|Back to main Menu|
|Back to Clinical|
8BL0. Patient on maximal tolerated antihypertensive therapy
246% O/E - blood pressure reading,
G73.. Other peripheral vascular disease
G73y. Other specified peripheral vascular disease (v26)
G73z. Peripheral vascular disease NOS
G73z0 Intermittent claudication
G73zz Peripheral vascular disease NOS
Gyu74 [X]Other specified peripheral vascular diseases
G734. Peripheral arterial disease
This exception is only applicable for the first ‘ever’ diagnosis of PAD for the patient. For a subsequent diagnosis, this exception rule is not considered.
Most cases of PAD are managed in primary care. The focus of treatment is on
the cardiovascular complications of atherosclerosis (that is, managing cardiovascular
risk factors such as high blood pressure). Two small UK studies assessing clinical
risk management based on the medical records of patients with PAD suggest that
these patients have poor hypertension control, use low levels of statin and
antiplatelet therapy, and receive low levels of smoking cessation advice. This
indicator addresses the issue of blood pressure control.
Bradley L, Kirker SG. Secondary prevention of arteriosclerosis in lower limb vascular amputees: a missed opportunity (2006) European Journal of Vascular and Endovascular Surgery 32: 491-493
Khan S, Flather M, Mister R et al. (2007) Characteristics and treatments of patients with peripheral arterial disease referred to UK vascular clinics: results of a prospective registry. European Journal of Vascular and Endovascular Surgery 33: 442-450
The SIGN guideline on the diagnosis and management of PAD, 89, recommends that hypertensive patients with PAD should receive treatment to reduce their blood pressure. The guideline developers noted that treatment of PAD has often been considered difficult because ofconcerns that antihypertensive drugs, especially beta blockers, may have adverse effects on PAD (for example, possible drug-induced peripheral vasoconstriction leading to further ischaemia in the leg).The developers did not find any strong evidence to suggest that beta-blockers should not be used in the presence of PAD, although no study was sufficiently large to demonstrate an absence of adverse events with certainty.
Recommendation 2.6 in the SIGN guideline does not specify a target blood pressure in patients with PAD. However, the guideline developers considered that 140/90 mmHg is a desirable upper limit and that around one third to one half of patients with PAD would be considered hypertensive above this level.
The NICE clinical guideline on Hypertension sets blood pressure thresholds for the initiation of drug treatment of hypertension and these are outlined in the rationale for the hypertension domain. All patients aged under 80 years with CVD and stage 1 hypertension (clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 or higher) are recommended drug therapy for hypertension.
The NICE clinical guideline on Hypertension recommends a target clinic blood pressure below 140/90 mmHg in patients aged 79 or under with treated hypertension and a clinic blood pressure below 150/90 mmHg in patients aged 80 years and over, with a treated hypertension.
For the purpose of QOF, a measurement of 150/90 has been adopted for this indicator.
Health economic modelling of PAD and the costs and consequences of treating high blood pressure over a patient’s lifetime suggests that this treatment is a cost effective use of NHS resources.
NICE CG127. Hypertension: clinical management of primary hypertension in adults.
See indicator wording for requirement criteria.
Prepared By Jean Keenan