Hypertension

Stages of Hypertension

Stage	Blood pressure (mmHg)
1	140/90 to 160/100
2	160/100 to 180/120
Severe	≥180/120

Risk Factors of Hypertension

• Age

• Alcohol

• Caffeine

• Ethnicity

• Exercise

• Salt intake

• Smoking

• Weight

Secondary causes of hypertension include endocrine disorders and renal disease.

Whilst in clinic, patients should be investigated for target organ damage caused by hypertension in the brain, eyes, heart and kidneys.

In addition, the risk of cardiovascular disease should also be measured using tools such as QRISK and JBS3.

Methods to Measure Hypertension

• Clinical blood pressure reading

• Ambulatory blood pressure monitoring (ABPM)

• Hospital blood pressure monitoring (HBPM)

Patients with a clinical blood pressure reading ≥140/90mmHg should be offered ABPM or HBPM to confirm a diagnosis. If ABPM is unsuitable then HBPM should be offered. If both are unsuitable, a diagnosis should nonetheless be confirmed and the stage of hypertension determined.

Interpreting Results of Hypertension

If a patient tests negative for both hypertension and target organ damage, the patient should aim to have their clinical blood pressure measured every 5 years. This may be performed more regularly if their reading is closer to 140/90mmHg.

If a patient tests negative for hypertension, but positive for target organ damage, the causes of damage to the affected organs should be investigated, e.g. the brain, eyes, heart and kidneys.

If a patient tests positive for hypertension, then they should be referred for both blood & urine tests, be advised on lifestyle interventions and be prescribed the appropriate drug treatment.

Same-Day Specialist Referral

Patients with severe hypertension with a clinical blood pressure reading ≥180/120mmHg or any of the below symptoms, require immediate specialist referral.

Referral symptoms:

• Retinal haemorrhage

• Life-threatening symptoms, e.g. acute kidney injury, chest pain, confusion or signs of heart failure

• Papilloedema

• Phaeochromocytoma, e.g. headache, palpitations and postural hypotension

Drug Treatment of Hypertension

The NICE treatment summary involves two main pathways depending on if a patient suffers from type 2 diabetes or not.

The first and most common pathway involves patients who are <55 years old and suffer from type 2 diabetes. First-line treatment involves either an ACE inhibitor or ARB, where ARBs are preferred for Afro-Caribbean patients and those who suffer from dry coughs. If hypertension remains uncontrolled, second-line treatment involves adding a calcium-channel blocker or thiazide-like diuretic. If hypertension is still not adequately controlled, then both second-line drugs would be added onto monotherapy.

The second pathway involves patients who are >55 years old, do not suffer from type 2 diabetes and are of Afro-Caribbean origin. First-line treatment, instead solely consists of a calcium-channel blocker, where ACE inhibitors or ARBs are instead used as second-line treatment or a thiazide-like diuretic. If hypertension is still not adequately controlled, then both second-line drugs would be added onto monotherapy.