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Hypertension Glos Care Pathway Overview

This Hypertension pathway has been updated with the latest NICE Hypertension guidance (NG136) published in August 2019.

                                                                            

Red Flags

Urgent treatment is needed in secondary care (Hypertensive emergency) if there is severe j-hypertension(180/120) and higher with -

  • Signs of Retinal haemorrhage or papilloedema(accelerated hypertension) or
  • Life threatening symptoms such as new onset confusion,chest pain ,signs of heart failure ,or acute kidney injury.
  • Suspected Phaeochromocytoma
Presentation

High blood pressure (BP) is usually asymptomatic, except where there is a Hypertensive Emergency (Headaches, blurred vision etc.).

Initial Primary Care Assessment

  • (symptoms are rare but if present may indicate more severe hypertension or secondary causes e.g. headaches, or paroxysmal sweats or palpitations, may suggest phaeochromocytoma.)

  • obesity, excess alcohol, salt intake and lack of exercise, environmental stress, and cardiovascular risk factors (smoking, diabetes, cholesterol and family history) ready for your management plan.

(non-steroidal anti-inflammatory drugs (NSAIDs), oestrogen containing  medication, steroids, liquorice, sympathomimetics, i.e. cold cures).

e.g. previous stroke or transient ischaemic attack (TIA), dementia, known left ventricular hypertrophy (LVH ) on ECG or Echo , coronary heart disease (CHD), peripheral arterial disease, or renal impairment. Consider ophthalmoscopy

Further information:

  • Check patient has not smoked, had caffeine containing drink or eaten, does not need to pass urine and has rested for at least 5 minutes.
  • Patient should be relaxed and SILENT
  • Need to check cuff is the right size for patient’s arm
  • Check pulse, if irregular undertake further assessment by ECG or AliveCor. Note patients with known AF should not have blood pressure assessed by electronic device.

  • Measure blood pressure (BP) in both arms.
  • If the difference in readings between arms is more than 20mmHg then repeat and if confirmed then subsequent BP readings should be taken in the arm with the higher blood pressure.
  • Blood pressure should be taken on at least one occasion standing and subsequently if symptoms suggest hypotension. 
  • If clinic blood pressure is more than or equal to140/90mmHg:
    • take a second measurement during the consultation,
    • if the second measurement is substantially different from the first, take a third measurement,
    • record the lower of the last two measurements as clinic blood pressure (BP).

 

Severe hypertension

  • If blood pressure in surgery/clinic is equal to or more than 180/110 mm Hg or higher then patients have severe hypertension
    • Do NOT wait for results of Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood pressure Monitoring (HBPM)
    • Start antihypertensive treatment immediately.
Confirming Diagnosis of Hypertension

  

Further Investigations and Assessment

Investigations

Whilst waiting for Ambulatory Blood Pressure Monitoring (ABPM) / Home Blood Pressure Monitoring (HBPM) undertake the following investigations for Cardiovascular Disease assessment / prevention:

  • Blood glucose /HBA1C
  • Non fasting cholesterol profile.
  • Liver Function Tests (LFTs)
  • Thyroid Stimulating Hormone (TSH)
  • Serum creatinine (eGFR)and electrolytes

  • Urine dipstick test for blood.
  • Send urine for albumin:creatinine ratio (ACR)
  • Serum creatinine (eGFR)and electrolytes
  • 12-lead ECG (looking for Left Ventricular Hypertrophy (LVH) or signs of Coronary Heart Disease (CHD)).

  • Renin/aldosterone levels - for primary aldosteronism / Conn’s syndromediscuss with clinical biochemist -ideally this test should be undertaken before starting treatment.
  • 24-hour urinary metanephrines (pheochromocytoma)
  • Urinary free cortisol and/or dexamethasone suppression test for (Cushings)
  • Plasma calcium.

  • Complete a formal Cardiovascular risk assessment such as:
    • CVD risk assessment (QRISK) Tool
    • QRISK LIFETIME TOOL
      • to assess management options in patients with Stage 1 hypertension
      • to assess cardiovascular disease risk for the primary prevention of cardiovascular disease in people up to and including age 84 years
      • to assess cardiovascular disease risk in people with type 2 diabetes.

​When not to use a risk assessment tool:

  • age 85yrs +
  • to assess cardiovascular disease risk in people with –
    • type 1 diabetes.
    • an eGFR less than 60 ml/min/1.73m2 and/or albuminuria. These people are at increased risk of cardiovascular disease. See advice on treatment with statins for people with chronic kidney disease.
    • with pre-existing cardiovascular disease.
    • high risk of developing cardiovascular disease because of familial hypercholesterolaemia (See NICE Guidance section) or other inherited disorders of lipid metabolism.

