Causes include:

• Essential
• Renal disease
• Endocrine disease – hypercortisolism, primary aldosteronism (PA) or Conn’s syndrome, acromegaly, phaeochromocytoma
• Coarctation of the aorta
• Iatrogenic – corticosteroids, NSAIDs, COCP
• Recreational drugs – cocaine, anabolic steroids, amphetamines, liquorice use

Signs and Symptoms:

Hypertension is often asymptomatic. Measure blood pressure (BP) to case find opportunistically, or in those with a clinical indication.

Refer for same-day specialist assessment if:

• clinic BP 180/120mmHg and higher with:
  • signs of retinal haemorrhage or papilloedema (accelerated hypertension),

or

• life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury
• suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor, abdominal pain or and diaphoresis)

If there are no symptoms or signs indicating same-day specialist assessment, assess for target organ damage as soon as possible:

• If target organ damage identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
• If no target organ damage, repeat clinic BP measurement within 7 days or ensure a clinic review within 7 days if monitoring using ABPM/HBPM.

• Palpate pulse prior to taking BP as irregular pulse may affect automated BP monitors
• Use an appropriately sized cuff
• Measure BP in both arms. If difference in readings between arms is greater than 15mmHg, repeat the measurements. If difference is greater than 15mmHg on second measurement, measure subsequent BPs using arm with higher reading.
• If initial BP between 140/90 to 179/119 mmHg, offer Ambulatory or Home BP Measurement
• Postural hypotension: for those at risk of postural hypotension (Over 80y, T2DM, symptomatic (falls/postural dizziness), BP is recommended to be checked sitting and standing. If there is a significant drop (equal to or greater than 20mmHg in SYSTOLIC BP on standing for 1 minute (from sitting/lying)), standing blood pressure readings should be used for subsequent monitoring BP readings

NICE guidance uses ambulatory or home monitoring to classify as stage 1 or stage 2 hypertension:

Stage 1 hypertension:

• Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg AND
  • subsequently Ambulatory Blood Pressure Monitoring (ABPM) daytime average or Home Blood Pressure Monitoring (HBPM) average blood pressure is 135/85 mmHg to 149/94 mmHg

Stage 2 hypertension:

• Clinic blood pressure of 160/100 mmHg or higher (but less than 180/120 mmHg) AND
  • subsequently ABPM daytime average or HBPM average blood pressure is 150/95 mmHg higher

Stage 3 or severe hypertension:

• Clinic systolic blood pressure 180 mmHg or higher or clinic diastolic blood pressure 120 mmHg or higher

Please see red flag section above. If there are no symptoms or signs indicating same-day specialist assessment, assess for target organ damage as soon as possible:

• If target organ damage identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
• If no target organ damage, repeat clinic BP measurement within 7 days or ensure a clinic review within 7 days if monitoring using ABPM/HBPM.

Indications to Evaluate Patients for Secondary Hypertension

• Acute rise in blood pressure in a patient with previously stable reading
• Age of onset before puberty
• Age younger than 40
• Severe hypertension - clinic systolic blood pressure 180 mmHg or higher or clinic diastolic blood pressure 120 mmHg or higher
• Resistant hypertension: defined as hypertension that is not controlled in adults taking the optimal tolerated doses of an ACE inhibitor or an ARB plus a CCB and a thiazide-like diuretic
• Suspected renal disease e.g., abnormal urinalysis / elevated urinary protein
• Suspected primary aldosteronism (PA) or Conn’s syndrome (found to occur in as many as 5-10% of adults with hypertension)
  • Hypokalaemia (spontaneous or diuretic-induced)
  • Resistant hypertension (especially if lower than 50 or FH of hypertension or CVE lower than 40)
  • All hypertensive first-degree relatives of patients with PA

1. Offer lifestyle advice to all:

Non-pharmacological lifestyle interventions should be offered initially and then periodically to people undergoing assessment or treatment for hypertension.

Non-pharmacological measures; weight reduction, reduced salt intake, reduced fat intake, limited alcohol consumption, aerobic exercise and increased fruit and vegetable consumption are effective in lowering BP (level 1 evidence).

