Hypertension in adults
Hypertension in adults-diagnosis and management. A summary of 2019 NICE guidance.
Measuring –Automated machines cannot measure accurately if a pulse irregularity exists e.g AF- use a manual method Postural hypotension is suspected ♦ measure BP supine or seated ♦ check again- interval atleast 1 minute with person standing ♦ a drop of 20 or more , when standing reflects a postural drop - in such cases - review medication - measure subsequent bp with the person standing - refer specialist care if the symptoms of postural hypotension ( e.g falls or postural
Equipment -validated , maintained and calibrated Both at home and clinic settings – standardise the environment and provide a relaxed , temperate setting person should be quiet , seated , arms outstretched and supported use the correct cuff size
Diagnosis-Hypertension diagnosis suspected-measure BP in both arms if the difference is > 15 mm hg- repeat difference persists > 15 on 2nd measurement , measure subsequent BP in the arm with the higher BP. BP equal to or > 140/90 -take a 2nd reading during the consultation 2nd reading -substantially different from 1st- take a 3rd reading record the lower of the last 2 measurements as the clinic bp. offer ABPM if ABPM not suitable offer HBPM If BP > 180/120 or higher. Investigate while awaiting confirmation of a diagnosis.-for target organ damage CV risk assessment using a tool for e.g QRisk2
ABPM-ensure atleast 2 measurements / hr-during usual waking hours e.g between -800 and 2200 use average value of atleast 14 measurements to confirm a diagnosis
HBPM-for each BP recording , 2 consecutive measurements are taken , atleast 1 min apart and with the person seated and twice daily recording continues for atleast 4 days ideally 7 Discard 1st day readings- use the average value of the remaining to confirm a diagnosis
Diagnose hypertension-clinic bp of 140/90 or higher ABPM daytime average or HBPM average of 135 /85 or higher
Stage 1 is ♦ clinic BP 140/90 to 159/99 mmHg ♦ subsequent HBPM from 135/85 to 149/94 Stage 2 ♦ clinic BP of 160/100 or higher but < 180/120 and subsequent ♦ ABPM daytime average or HBPM average BP of 150 /95 or higher Stage 3 or severe hypertension ♦ clinic systolic BP of 180 or higher or ♦ clinic diastolic BP of 120 or higher
target organ damage without hypertension-If hypertension is not diagnosed but tests indicated target organ damage – look for alternative causes and carry out further investigations ( NICE recommends visiting guidance on CKD and chronic heart failure )
Hypertension not diagnosed-measure BP atleast every 5 yrs more frequently if bp nearer to 140/90 annually in people with type 2 diabetes with no pre-existing hypertension or renal disease reinforce lifestyle measures advice
Referral-Refer specialist if secondary causes suspected- remember most patients have primary hypertension but 5-10 % may have an underlying potentially reversible cause
BP > 180/120- Severe hypertension but no symptoms or signs indicating same-day referral check for end organ damage ASAP if target organ damage found- consider starting treatment without waiting for ABPM or HBPM result If no target organ damage- repeat clinic BP within 7 days. ♦ signs of retinal haemorrhage or papilloedema or ♦ life-threatening symptoms as new onset confusion , chest pain , signs of heart failure or acute kidney injury suspected phaeocromocytoma - refer same day
Cardiovascular risk assessment-Formal CV risk estimation using ♦ clinic BP ♦ estimate CV risk in line with recommendations on identifying and assessing CV disease risk in NICE guideline on CV disease Discuss prognosis and healthcare options – both for raised BP and modifiable risk factors. protein in urine -ACR ratio and test for haematuria using a reagent strip HbA1C Us and Es with eGFR Total cholesterol and HDL cholesterol Examine fundi 12 lead ECG
Treatment-Offer to all people with suspected or diagnosed and continue to offer periodically Diet , exercise patterns Alcohol Coffee and caffeine rich products- discourage excessive consumption Low dietary sodium intake – reduce or substitute sodium salt Do not offer calcium , magnesium or potassium supplements for reducing BP Smoking Local initiatives.
Offer treatment to adults of any age with persistent stage 2 hypertension Adults aged under 80 with persistent stage 1 hypertension + any 1 or more of the following ♦ target organ damage ♦ established CV disease ♦ renal disease ♦ diabetes ♦ estimated 10 yr CV disease risk of 10 % or more Discuss individual CV risk preferences , risks, benefits & lifestyle incl no treatment People > 80 with a clinic BP of > 150/90 ♦ consider treatment + lifestyle Adults < 60 with stage 1 hypertension and an estimated 10 yr risk below 10 % ♦ consider treatment ♦ take into account that 10 yr CV risk may underestimate the lifetime probability of developing CV disease Adults < 40 with hypertension ♦ consider referral ♦ may need further investigations for secondary causes and to ♦ discuss benefits and risks of long-term treatment
Target-Age < 80 ♦ clinic BP < 140/90 ♦ ABPM / HBPM < 135/85 Age > = 80 yrs ♦ clinic BP < 150/90 ♦ ABPM / HBPM < 145/85 Frailty or multimorbidiy- use clinical judgement
This is for people with or without type 2 diabetes CKD- see separate NICE guidance People with isolated systolic hypertension should be treated in same way as people with both raised systolic and diastolic BP An ARB is preferred over ACEi in adults of black African or African- Caribbean family origin
Confirm resistant hypertension – confirm elevated BP with ABPM or HBPM , check for postural hypotension and discuss adherence Consider seeking specialist advice or adding a : low dose spironolactone if K + level is < = 4.5 mmol/l alpha blocker or beta blocker if blood K + level is > 4.5 mmol/l Seek expert advice if BP is uncontrolled on optimal tolerated doses of 4 drugs.
References Secondary Hypertension : Discovering the Underlying Cause Am Fam Physician . 2017 Oct 1; 96 (7) : 453-461 NICE proposes lower threshold for treating high blood pressure Hypertension in adults : diagnosis and management NICE Guideline 136 August 2019 NICE updates hypertension guidelines by Felix David Trends in Urology and Men’s Health NICE Pathways- hypertension