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HYPERTENSION (Diagnosis: Suspect hypertension if BP 140/90mmHg or higher.,…
HYPERTENSION
Diagnosis
: Suspect hypertension if BP 140/90mmHg or higher.
Home BP monitoring
to confirm - BP twice daily. 2 consecutive measurements are taken, at least 1 minute apart with person seated. for 7 days
Note:
suspect a
'white coat effect
' in people with persistently raised clinic blood pressure readings whose home or ambulatory blood pressure monitoring readings are lower, with a discrepancy of more than 20/10 mmHg. They may also exhibit signs in clinic such as tachycardia, sweating, or palpitations.
INVESTIGATIONS
INITIAL
LIPID PROFILE: TOTAL CHOL, HDL,LDL & TRIG alsoFBC U&E LFT TFT : CLINIC urine : send for ACR
Estimate the person's 10-year risk of developing cardiovascular disease (CVD) using the Assign
score
ECG
— to assess cardiac function and detect left ventricular hypertrophy
Blood pressure should be measured in
both arms
. If the difference in readings between arms is
more than 20 mmHg
, repeat the measurements. If the difference in readings between arms remains more than 20 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading.
MANAGMENT
L
IFESTYLE ADVICE *
Diet & exercise advice, stress management, smoking cessation, alcohol consumption.
MEDICATION
If the person has severe hypertension, consider starting antihypertensive drug treatment immediately, before obtaining results of ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM).
Examine the fundi for evidence of hypertensive retinopathy
Step 1 treatment:
< 55 years treatment with an angiotensin-converting enzyme (ACE) inhibitor. If an ACE inhibitor is not tolerated (for example, because of cough), offer a low-cost ARB. Do not combine an ACE inhibitor with an ARB to treat hypertension. African/Caribbean =CCB
Step 2 treatment
(if blood pressure is not controlled by step 1 treatment)
Add
in CCB in combination with either an ACE inhibitor or an ARB.
OR
ACE if on CCB
black people of African or Caribbean family
origin,
consider an ARB
in preference to an ACE inhibitor, in combination with a CCB
If a
CCB is not suitable
, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a
thiazide-like diuretic
.
.
Step 3 treatment
consists of a combination of an ACE inhibitor or angiotensin II receptor blocker, a calcium-channel blocker, and a thiazide-like diuretic.
Step 4 treatment
(if clinic blood pressure remains higher than 140/90 mmHg after ensuring that the person is concordant with treatment and that it is at optimal or best tolerated doses used in step 3 treatment)
Consider adding a f
ourth antihypertensive
drug and/or seeking expert advice. Options for drug therapy include:
Low-dose spironolactone (25 mg once daily)
if the blood potassium level is 4.5 mmol/l or lower (off-license use — informed consent should be obtained and documented). Use particular caution in people with a reduced estimated glomerular filtration rate because of increased risk of hyperkalaemia.
Higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5 mmol/l. When using further diuretic therapy, monitor blood sodium and potassium and renal function within 1 month, and repeat as required thereafter.
An alpha
(doxasosin)- or beta-blocker if further diuretic therapy is contraindicated, not tolerated, or ineffective.
If blood pressure remains
uncontrolled
with the
optimal
or
maximum tolerated doses of four drugs,
refer for advice.
Annual review
-Check BP, re-assess CVD risk :QRISK2, check renal function, review medication dosage - side effects, lifestyle - smoking, exercise, alcohol, diet.
Definition
Hypertension is persistently raised arterial blood pressure.
Hypertension clasifications
Stage one hypertension
— clinic blood pressure at least 140/90 mmHg, and subsequent ABPM daytime average or HBPM average at least 135/85 mmHg.
Stage two hypertension
— clinic blood pressure at least 160/100 mmHg, and subsequent ABPM daytime average or HBPM average is at least 150/95 mmHg.
Severe hypertension
— clinic systolic blood pressure at least 180 mmHg or clinic diastolic blood pressure at least 110 mmHg.
Primary hypertension
- no identifiable cause.
Secondary hypertension
- result of a known underlying cause eg. Conn's adenoma, renovascular disease or phaeochromocytoma.
Accelerated hypertension
— clinic blood pressure usually higher than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage.
Risk factors
Age, sex, ethnicity, genetic factors, social deprevation, lifestyle, anxiety & emotional stress.
Refer
the person for same-day specialist care if they have:
Blood pressure higher than 180/110 mmHg
with signs of
papilloedema
and/or retinal haemorrhage (accelerated hypertension).
Suspected*
phaeochromocytoma*
(renal tumour) IF(labile or postural hypotension, headache, palpitations, pallor, and diaphoresis).
