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Hypertension, Classification of Hypertension Stage 1 hypertension —…
Hypertension
Diagnosis
Ensure a quiet and relaxed environment for obtaining measurement
Measure both arms, if difference > 15mmHg, repeat. If remains high, use higher high for subsequent readings.
Postural hypotension measure BP with person supine/seated and then measure again after standing for at least 1 minute. If reading falls > 20mmHg measure subsequent BPs when standing
If greater than 140/90 mmHg or higher take second reading, if different, take a third. Record the lower of the last two measurements.
Between 140/90 mmHg and 180/120 mmHg offer ambulatory (ABPM) or home monitoring (HBPM) to confirm diagnosis.
Carry out investigations for target organ damage and evaluate cardiovascular risk.
BP 180/120 mmHg or higher, refer for same-day specialist assessment if there are signs of retinal haemorrhage and/or papilledema or life threatening symptoms such as new onset confusion, chest pain, signs of heart failure or AKI. If no symptoms indicating same-day referral carry out investigations for target organ damage as soon as possible and consider commencing antihypertensive immediately.
If hypertension confirmed classify the severity: Stage 1, Stage 2 and stage 3.
If hypertension not diagnosed with evidence of target organ damage carry out investigations for CKD and Heart failure. No evidence of organ damage measure in clinic BP at least every 5 years or more frequently depending on clinical judgement.
Risk Factors
Ethnicity
Genetic factors
Sex: Men under 65, women over 65.
Genetic factors
Age
Social deprivation
Lifestyle
Anxiety and emotional stress
Management: Referral not indicated
Carry out investigations of target organ damage
Formal assessment of cardiovascular risk for QRISK
Lifestyle advise: diet and exercise, caffeine, dietary sodium, smoking, alcohol.
Offer information leaflets on hypertension
Stage 2: Offer antihypertensive drug treatment in addition to lifestyle advise
Stage 1: Consider antihypertensive drug treatment alongside lifestyle advise dependent on clinical judgement, age, target organ damage, cardiovascular risk and other risk factors.
Under 40 years old: seek specialist evaluation of secondary causes of hypertension.
NICE: Hypertension diagnosis and treatment summary:
https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517
Investigations for Target organ damage
Electrolytes, creatinine, and eGFR (test for CKD)
Examine the fundi (hypertensive retinopathy)
HbA1C (diabetes)
Arrange 12-lead ECG (assess cardiac function and detect left ventricular hypertrophy)
Urine albumin : creatinine ratio (test for presence of protein in urine)
Consider if specialist investigation required in those with signs and symptoms of secondary cause
Test for haematuria
Complications/Increased Risk with Hypertension
Heart failure
Coronary artery disease
Stroke
Chronic Kidney Disease
Peripheral arterial disease
Vascular dementia
Secondary causes of Hypertension
Renal disorders : Most common secondary cause. Chronic pyelonephritis, diabetic nephropathy, glomerulonephritis, polycystic kidney disease, obstructive uropathy, renal cell carcinoma.
Vascular disorders: Coarctation of the aorta, renal artery stenosis.
Endocrine disorders: Primary hyperaldosteronism, phaeochromocytoma, Cushing's syndrome, acromegaly, hypothyroidism, hyperthyroidism.
Drugs and other substances: Alcohol, Ciclosporin, cocaine and other substances of abuse, combined oral contraceptive, corticosteroids, erythropoietin, leflunomide, liquorice, NSAIDs, sympathomimetics and venlaflaxine.
Other: Connective tissue disorders, retroperitoneal fibrosis, obstructive sleep apnoea.
Annual Review
Check renal function by measuring serum creatinine, electrolytes, eGFR and dipstick urine to check proteinuria.
For those not on antiplatelet drug or a statin, reassess cardiovascular disease risk by using the QRISK assessment tool
Check BP - If out with target range confirm this is persistent. Assess for secondary causes and consider additional antihypertensive drugs.
Adherence to treatment
Offer information on hypertension
Antihypertensive Drug Treatment
Angiotensin-converting enzyme (ACE) inhibitor (Ramipril) or angiotension-II receptor blocker (ARB) (Losartan) - (aged under 55 year who are not of black African or African-Caribbean family origin)
Calcium-channel blocker(CCB) (Amlodipine) - For those aged 55 years or over and people of black African or African-Caribbean family origin.
Thiazide-like diuretic (Indapamide) - If there is evidence of heart failure
First step:
See guidelines for second step
Investigations: Cardiovascular Risk
Serum total cholesterol and high density lipoprotein (HDL) cholesterol
Estimate 10-year risk of developing CVD using QRISK assessment tool
Management: Same-day referral
Clinic BP of 180/12 mmHg or higher with signs of retinal haemorrhage and/or papilloedema, or life threatening symptoms such as new onset confusion, chest pain, signs of heart failure or AKI.
Hypertension is persistently raised arterial blood pressure. The current threshold for suspecting hypertension is clinic systolic blood pressure sustained above or equal to 140 mmHg, or diastolic blood pressure sustained above or equal to 90 mmHg, or both. There are different types of hypertension: Primary, Secondary, Accelerated (malignant), White Coat or Masked.
Classification of Hypertension
Stage 1 hypertension — clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 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 subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.
Stage 3 or severe hypertension — clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.