Newsletter - Spring 2003 edition
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Letter from the Editor | Report from the BHS Blood Pressure Monitor Committee (BPMC) | European Society of Hypertension | Questionnaire Results - Nurses and Pharmacological Treatment in Hypertension | Diary Dates | Job Opportunity: Peart-Rose Clinic, St Mary’s Hospital | Blood Pressure Association - an update | Hypertension in the elderly - a brief overview | BHF: Sudden death in adults
Letter from the Chair - Susan Kennedy
Since the publication of the last newsletter the NHA committee have been working hard on your behalf. Firstly I would like to thank all the nurses who returned their questionnaire on prescribing in hypertension. There is a short report on the results in this newsletter and there will be a presentation at the Scientific Meeting in September with opportunity for discussion. Questionnaires are a useful method to determine general information and possibly identify areas that require further research. It would be good if we could now undertake some qualitative interviews on some of the prescribing issues raised.
The Spring Update meeting was initially established as an opportunity for our membership to attend an event together. Latterly it has been advertised to other nurses in and around the area where the event took place, it was also an opportunity to raise some funds. Unfortunately for the last two years, apart from committee members, the response has been so poor that we would have lost money on running this. I would like to thank both Sally Brett and Alison Cox for all their hard work booking venues, advertising and writing to speakers etc. It was not an easy decision to cancel but it is the view of the committee that the Spring Update Meeting is no longer attracting either our own membership or local nurses. A new format will be tried next year. As a pilot there will be a Hypertension Meeting for all nurses in Scotland in the Autumn. The programme will be announced at the Scientific Meeting and could be a template for other regions to follow in the Spring. This has to be an event that raises money for the NHA otherwise attendance at the Scientific Meeting will not be subsidised. It is clear from comments and rates of attendance at this meeting that it remains the most important aspect of your NHA membership.
As intimated at the last AGM the finances of the NHA are currently poor. I wrote to the BHS in the autumn warning that the current arrangements for our attendance at the Scientific Meeting may not be viable in 2004. In response the BHS invited myself to join their committee meeting in May to discuss this situation. I found this meeting to be very positive and the committee to be receptive to our difficulties. They have been most supportive and have offered to assist the NHA financially over the next two years. It is important for the membership to realise that this is to allow us to establish a more reliable method of regular income. As it stands the NHA require to find over £300 for each nurse who attends the Scientific meeting, this is approximately £14,000 / year. In the past three years there has only been one large donation from HIT. As many of you are aware the pharmaceutical companies have in many cases joined together and it is increasingly difficult to receive donations. For the NHA to be given money from them requires us to assist them in some way. This usually means volunteered time either writing, teaching or attending meetings which many of us do not have. It is imperative that all members whether attending the AGM or not think about ways we can raise funds on a more regular way. I will be delighted to hear from anyone who would like to offer their services in any way. Brian Williams will address the NHA AGM to discuss this matter further with us.
The website continues to be well used. Alison, our secretary, responds to various requests every week and we are very grateful to her for this. It is essential that the profile of the NHA should be raised if we are to grow. If therefore you are asked to represent nurse about hypertension do let people know you are a member of the NHA. As soon as you receive the application form for the Scientific Meeting be sure to return this as soon as you can. If you have any difficulty registering then please let Alison Cox, the secretary, know as it is often possible to ask one of our own members who are also BHS members to invite you as a guest.
I hope you find the second edition of this longer newsletter to be of interest and I look forward to seeing and hearing of many of you again in Cambridge.
Susan Kennedy
Letter from the Editor - Sally Brett
I do hope you enjoy the second edition of your newsletter. Thank you to all those people that sent in information and articles that they wanted to be included in the newsletter in order to reach the NHA membership. Once again I send out a plea to anyone who has anything that they wish to be included to let me know, (sally.brett@kcl.ac.uk). This can include articles, adverts for courses or jobs or just general information that they wish to share with the NHA membership.