 

If hypertension is NOT diagnosed and there is evidence of target organ damage such as left ventricular hypertrophy, albuminuria or proteinuria:  investigate alternative causes of the target organ damage.  (See Investigations section)

 

Urgent ongoing assessment in primary care is needed if there is –

severe hypertension( 180/ 120mm/Hg) and absence of retinal signs or life threatening symptoms

  • Assess for Target Organ Damage. 
  • If no TOD repeat BP within 1 week. 
  • If TOD start treatment.
Differential Diagnosis

Primary or essential hypertension (primary, cause unknown) accounts for the majority of cases, particularly in the older patient.

Secondary hypertension:

  • Renal Disease
  • Endocrine disease:
    • Cushing's syndrome
    • Conn's syndrome
    • Thyroid dysfunction
    • Phaeochromocytoma
    • Acromegaly
    • Hyperparathyroidism
  • Coarctation of the aorta.
  • Obstructive sleep apnoea.
  • Pre-eclampsia and hypertension in pregnancy- NICE Guidance
  • Pharmacological substances and toxins – e.g. alcohol, cocaine, amphetamines, antidepressants (e.g. venlafaxine ) the combined oral contraceptive (COC) pill, ciclosporin, tacrolimus, erythropoietin, adrenergic medications, decongestants containing ephedrine and herbal remedies containing liquorice or ginseng.
Initial Primary Care Management

Discuss lifestyle measures in patients undergoing assessment for, or treatment of, hypertension.

Inform about any local initiatives, and supplement advice with leaflets or audiovisual information. For information on lifestyle and wellbeing services to refer patients to see to the lifestyle and wellbeing pages.

  • Weight reduction should be suggested if necessary, to maintain an ideal body mass index (BMI) of 18.5-24.9 kg/m. Offer a diet sheet and/or dietetic appointment, Dietary self-help – see NHS Choices Losing Weight guide , Slimming World via Healthy Lifestyles Service may be appropriate. Encourage physical activity as well. NICE guidelines for obesity make further recommendations about pharmaceutical and surgical options, such as bariatric surgery, where appropriate.
  • Use of wholegrain varieties of starchy food (e.g., rice, pasta, bread) where possible.
  • Reduction of saturated fats, and increasing mono-unsaturated fats, using olive or rapeseed oils and spreads.
  • Reduction in sugar intake and that of foods containing refined sugars.
  • Eating at least five portions of fruit and vegetables per day.
  • Eating at least two portions of fish per week, including a portion of oily fish.
  • Eating at least 4-5 portions of unsalted nuts, seeds and legumes per week
  • Reducing any excessive caffeine consumption.
  • Low dietary salt (see section below).
  • Keeping alcohol within current national recommended levels. (Currently no more than 14 units per week for men and women, spread through the week, with at least two days alcohol-free(patients with excess alcohol should be offered lifestyle advice in primary care and refer to Healthy Lifestyles Service for support)
  • Calcium, magnesium or potassium supplements are not recommended.

Patients should stop smoking.

Offer help plus nicotine replacement therapy. The Healthy Lifestyles Service (HLS) offers Smoking Cessation and also some pharmacies.

  • Over a week, activity should add up to at least 150 minutes of moderate intensity activity in bouts of 10 minutes or more e.g. 30 minutes on at least 5 days per week
  • Make physical activities part of everyday life (e.g. walk or cycle to work, use the stairs instead of the lift, walk at lunchtime) and build in enjoyable activities to leisure time every week (e.g. walking, cycling, gardening, swimming, aerobics, etc.).
  • Minimise sedentary activities (e.g. limit television watching or sitting at a computer or playing video games).
  • In addition, look for local activities, join a sporting group, take advantage of taster sessions and get used to exercising regularly, ideally several times a week. The Community Wellbeing service and the Healthy Lifestyles Service (HLS) might be able to help.

Advise patient to reduce salt intake in diet. 

  • Salt reduction to 4.4 g per day results in a reduction of ~4/2 mm Hg in blood pressure (BP). (NICE is aiming for a ‘maximum intake of 6 g per day per adult by 2015 and 3 g by 2025’ (about one teaspoon).)
  • Guidelines recommend that we should have no more than 5-6 grams of salt per day.
  • Patients should be advised not to add salt to food/cooking and to avoid processed foods.
  • Food labelling is making it easier to determine the salt content of food.
  • Be mindful using a salt substitute such as ‘LoSalt’ may increase levels of potassium.
  • The Dietician service at GHNHSFT might be able to help.
Prescribing Guidance - Hypertension

Pathway for Hypertension Prescribing


        

Consider treating immediately if blood pressure (BP) in clinic is more than or equal to 180/110 mm Hg

Otherwise, consider after results of Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM), blood tests and cardiovascular risk assessment are available.

