Diagnosis

• Stage 1 > 140/95 (clinical setting); 135/85 (ABPM)
• Stage 2 > 160/100 (clinical); 150/85 (ABPM)
• Severe > 180/110
• If pulse irregularity measure manually
• If automated ensure calibrated and cuff size adequate
• If Stage 1 measure 3 x taking lower of latter readings in clinic, if confirmed offer ABPM (2 per hour)

Investigation

• While waiting for confirmation of hypertension diagnosis look for evidence of end organ damage: LVF, CKD (albuminaemia or proteinaemia) and hypertensive retinopathy
• Assess cardiovascular risk score (e.g. Qrisk)
• For all patients with hypertension:
  • Urine: Albumin creatinine ratio
  • U+E, eGFR
  • Serum cholesterol and HDL
  • Examine Fundi
  • 12 lead ECG

Management

• Lifestyle interventions: diet, exercise, alcohol patterns, smoking cessation and suggest but not offer relaxation therapies
• Discourage caffeine and salt intake
• If severe consider treating immediately with anti-hypertensives
• If severe and papilloedema then accelerated hence refer to specialised care same day
• If systolic falls > 20 mm Hg on standing review medication or refer for postural hypotension (+ headache, palpitations and pallor consider phaeochromocytoma (adrenal medullary tumour) and refer same day)

Pharmacological offer oral anti-hypertensives:

• Stage 1 (< 80) and target organ damage, renal disease, diabetes or cardiovascular disease, with end target < 140/90 or 150/90 if > 80 yrs
• Stage 1, < 40 yrs and none of the above risk factors investigate secondary causes as risk underestimated
• Stage 2 at any age

Step 1:

• < 55 yrs ACE or if not tolerated ARB
• > 55 or Afro-Caribbean offer CCB, if oedema not tolerated or HF risk then consider Thiazide diuretic
• Offer Thiazide type diuretic (Indapamide or Chlotalidone) in preference to Bendroflumethazide
• Only consider Beta Blocker if ACE/ARB not tolerated or woman child bearing age

Step 2:

• If BP still not controlled offer CCB in combination with ACE / ARB (in black person ARB + CCB)

Step 3:

• Diuretic + CCB + ACE / ARB

Step 4:

• Consider Spironolactone (if K+ < 4.5) or increase Thiazide dose, monitoring electrolytes and creatinine
• Consider an Alpha Blocker or Beta Blocker

NICE Source: CG127 Hypertension in adults: diagnosis and management. Summary compiled by Dr D P Sheppard MBBS.