Hypertension
Diagnosis:
Pulse irregularity?
Manual measurement using direct auscultation over the brachial artery
BP: right: / mmHg
BP: left: / mmHg
Difference between arms more than 15 mmHg?
Repeated measurement: Difference remains more than 15 mmHg? Subsequent BP measurements in the arm with the higher reading
Symptoms of postural hypotension (eg postural dizziness)?
Repeated measurement after standing for at least 1 minute:
Systolic BP falls by ≥ 20 mmHg when standing?
Subsequent measurements while standing
BP ≥ 140/90 mmHg?
2nd measurement during the consultation
2nd measurement substantially different?
3rd measurement with recording of the lower of the last 2 measurements
BP between 140/90 mmHg and 180/120 mmHg?
Ambulatory BP monitoring (ABPM) to confirm the diagnosis of hypertension
ABPM is unsuitable or unable to tolerate it?
Home BP monitoring (HBPM) (by recording BP twice daily, ideally in the morning and evening, for at least 4 days, ideally for 7 days, by taking for each BP measurement 2 consecutive measurements at least 1 minute apart and with the person seated and discarding the measurements taken on the first day and using the average value of all the remaining measurements)?
BP ≥180/120 mmHg? Signs of retinal haemorrhage and/or papilloedema?
Life-threatening symptoms (eg new onset confusion, chest pain, signs of heart failure or acute kidney injury)?
Referral for same day specialist assessment
No symptoms or signs indicating same-day referral?
Investigations for target organ damage
Target organ damage?
Considered starting antihypertensive drug
No target organ damage identified?
Repeat BP in one week
Confirmation of diagnosis:
Clinic BP ≥ 140/90 mmHg + ABPM daytime average or HBPM average ≥ 135/85 mmHg
Stage 1 hypertension Clinic BP 140/90 - 159/99 mmHg + ABPM daytime average or HBPM average 135/85 - 149-94 mmHg
Stage 2 hypertension
Clinic BP 160/100 - 179/119 mmHg + ABPM daytime average or HBPM average ≥ 150/95 mmHg
Stage 3 hypertension
Clinic BP ≥ 180/120 mmHg
Suspected masked hypertension
Clinic BP < 140/90 mmHg + ABPM daytime average or HBPM average ≥ 140/90 mmHg
Investigations:
Target organ damage?
- Urine reagent strip for haematuria?
- Urine albumin:creatinine ratio? - Electrolytes?
- Creatinine, estimated glomerular filtration rate?
- Examination of fundi for the presence of hypertensive retinopathy?
- ECG?
- Total and HDL cholesterol?
- QRISK?
Secondary causes of hypertension?
Advised:
- Healthy diet
- Regular exercise
- Avoidance of excessive consumption of coffee and other caffeine-rich products
- Low dietary sodium intake (< 1/4 tsp per day, Action on Salt (free FoodSwitch App), free cookbook PDFs, recipe books (No-Salt Cookbook, Dash Diet Cookbook), BHF, recipe website that give nutritional info, e.g. Jamie Oliver)
- Smoking cessation if smoking
- Avoidance of excessive alcohol consumption
- Stress management
- Information from British Heart Foundation (BHF) ‘Blood pressure’ and British Dietetic Association (BDA) ‘Hypertension and diet’
Consider a trial of lifestyle optimisation for 3 months if BP is borderline elevated, especially where there are modifiable risk factors including obesity, excess salt or excessive alcohol intake
If clinic BP ≥ 160/100 mmHg (Home Average BP ≥ 150/95 mmHg) direct to step 2
Treat to Target: < 80: ABPM/HBPM < 135/85 mmHg (clinic < 140/90 mmHg) 80+: ABPM/HBPM < 145/85 mmHg (clinic < 150/90 mmHg)
Frailty or multimorbidity: clinical judgement
Step 1 Monotherapy:
If < 55 years + not of black African or African–Caribbean family origin?
Angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB)
If ≥ 55 years or black African or African–Caribbean family?
Calcium-channel blocker (CCB)
If CCB not tolerated (eg because of oedema)?
Thiazide-like diuretic (eg indapamide)
Evidence of heart failure?
Thiazide-like diuretic (eg indapamide)
Control after 4-6 weeks
Step 2 Dual therapy (ideally SPC):
ACEi or ARB + CCB
Control after 4-6 weeks
Step 3 Increased doses (ideally SPC):
Increased dose of ACEi or ARB and/or CCB
Control after 4-6 weeks
Step 4 Triple therapy (ideally SPC):
Add thiazide-like diuretic
Control after 4-6 weeks
Confirm resistant hypertension with HBPM/ABPM Discuss adherence and consider a SPC Consider other causes
Assess for postural hypotension
Initiate spironolactone
Consider referral for specialist advice
Step 5 Quadruple therapy:
Potassium ≤ 4.5 mmol/l?
Spironolactone 12.5 mg od (Note: particular caution if reduced estimated glomerular filtration rate because of increased risk of hyperkalaemia and monitoring of sodium, potassium and renal function within 1 month of starting treatment and repeat as needed thereafter)
Potassium > 4.5 mmol/l?
Doxazosin XL 4 mg od
Bisoprolol 2.5 mg od
Further options: Amiloride 5-10 mg od
ACEi Perindopril 4-8 mg od
Lisinopril 10-20 mg od
ARB Lorsartan 50-100 mg od
Candesartan 8-16 mg od
Ensure recent electrolytes and creatinine
Recheck in 4-6 weeks and at regular intervals
If eGFR decreased by > 25% or creatinine rises by > 30% STOP ACEi or ARB and recheck electrolytes and creatinine
Dihydropyridine CCB
Amlodipine 5-10 mg
Leranidipine 10-20 mg
Thiazide-like diuretic
Indapamide 2.5 mg od
Indapamide SR 1.5 mg od
Chlortalidone 25 mg od
Check electrolytes and creatinine within 2 months and at regular intervals in case of electrolyte disturbance consider stopping the drug and recheck electrolytes and creatinine
Emergency/same day referral: Malignant/accelerated phase hypertension with BP ≥180/120 mmHg and signs of retinal haemorrhage and/or papilloedema Hypertensive crisis with life threatening target-organ damage (even in the context of mild or severe hypertension) including, but not limited to, AKI, acute myocardial ischaemia, acute HF, acute stroke, phaeochromocytoma or acute aortic dissection
Severe hypertension in pregnancy
Pre-eclampsia
Routine referral:
Aged under 40 years at diagnosis, irrespective of current age
Suspected secondary hypertension, including, but not limited to - hyperaldosteronism (eg hypokalaemia) - phaeochromocytoma (eg palpitations, headache, flushing, family history, history of neurofibromatosis) - drug-induced hypertension (eg concomitant prescription of combined oral contraceptive pill or implant, hormone substitutes, steroids, NSAIDs, VEGF inhibitors, tyrosine kinase inhibitors (TKIs), tricyclic antidepressants, SSNRIs, dexamphetamine, methylphenidate)
Hypertension in pregnancy (requires a multi-disciplinary team approach)
Women who remain hypertensive postpartum
Resistant hypertension, uncontrolled on maximum tolerated doses of ACEi or ARB + CCB + thiazide-like diuretic
Persistent symptomatic postural hypotension, despite medication adjustment (supine to standing after at least
1 minute, SBP falls by ≥20 mmHg and/or DBP falls by ≥10 mmHg)
Complex polypharmacy
Resource(s): BIHS: Adult hypertension referral pathway and therapeutic management: British and Irish Hypertension Society position statement NICE CKS: Hypertension
Information for patients/carers: British Heart Foundation (BHF): Blood pressure British Dietetic Association (BDA): Hypertension and diet