Hypertension treatment should be discussed with patients- discuss individual CVD Risk and preferences for treatment, including no treatment, and explain risks and benefits before starting drug treatment –

Offer Treatment if Stage 1 Hypertension plus -

  • aged under 80 years with stage 1 hypertension (see diagnosis section) with
  • 10-year cardiovascular disease risk more than or equal to10% (as per NICE guidance-)(and consider drug treatment in younger adults <60 years old even if CVD risk <10% as the 10 year risk may underestimate lifetime risk)
  • with stage 2 hypertension (any age)
  • with isolated systolic hypertension – more than or equal to160mmHg.

For patients 80 yrs+ with hypertension and Frail refer to the Rockwood prescribing guidance (For confirming Frailty in patients 80 years or over please refer to the Rockwood Frailty guidance.)

Choosing antihypertensive drug treatment -

  • Where possible, recommend treatment with drugs taken only once a day.
  • Prescribe non-proprietary drugs where these are appropriate and minimise cost.
  • Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure.
  • Do not combine an ACE inhibitor (ACEi) with an Angiotensin Receptor Blocker (ARB) to treat hypertension.

Newly diagnosed Hypertensives – Community Pharmacy service

Consider using your local Community Pharmacy for ‘NMS’ New Medicines Service which most pharmacists offer with any new antihypertensive. This can help with monitoring of side effects and compliance.  Suggest putting ‘NMS please’ on prescription to remind pharmacy to offer it.

Step 1 

  • Give antihypertensive drug treatment to all people less than 80 years old with stage 1 hypertension and one or more of:
    • target organ damage
    • established CV disease
    • renal disease
    • diabetes
    • 10-year CV risk equal to or more than 10%.
  • Give antihypertensive drug treatment to people of any age with stage 2 hypertension.
  • For people less than 55 years give an ACE Inhibitor (ACEI) or low cost Angiotensin Receptor Blocker (ARB). If an ACE Inhibitor (ACEI) is prescribed and not tolerated – give a low cost Angiotensin Receptor Blocker (ARB).
  • For people aged more than 55 years and black people of African or Caribbean descent of any age give a Calcium Channel Blocker (CCB). If a Calcium Channel Blocker (CCB) is unsuitable due to oedema or intolerance, or with/at high risk of heart failure give a thiazide-like diuretic.
  • Refer people less than 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular or renal disease or diabetes for specialist evaluation.

Step 2

  • If blood pressure not controlled at step 1; give a Calcium Channel Blocker (CCB) with an ACE Inhibitor (ACEI) / Angiotensin Receptor Blocker (ARB).
  • For black people of African or Caribbean descent; give an Angiotensin Receptor Blocker (ARB). in preference to an ACE Inhibitor (ACEI), in combination with a Calcium Channel Blocker (CCB).
  • If a Calcium Channel Blocker (CCB) is not suitable due to oedema or intolerance, or with/at high risk of heart failure give a thiazide-like diuretic.
  • Review drug treatment to ensure at optimal doses before considering Step 3.

Step 3

  • Give an ACE Inhibitor (ACEI) or an Angiotensin Receptor Blocker (ARB) in combination with a Calcium Channel Blocker (CCB) and a thiazide-like diuretic.

If clinic blood pressure remains equal to or more than 140/90mmHg with optimal drug treatment – regard this as resistant hypertension and consider step and/or seek specialist advice.

Step 4

  • For patients with resistant hypertension; add a further diuretic:
    • if serum potassium equal to or less than 4.5mmol/L: give spironolactone** º 25mg once daily,
    • if serum potassium more than 4.5mmol/L: give consider a higher-dose thiazide-like diuretic.

If further diuretic therapy is not tolerated, is contraindicated or ineffective; consider an alpha-blocker or beta-blocker. If BP remains uncontrolled with optimal drug treatment - seek specialist advice.

Note

Prescribing guidance (NICE)

  • Give patients with isolated systolic hypertension (systolic blood pressure equal to or more than 160 mmHg) the same treatment as patients with both raised systolic and diastolic blood pressure.
  • For patients over 80 years of age give the same treatment as patients aged equal to or more than 55 years of age. Take account of any comorbidity and concurrent drugs.