We are all looking forward to the Annual Scientific Meeting in September, held this year at St John's College, Cambridge. The response to a call for abstracts has been good. Year on year NHA members appear to be becoming more confident when it comes to writing abstracts and presenting their own work. The purpose of the meeting has always been to provide a friendly atmosphere in which nurses in the field of hypertension can present research to an informed audience. Hopefully this continues to be the case.
Hampton Medical Conferences Ltd will be in touch in due course with information on registration and the provisional programme.
Sally Brett
Report from the BHS Blood Pressure Monitor Committee (BPMC)
I was nominated by the NHA committee to represent the NHA on this new BHS committee and I attended the first meeting at the end of March. It is intended that the BPMC will meet once a year and correspond regularly via email for the rest of the year. Our remit is to appraise current validation criteria for BP monitors and laying down the criteria to be adopted by the BHS for the validation of such monitors to include home, clinic, 24hr ambulatory and beat to beat BP devices. We will assess on a regular basis the published evidence on the validation of all new BP monitors and provide additional information over and above that of the validation process on these devices. The committee will liase closely with the BHS Information Service and answer queries submitted relevant to its remit.
The BPMC will consider the BHS response to the removal of mercury sphygmomanometers in clinical practice.
It was thought of value if more information than just validation criteria could be included on each monitor such as price, availability of cuffs, prices of accessories including cuffs and attachable printers, robustness in clinical use, servicing/repair costs and ease of calibration. Towards this end it was suggested that all members of the BHS and members of the NHA would be contacted for them to feedback experiences with individual, currently available, monitors.
We will shortly be sending every NHA member a questionnaire to this effect and would be grateful if you could complete and return it quickly so that we can collate the results well in advance of the Scientific meeting in September. You can refer to the BHS website, which will be updated regularly, for the latest devices that have been approved. The Microlife monitors at the time of writing have not been approved; several protocol violations were noted and the authors are to be contacted to seek clarification of several issues. I would be very interested to hear if you have any views, good or bad, on the monitors that you are using please give as much information as you can on the questionnaire.
Clare Addison - NHA committee member
The European Society of Hypertension
The ESH publish their newsletter on their website, www.eshonline.org
This newsletter is in journal form and is full of original articles and relevant information.
Questionnaire Results - Nurses and Pharmacological Treatment in Hypertension
Many thanks to the 63 NHA members out of a possible 103 who returned the questionnaire about their views on possible prescribing trends. You may already have received a request to complete another questionnaire this time on different manometers in your practice and invite at least 10 other nurses to also complete one for their area of clinical practice. The committee feel that we need to have some information about our membership so that we can represent you at a higher level. The results of the first questionnaire have been very useful and hopefully you will make a special effort to return the BP measurement one too. The BHS have approved this manometer questionnaire and would like to present the results at the September Scientific meeting.
The letter accompanying the questionnaire explained why the NHA decided to undertake this survey. Both Independent and Supplementary Prescribing training has bee established in the UK therefore the role of the nurse in prescribing is developing. As nurses belonging to an organisation with a special interest in hypertension there is no information about your views in this area. So far the analysis of the results is descriptive and for the purpose of this short report there are three sections.
The nurses who responded were working in different areas. The majority worked in secondary care (39%), then research (37%), primary care (13%) with 16% working both in research and secondary care. There were a small number who did not currently care for patients with hypertension directly. Nurses who were currently initiating hypertension medication numbered 18 and about half did this with doctor supervision, i.e. the doctor wrote the prescription for the nurse who took it back to the patient. The other half did this under a research protocol. A very few were using Patient Group Directives. Some nurses did not indicate how they were doing this. The pattern was very similar for altering medication, with slightly more stating they did this under research protocol. There were only eight primary care staff represented in this survey, nearly all indicated in the comment section that they had a good partnership with their general practitioner sharing some responsibility for changing treatment regimes.
Nurses were asked to decide if they definitely agreed, agreed, possibly agreed, or disagreed with 10 statements about prescribing issues. Table 1 shows the results. The nurses mainly agreed with statements b,c,d,e,and g. It was interesting to note that the results were similar for a and f which both raised the issue of nurses initiating new treatment. The respondents were divided about this. Interestingly there was strong disagreement about the role of the pharmacist in h and i. Finally most nurses did not agree with a health care assistant undertaking the assessment of blood pressure.
