Hypertension - severe
Questionnaire/history:
Symptoms?
Signs?
Past medical history?
- Causes of secondary hypertension?
- Cardiovascular risk factors?
Current medication?
Known drug allergies?
Examination:
Blood pressure (BP)?
- ≥ 180/120 mg?
End-organ damage?
- Hypertensive retinopathy (grade 3: retinal haemorrhage, grade 4: papilloedema)?
Investigations:
ECG?
- Left ventricular hypertrophy?
Urine dipstick?
- Haematuria?
Urine albumin : creatinine ratio
Bloods (electrolytes, creatinine, estimated glomerular filtration rate, total and HDL cholesterol, HbA1c)?
Management:
Same-day assessment:
If clinic BP > 180/120 mmHg +
- Retinal haemorrhage or papilloedema OR
- Suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor, abdo pain or diaphoresis) OR
- Life-threatening symptoms (hypertensive emergency - see below) (eg new-onset confusion (hypertensive encephalopathy), chest pain, signs of heart failure or acute renal impairment)?
No need for same-day assessment:
If clinic BP > 180/120 mmHg:
- Target organ damage identified: considered starting oral antihypertensive treatment immediately without waiting for results of ABPM or HBPM
- No target organ damage identified: repeat clinic BP within 7 days
Drug management:
If initiating drug treatment in urgent care: aim: < 160/100 mmHg over 6-24 hours (more rapid reduction can cause ischaemic organ damage):
- ACEi or ARB if DM or under 55yrs.
- CCB if over 55yrs or of African or Caribbean family origin
(Notes:
High profile American and European Hypertension guidelines both made strong recommendations that any patient with stage 2 hypertension (average home BP readings ≥ 150/90) should be considered for initial combination drug treatment:
- ACEI or ARB + CCB or
- ACEI or ARB + diuretic (if CCB unsuitable)
Initiating an ACEi/ARB in an urgent care setting without knowledge of patients' eGFR is not without risk & may dictate which agent is prescribed: Nifedipine MR or amlodipine are possible agents in this scenario
To avoid using short-acting agents as severe rebound hypertension and organ damage can occur
Important to make sure patient has an appropriate follow-up with their own GP to monitor BP & review investigations
Secondary care approach:
Severe hypertension: BP > 180/120 mmHg but typically BP > 220/120-130 mmHg
Hypertensive emergency: severe hypertension + ACUTE end-organ damage, which includes:
- Cerebral infarction or haemorrhage
- Acute pulmonary oedema
- Hypertensive encephalopathy
- Acute aortic dissection
- Acute coronary syndrome
- Eclampsia (can occur at lower pressures)
- Acute renal failure
- Phaeochromocytoma
Life-threatening and should be treated with emergency response
Hypertensive urgency: severe hypertension + progressive, non-acute end-organ damage:
- Retinal haemorrhage or papilloedema: same day referral - often treated in secondary care with oral agents and closely monitored
- Other progressive target end-organ damage (eg LVH, abnormal urine dipstick: considered starting oral antihypertensive treatment immediately in primary care without waiting for results of ABPM or HBPM
Those with severe hypertension but without evidence of end organ damage do not meet the classification of hypertensive urgency and clinic BP can be repeated within 7 days in primary care
Resource(s):