Diuretics

  • Bendroflumethiazide or hydrochlorothiazide are no longer the recommended thiazide-like diuretics for hypertension.
  • If a diuretic is started or changed, give:
    • Indapamide 2.5mg immediate release preparation only
  • For people already taking bendroflumethiazide or hydrochlorothiazide whose Blood Pressure is stable;
    • continue with this treatment.
  • Use spironolactone with caution in patients with a reduced eGFR due to the increased risk of hyperkalaemia particularly when taking concomitant ACE Inhibitor (ACE) / Angiotensin Receptor Blocker (ARB)

Calcium channel blocker

  • Calcium Channel Blockers (CCBs) are now the preferred treatment option at step 2 as they are cost effective.

Beta-blockers

  • Beta-blockers are not recommended but can be used in step 1 for:
  • younger people when an ACE inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) is contraindicated or not tolerated or,
  • there is evidence of increased sympathetic drive or,
  • in women of child-bearing potential.

If a patient requires a second drug, add a Calcium Channel Blocker (CCB) rather than a thiazide-like diuretic to reduce the risk of developing diabetes.

*Chlortalidone is only available in the UK in 50 mg strength tablet. The recommended dose can only be given if tablets are halved or quartered. This is not practical for most patients and would not guarantee a consistent daily dose.

Do NOT give calcium, magnesium or potassium supplements to reduce blood pressure.

**Spironolactone – The PATHWAY-2 trial, published in 2015, suggested that spironolactone is the most effective fourth-line agent for resistant hypertension. A drug safety update from the Medicines and Healthcare products Regulatory Agency (MHRA) in 2016 warns of the risk of hyperkalaemia when an ACE inhibitor or AIIRA is combined with spironolactone. Routine use of this combination is not recommended but where it is, the lowest possible dose should be used and electrolytes monitored closely.

Ongoing Primary Care Management

Monitor response to treatment  - in Primary Care Hypertension clinic/Annual review – consider using Health Care Assistant’s (HCA’s) / Practice Nurses (PN’s), GP Pharmacist or Community Pharmacy Medicine Use Review Service if not already doing so.

Review risk factors for cardiovascular disease - delivered as part of an annual review of care to address modifiable risk factors.

Bloods monitoring

  • Monitor renal function and electrolytes where appropriate
  • Consider cholesterol-lowering treatment if CVD risk is equal to or more than 10%. See Lipid Measurement - NICE

Further Ambulatory Blood Pressure Monitoring (ABPM) / Home Blood Pressure Monitoring (HBPM) may be needed to avoid overtreatment due to 'white coat hypertension'.

Hypertension treatment targets

  • People aged less than 80 years: clinic less than140/90 mm Hg, ABPM/HBPM less than 135/85 mm Hg. (NICE Guidance)
  • People aged 80 years or over: clinic less than150/90 mm Hg, ABPM/HBPM less than145/85 mm Hg. ( use clinical judgement in those with frailty or multimorbidity)
  • Use STANDING BP readings if postural drop <20 mmHg or symptoms of postural hypotension or patients with Type 2 Diabetes
Blood Pressure Monitoring Devices

A list of validated BP monitoring devices is available on the British & Irish Hypertension Society’s website: Healthcare professionals using monitoring devices should be trained to use the device and interpret data. Please follow the resource link below to the website.

When to Refer

If Hypertension is not responsive to above treatments consider -

  • Secondary hypertension (confirmed or suspected): Possible underlying cause: low K+, Na+ elevated (possible Conn's syndrome); elevated creatinine, proteinuria or haematuria due to renal disease; young age (consider specialist assessment for those under the age of 40 years).
  • Resistant hypertension (i.e. needs more than 4 therapeutic agents);
    • Therapeutic problems: unusual Blood Pressure (BP) variability, intolerance to multiple medications or contra-indications, persistent non-adherence or treatment refusal. (Step 4 –consider compliance to medication)

Refer same day if:

OR

  • Patient has suspected phaeochromocytoma
  • Consider urgent referral if signs/symptoms suggesting a secondary cause for hypertension.

 

Health Care Assistant's (HCA's)

Refer to GP if:

  • Diagnosis of Hypertension is confirmed from Ambulatory Blood Pressure Monitoring (APBM) or Home Blood Pressure Monitoring (HBPM) (as per Diagnosis section) so that they can start prescribing treatment.
  • Patient is not being managed to Blood Pressure target

Refer to specialist if -

  • Patient is pregnant, even if already seen in ANC, to ensure control optimised and suitable management plan put in place prior to delivery.
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