Hypertension: Clinical Management

In a station which involves diagnosing high blood pressure, here is what you need to know.

Table of Contents

New diagnosis of high blood pressure

Clinic Blood Pressure (BP):

Ideal: Below 140/90 mmHg – advise to recheck at least every 5 years

Stage 1 Hypertension: 140/90 to 159/99 mmHg – offer ABPM or HBPM

Stage 2 Hypertension: 160/100 to 179/119 offer ABPM or HBPM

Stage 3 Hypertension: If BP > 180/120mmHg, you have two options.

Refer for same day assessment to hospital if there are signs of retinal haemorrhage, papilloedema, confusion, chest pain, signs of heart failure or new AKI, headache, palpitations, sweating, pallor, abdominal pain or postural hypotension (drop more than 20mmHg systolic or 10mmHg diastolic from sitting to standing)
Carry out investigations asap in clinic if there might be signs of target organ damage. This can be identified by checking urine for haematuria and proteinuria (urine dipstick) + ACR, arranging for ECG and routine blood tests to check Hba1C, electrolytes and renal function. Follow up patient within 7 days to repeat BP.

2. Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM):

Used if clinic BP is between 140/90 and 179/119 mmHg, or if ABPM is declined or not tolerated.

If patient <40 and new diagnosis of hypertension, suspect secondary hypertension, which may indicate a referral is required for further investigations.

Management

Investigations: Examination, blood tests (Renal function, Hba1c, cholesterol), Urine (dipstick for haematuria and proteinuria and ACR), ECG, Fundoscopy

Advice:

Smoking: Offer smoking cessation
Diet and exercise: Advise healthy balanced diet (can send PIL) and advise 30 mins moderate intensity exercise 5 times a week
Caffeine: Reduce excessive consumption of caffeinated drinks (coffee, tea, energy drinks)
Reduce salt: Reduce salt in diet
Alcohol: If drinking more than 14 units per week, advise to reduce alcohol intake as this can also reduce blood pressure and contribute to other health benefits.
Offer Patient Information Leaflets such as this one: PIL on controlling blood pressure.

Prior to commencing blood pressure medication, it is important to always confirm the raised BP with either ABPM or HBPM.

ABPM/ HBPM

Stage 1 Hypertension: from 135/85 mmHg to 149/94 mmHg

Offer all the lifestyle advice mentioned above
Discuss starting antihypertensive drug treatment based on risk factors, for example if they are under 80 and have target organ damage, CVD, renal disease, diabetes or a QRisk >10%. Also consider it if <60 and QRisk is <10%.
If <40, consider specialist referral or further investigations to rule out secondary causes.

Stage 2 Hypertension: 150/95 mmHg or higher

Offer all the lifestyle advice from the above
Offer antihypertensive medication to ALL regardless of age.

Starting, Reviewing and titrating anti hypertensive medication

Always fully titrate a single medication to the maximum tolerable dose before starting another agent
Consider ARBs for people of black African or African Caribbean origin, instead of ACE Inhibitors.
Avoid ARBs and ACE Inhibitors if pregnant, breastfeeding or planning pregnancy.

1. Hypertension without Type 2 Diabetes:

Step 1: ACE inhibitor (ACEi) or Angiotensin-II Receptor Blocker (ARB), or Calcium Channel Blocker (CCB). This depending on age and ethnicity. If CCB not tolerated (e.g. due to oedema secondary to Amlodipine) you can also go directly to offering a thiazide diuretic (Indapamide) rather than an ACEi. Indapamide would also be more suitable if person has evidence of heart failure.

Step 2: Always check adherence! Then offer combination of ACEi or ARB with CCB or thiazide-like diuretic.

Step 3: Always check adherence! Then offer triple therapy with ACEi or ARB, CCB, and thiazide-like diuretic.

Step 4: Also known as resistant hypertension. Add low-dose spironolactone or consider alpha-blocker or beta-blocker and seeking expert advice at this stage. Resistant hypertension can be more tricky to manage so you wouldn’t be blamed if you were to refer to a specialist instead of starting a fourth line medication. You must also check for postural hypotension and re-confirm elevated BP with ABPM or HBPM.

For a better representation, check out this NICE Flowchart.

2. Hypertension with Type 2 Diabetes:

•Treatment choices align with those for patients without type 2 diabetes but tailored to individual needs.

Overall, aim for the following ABPM/ HBPM blood pressures:

<80 years old: BP below 135/85mmHg

80 years old: BP below 145/85mmHg

Annual review

Check and encourage adherence to treatment
Offer lifestyle advice again, considering the domains mentioned above e.g. smoking, diet, exercise, salt intake, alcohol and offer signposting, PILs or advice when appropriate
Check BP both in clinic and if raised, arrange ABPM/ HBPM to rule out white-coat hypertension
If patient complains of side effects from BP, change the class of antihypertensive
Annual bloods: Renal function inc. eGFR and urine ACR.
Ensure review next calendar year.