The final section raised the issue of training or education to undertake supplementary prescribing over and above the statutory requirement for legally prescribing. Only 2 nurses thought that there would be no need for anything further. Three did not know. Many respondents ticked more than one box. The most popular qualification identified was that of a Specialist Nurse Qualification (no. 39 nurses), closely followed by a disease specific course on hypertension (no. 34 nurses). There were also 20 nurses indicating the need for chronic disease management courses. The most popular combination was disease specific course and a specialist nurse qualification. It appears that the NHA respondents think that supplementary prescribing should be supported by further education, interestingly 21% think this should be at Masters level.
Further analysis will be conducted and presented at the Scientific Meeting and it is hoped that there will be time to discuss some of the implications of this survey. Many thanks to all who took the time to respond and those of us on the small group who devised the questionnaire hope that the results have been of some interest to you.
| Statement on Hypertension Prescribing | Definitely Agree | Agree | Possibly Disagree | Disagree |
|---|---|---|---|---|
| a) Nurses could initiate medication for untreated hypertension after nurse assessment and diagnosis | 6 | 22 | 16 | 27 |
| b) Nurses could initiate medication for untreated hypertension at the request of a medical practitioner | 24 | 22 | 13 | 3 |
| c) Nurses could discontinue medication for hypertension because of side effects | 20 | 24 | 16 | 2 |
| d) Nurses could add a new medication for hypertension if blood pressure target not reached | 20 | 26 | 13 | 3 |
| e) Nurses could increase the dose of a medication for hypertension if blood pressure target not reached | 29 | 21 | 11 | 1 |
| f) Nurses could use own knowledge/skills to decide which medication for hypertension to initiate | 9 | 20 | 25 | 8 |
| g) Nurses could follow a protocol on medication for hypertension that includes choosing type and dose to be used | 35 | 19 | 7 | 1 |
| h) Pharmacists could initiate medication for untreated hypertension after nurse assessment | 2 | 12 | 26 | 22 |
| i) Pharmacists could initiate medication for hypertension after health care assistant assessment of blood pressure | 0 | 3 | 6 | 53 |
| j) Doctors could initiate medication for hypertension after health care assistant assessment of blood pressure | 3 | 12 | 16 | 31 |
By Susan Kennedy with thanks to Pat Hamilton (Derbyshire Royal Infirmary) and Victoria Wharfe (Manchester Royal Infirmary)
Diary Dates 2003
Annual Autumn Scientific Meeting - St. Johns College, Cambridge
Monday 15th - Wednesday 17th September 2003 (NHA members only)Our scientific meeting is held annually in September in conjunction with the British Hypertension Society.
There will be several guest speakers, members will present their own research and abstracts will be published in the Journal of Human Hypertension.
The meeting will be held at:
St. Johns College
University of Cambridge
Cambridge
CB2 1TP View
Map to St Johns College
Website: www.joh.cam.ac.uk
Notification will be sent out to all NHA members in due course by Hampton Medical Conferences Ltd. We look forward to seeing you there.
St Georges Hospital Medical School - Meetings for Nurses 2003
7th October 2003
Hypertension for Nurses
cost: £50
For further information contact:
Nirmala Markandu
Hon Senior Lecturer/Clinical Manager
Blood Pressure Unit
St Georges Hospital Medical School
London
SW17 0RE View
Map to St Georges Hospital
Tel: 020 8725 2849
Fax: 020 8725 2959
Research for Cardiovascular Health in the Community
Monday 30th June 2003 Queen Elizabeth II Conference Centre
Broad Sanctuary
Westminster
London
SW1P 3EE See
Map to QEII Conference Centre
This one day event will include a series of presentations to be given by key researchers who have undertaken studies relevant to the prevention, diagnosis and treatment of coronary heart disease. All the work undertaken will support the delivery of the National Services Framework for Coronary Heart Disease and has been funded via various sources.
This conference will be of interest to anyone with an active interest in current R&D undertaken across the NHS. Presentations will cover work undertaken in both primary and secondary care.