Weight reduction

• Recommendation: Maintain BMI 20-25
• Expected SBP reduction: 5-10mmHg per 10kg weight loss

DASH eating plan

• Recommendation: Diet rich in fruit, vegetables, low-fat dairy produce
• Expected SBP reduction: 8-14mmHg

Dietary sodium restriction

• Recommendation: lower than 6g salt per day (= 2.4g sodium or 100mmol)
• Expected SBP reduction: 2-8mmHg

Physical activity

• Recommendation: At least 30 minutes most days
• Expected SBP reduction: 4-9mmHg

Alcohol moderation

• Recommendation: Men and 21 units or under per week, women 14 units or under per week
• Expected SBP reduction: 2-4mmHg

Alone or in combination these interventions can reduce the need for drug therapy and enhance the effect of antihypertensive agents. A favourable effect on cardiovascular outcome is assumed, but not proven.

To reduce overall cardiovascular risk, patients should stop smoking, reduce total fat and saturated fat intake and increase consumption of monounsaturated fats and oily fish.

2. Check for end-organ damage:

• Examination
  • Fundoscopy
• Blood tests
  • Renal function test
  • HbA1c
  • Lipid profile including total cholesterol and high-density lipoprotein (HDL) cholesterol (non-fasting)
• Urine tests
  • Urine for ACR (more sensitive than urine dipstick test)
• ECG

3. Calculate cardiovascular disease (CVD) risk using the QRISK3 risk assessment tool to assess risk for the primary prevention of CVD in people up to and including age 84 years.

Do not use the risk assessment tool for patients with established cardiovascular disease.

Stage 1 hypertension:

• Over 80 years of age with clinic BP over 150/90mmHg, consider starting antihypertensive drug treatment (use clinical judgement for people with frailty or multimorbidity)
• Under 80 years of age, discuss starting antihypertensive drug treatment with people who have one or more of the following:
  • target organ damage
  • established cardiovascular disease
  • renal disease
  • diabetes
  • a 10-year risk of cardiovascular disease of 10% or more
• Under 60 years of age with 10-year risk of cardiovascular disease below 10%, consider antihypertensive drug treatment. Encourage healthy lifestyle changes.
• Note, the evidence of benefit from treatment for people with a low cardiovascular risk is uncertain. Bear in mind that 10-year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease.
• Under 40 years of age, consider seeking specialist evaluation of secondary causes of hypertension and assessment of long-term benefits and risks of antihypertensive drug treatment.

Stage 2 hypertension:

• Offer antihypertensive drug treatment to adults of any age.
• Under 40 years of age, consider seeking specialist evaluation of secondary causes of hypertension and assessment of long-term benefits and risks of antihypertensive drug treatment.

Stage 3 or severe hypertension:

• Clinic systolic blood pressure 180 mmHg or higher or clinic diastolic blood pressure 120 mmHg or higher
• Please see red flag section above.
• If there are no symptoms or signs indicating same-day specialist assessment, assess for target organ damage as soon as possible:
• If target organ damage identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
• If no target organ damage, repeat clinic BP measurement within 7 days or ensure a clinic review within 7 days if monitoring using ABPM/HBPM.

Postural Hypotension:

• If there is a significant drop (equal to or greater than 20mmHg in SYSTOLIC BP on standing for 1 minute (from sitting/lying)), standing blood pressure readings should be used for subsequent monitoring BP readings

Frailty/multimorbidity:

• Use clinical judgement

4. Medication choice

• For more information please refer to NICE guidance NG136 / choosing antihypertensive drug treatment. Devon Formulary treatment options can be found here:
  • Section 2.5 Hypertension and heart failure (North & East / South & West)
• Offer patient education: impact of asymptomatic condition on CVD risk, knowledge of targets and importance of adherence to drug treatment
• Target levels
  • Clinic readings:
  • • BP less than 140/90 in patients aged under 80
    • BP less than 150/90 in those 80 and over
  • ABPM/HBPM readings:
    • BP less than 135/85 in patients aged under 80
    • BP less than 145/85 in those 80 and over

5. Monitoring drug treatment

• Review annually including BP, adherence, lifestyle, renal function, and if obese also check HbA1c

Referral Criteria

• Suspected secondary hypertension (see investigation section)
• If unable to control BP with four medications
• If unable to control BP with three medications and other complicating factors

Referrals may be returned if the criteria are not evident in the referral letter.

Referral Instructions

e-Referral Service Selection

• Specialty: Cardiology
• Clinic Type: Hypertension
• Service: DRSS--Cardiology-Devon ICB- 15N

Referral Form

DRSS Referral Form

Evidence

NICE guidance NG133 Hypertension in pregnancy

British Hypertension Society - how to measure blood pressure

NICE guidance NG136 Hypertension in adults: diagnosis and management

Pathway Group

This guideline has been signed off on behalf of NHS Devon

Publication date: November 2017

Updated: August 2023