Hypertension

Scope

The diagnosis and management of adults presenting with high blood pressure (HBP)

Out of scope

Management of hypertension in pregnancy or women with child bearing potential (see NICE CG107), Hypertension in pregnancy)

For more information please refer to the Joint Formulary guidance on hypertension

Please note pre-referral criteria may be applied to referrals for patients with this condition.

To see information required please see Referral Section, referrals submitted without this information may be returned.

Key pre-referral criteria summary:

  • If concerns related to secondary cause
  • If unable to control BP with four medications
  • If unable to control BP with three medications and other complicating factors

Assessment

Causes

  • Essential
  • Renal disease
  • Endocrine disease – Cushings, Conns, carcinoid, phaeochromocytoma
  • Coarctation of the aorta
  • Latrogenic - corticosteroids

Signs and Symptoms

Hypertension is usually asymptomatic.

  • Measure blood pressure (BP) to case find opportunistically, or in those with a clinical indication.

Red Flags

BP greater than 180/110

  • Check for papilloedema or retinal haemorrhage
  • Admit if present
    • Otherwise consider starting treatment immediately.

Suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor and sweating) – admit patient

Investigations

  • Palpate pulse prior to taking BP as irregular pulse may affect automated BP monitors
  • Measure BP in both arms; if more than 20mmHg difference, use the higher reading arm
  • If initial BP greater than 140/90 offer ambulatory or home BP measurement

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

Stage 1 hypertension:

  • Clinic blood pressure is 140/90 mmHg or higher and
    • subsequently Ambulatory blood pressure monitoring (ABPM) daytime average or Home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher

Stage 2 hypertension:

  • Clinic blood pressure is 160/100 mmHg or higher AND
    • subsequently ABPM daytime average or HBPM average blood pressure is 150/95 mmHg higher

Severe Hypertension

  • Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher

For more information please refer to the Joint Formulary guidance on hypertension

Management

Check for end-organ damage

  • Renal function test
  • ECG
  • Fundoscopy
  • Urine for ACR (more sensitive than urine dipstick test)
  • Urine dip for haematuria (ignore if only 1+) Check for other risk factors
  • Lipids full profile including triglycerides, (non-fasting)
  • HbA1c
  • Excess alcohol and salt intake

Possible Secondary hypertension: check

  • Plasma aldosterone : renin ratio (phlebotomy to be done within the hospital where the laboratory is based as it needs to be processed rapidly)
  • 24 hour urine metanephrines
  • 24 hour urine cortisol

Calculate cardiovascular disease (CVD) risk using the QRISK2 http://www.qrisk.org/ risk assessment tool to assess risk for the primary prevention of CVD in people up to and including age 84 years.

Offer lifestyle advice to all

  • Smoking
  • Diet
  • Weight
  • Exercise

Stage 1 hypertension:

  • Offer drug treatment if aged under 80 and additional risk factors – diabetes, renal disease, CVD or 10 year risk greater than 20%, end organ damage

Stage 2 hypertension:

  • Clinic blood pressure is 160/100 mmHg or higher AND
    • subsequently ABPM daytime average or HBPM average blood pressure is 150/95 mmHg higher
  • Offer drug treatment to all

Severe Hypertension

  • Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher
  • Start drug treatment immediately.

Target levels are BP less than 140/90 in patients aged under 80 and less than 150/90 in those 80 and over.

  • Offer patient education: knowledge of targets and importance of adherence to drug treatment

If patient aged under 55

Step 1

  • ACE inhibitor or low-cost angiotensin ii receptor blocker (ARB)

Or

If person aged over 55 or black person of African or Caribbean family origin of any age:

Step1:

  • Calcium-channel blocker

Step 2:

  • ACE inhibitor or ARB + calcium-channel blocker

Step 3:

  • ACE inhibitor or ARB + calcium-channel blocker + thiazide-like diuretic

Step 4 – Resistant hypertension:

  • ACE inhibitor or ARB + calcium-channel blocker + thiazide-like diuretic + consider further diuretic or alpha-blocker or beta blocker
  • Consider seeking expert advice

Monitoring drug treatment

  • Review annually, check renal function, and if obese also check HbA1c

For more information please refer to the Joint Formulary guidance on hypertension

Refer to NICE guidance CG127 Clinical management of primary hypertension in adults for more detailed recommendations

Referral

Referral Criteria

  • If concerns related to secondary cause
  • 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

eReferral Service Selection

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

Referral Forms

DRSS Referral forms

Supporting Information

Evidence

British Hypertension Society

NICE guidance CG107 Hypertension in pregnancy:diagnosis and management

NICE guidance CG 127 Clinical management of primary hypertension in adults for more detailed recommendations.

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG

Publication date: November 2017

 

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