The day will feature speakers including Sir John Pattison, Director of Research, Analysis & Information and Dr Roger Boyle, National Director of Heart Disease, Department of Health. There is no charge to delegates. CPD approval has been granted for this event by the Royal College of Physicians.
For further information, a booking form and draft programme please contact:
Beverley Hilton bhilton@liv.ac.uk, 0151 794 4887.
European Society of Hypertension
13th - 17th June 2003
13th European Meeting on Hypertension
Milan, Italy
Job Opportunity: Peart-Rose Clinic, St Mary's Hospital
F Grade Nurse
An exciting opportunity exists to join the multi-disciplinary team at the Peart-Rose Clinic. The Clinic specialises in Hypertension, Heart Failure & Cardiovascular Disease Prevention.
The Peart-Rose Clinic is part of the Department of Clinical Pharmacology and the International Centre for Circulatory Health. The ICCH is a ground breaking collaboration between St Mary's Trust and Imperial College. The Clinic leads many of the research activities within this initiative.
We are looking for a proactive, enthusiastic and caring individual who will enjoy working in a challenging environment. An ability to organise your own workload, work to tight deadlines and excellent interpersonal skills are essential to the role.
You must have relevant experience, preferably within Hypertension or Cardiovascular Medicine.
For further information please contact Dr Simon Thom, 020 7886 1172, s.thom@imperial.ac.uk or Rodney Brooks, 020 7886 1521, rodney.brooks@st-marys.nhs.uk
Blood Pressure Association - an update
The Association is gearing up for its third national blood pressure testing week, which runs from September 15th to 21st. Letters will shortly be going out to all those who took part last year and I hope that those of you that had pressure testing stations last year will take part again.
In 2002, volunteers set up and manned almost 1500 pressure testing stations throughout the UK and we tested close to 100,000 people. For some it was the first time they had had their blood pressure checked and many of the readings were found to be high.
There was extensive media coverage, and accurate reporting of hypertension and its impact on health.
This year's event looks to be bigger again. We hope you will make it a part of your annual calendar of events. If you would like to know more about the week, please contact Donna Robertson for more information on 020 8772 4992.
The BPA has taken on a new member of staff, Gemma Heiser, and part of her work will be to develop a regional network of local groups to help people with hypertension to support each other. If you think that your local community would benefit from a 'support group' please contact Gemma on 020 8772 4989 for more details of the programme.
A new booklet called Medicines for High Blood Pressure will be available from the beginning of June. Copies are free to individual members of the public and available to health professionals in bulk for a small fee. All NHA members will receive a sample copy when the booklet becomes available, along with an order form.
Sarah Ransome, Information and Support Manager
Hypertension in the elderly - a brief overview
Measuring BP in the elderly can be problematic. Several factors are known to influence the accuracy of indirect BP measurement. Amongst these rigidity of the arterial wall can cause overestimation and a large auscultatory gap can cause underestimation of SBP. There are also large SBP falls between readings that can cause falsely high SBP levels being recorded if only the first reading is taken. Orthostatic falls in BP may be missed if a standing BP is not taken.
Renal function declines with age but is not clinically significant unless it is accelerated by the presence of renal parenchymal disease or renal arterial disease. Renal failure due to renal atheroma is more common in the elderly. The possibility of reduced renal blood flow in these patients makes them more susceptible to renal impairment as a result of ACE inhibitor treatment. Elderly patients are also more sensitive to sodium depletion produced by diuretic treatment.
Compensatory cardiovascular reflexes may be impaired in the elderly as a result of impaired baroreceptor sensitivity. This would reduce the capacity for sustaining BP in response to standing upright or volume depletion. Because the prevalence of cardiac failure increases rapidly the tolerance of drugs with a negative inotropic action such as b-blockers is reduced.
Cerebrovascular disease is much more common in the elderly making BP reduction important in these patients, however the presence of extra and intra cranial vascular disease means patients are much more liable to cerebral ischaemia as a result of excessive BP lowering. Confusion and forgetfulness may contribute to poor compliance with medication.
