly to see the practice nurse (or practice pharmacist) first.
The surgery might want to consider some blood tests such as lipid profile, HbA1C, electrolytes and renal function, and liver function. In addition, a urine test checking for proteinuria and glycosuria would be useful and, possibly, an ECG too.
Community pharmacists can have a significant continuing role in supporting this person to improve her lifestyle, particularly with smoking cessation and blood pressure monitoring, in collaboration with the GP practice if indicated. If the patient is able to lose weight and increase exercise, this would help to lower her blood pressure.
Resources and references
- Pharmaceutical Services Negotiating Committee. Hypertension case-finding service
- Pharmacy Magazine. Pharmacies provide over 115k blood pressure checks since service launch
- BHF Heart Stats Factsheet, January 2022
- Health Survey for England, 2019
- Editorial (2021). 50 years of the inverse care law. The Lancet; 397(10276):767. doi: 10.1016/S0140-6736(21)00505-5
- NICE August 2019. Hypertension in adults: diagnosis and management. NG 136
- Training Matters Centre for Pharmacy Postgraduate Education (CPPE). Hypertension
- Pharmaceutical Services Negotiating Committee. Briefing for pharmacy teams on hypertension case finding service
- QRISK3-2018 risk calculator.
Clinical
In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.