While the proportionate risk associated with hypertension is no greater in an elderly population, the absolute risk of a stroke or heart attack is much greater. Therefore the individually risk associated with hypertension is high and the potential benefits of treatment are great.
BHF: Sudden death in adults
From the BHF press office:
SUDDEN DEATH IN ADULTS:
COULD REMEDIES FOR ’COMMON COMPLAINTS’ BE MAKING PEOPLE VICTIMS OF MYSTERY HEART KILLER?
The British Heart Foundation (BHF) is funding an important £1.6million project, which aims to discover whether hundreds of 'apparently healthy' adults in the UK could be at risk from potentially fatal heart arrhythmias after taking over-the-counter remedies for common complaints such as hay fever or indigestion.
The five year research programme, which is being launched today (29 April 2003) at the annual British Cardiac Annual Scientific Conference in Glasgow, will investigate around 500 cases of 'drug-induced' arrhythmia (abnormal heart rhythm) - hoping to provide some critical answers to this life threatening phenomenon.
Fears about the suspected link between some commonly prescribed drugs and fatal heart arrhythmia have already lead to the withdrawal of leading remedies such as Triludan (an antihistimine prescribed for hay fever) and Prepulsid (often taken for acid indigestion). However, some drugs - such as treatments for malaria or antibiotics for people allergic to penicillin - cannot be banned from widespread general use and it is therefore vital that 'at risk' individuals can be identified early so that GPs can consider alternative treatments.
The research team - based at St George's Hospital Medical School, London and the Drug Safety Research Unit (DSRU), Southampton, are now asking all consultant physicians and GPs throughout England to become involved in the project by identifying patients who have developed abnormalities of their ECG and / or heart rhythm after taking medicines which are known to have this serious side effect. It is hoped that around 2,000 'control' patients will also take part.
The study aims to improve understanding of this type of sudden death as a public health issue. However, research in this area is currently very limited due to under-reporting and the clinical difficulties in linking sudden death to drug therapy in retrospect, after that person has died.
Researcher, Dr Elijah Behr, says; "Although we are at the very early stages of this exciting new project, our goals are clear - to raise awareness of this phenomenon, to help us predict who might be at risk from it and to ultimately ensure safer prescribing practice by physicians, GPs and pharmacists."
It is believed that many of the people who could be at risk from this type of sudden cardiac death may suffer from mild forms of genetic conditions such as the Long QT or Brugada syndromes that may be uncovered by the drug. These are thought to be relatively rare conditions affecting the heart's rhythm (around 1 in 5-10,000) but because they are hard to detect, it is thought these cases could represent the tip of an iceberg.
In fact, many of these patients may carry the faulty genes which put them at risk from drug-induced sudden death but display no obvious signs (such as an abnormal heart rhythm during an ECG test) highlighting the importance of identifying and monitoring anyone who has experienced a suspected drug-induced arrhythmia.
It is also predicted that underlying abnormalities might be picked up in some of the cases referred to in this study - leading to appropriate medication or life saving interventions such as implantable cardioverter defibrillators (ICD). Researchers hope this will encourage GPs to take part in the project and refer any suitable candidates quickly.
Prof Saad Shakir of the DSRU, says; "This project is vitally important - not only because it has the potential to save lives in people who may have a yet undetected risk factor, but also to avert unnecessary panic about those drugs which are largely safe and beneficial to the majority of the population.
He adds; "We do not want to see drugs withdrawn from the market, especially if there is not a viable alternative for patients. We must remember it's not these remedies per se which pose a danger - but simply a small minority of people who cannot tolerate their effects. We therefore hope this grant will enable us to identify those people and ensure they are protected from the risk."
The first phase of this project will aim to generate a 'unique population' for future investigation, ultimately making drug-induced arrhythmia predictable and avoidable. The secondary aim of the study will lead to the development of drugs and therapies which can be tailored to an individual's genetic composition.
For more media information or to arrange an interview with one of the key researchers, please call Jo Hudson at the BHF press office on 020 7487 7178 or 020 7487 7172 or (out of hours) 07764 290381.
For details about how to become involved in the study, please contact: dare@dsru.org or 023 8040 8615