Definitions
Stage 1 hypertension
Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.
Stage 2 hypertension
Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure
Severe hypertension
Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.
HOW TO DIAGNOSE HTN??
When considering a diagnosis of hypertension, measure blood
pressure in both arms. If the difference in readings between arms is more than 20 mmHg, repeat the measurements.
If the difference in readings between arms remains more than 20 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading.
If blood pressure measured in the clinic is 140/90 mmHg or higher:
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 the clinic blood Pressure
If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension
If a person is unable to tolerate ABPM, home blood pressure monitoring (HBPM) is a suitable alternative to confirm the diagnosis of hypertension.
If the person has severe hypertension, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
If hypertension is not diagnosed, measure the person’s clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person’s clinic blood pressure is close to 140/90 mmHg.
Refer the person to specialist care the same day if they have: accelerated hypertension, that is, blood pressure usually higher than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage or
suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor and diaphoresis).
Consider the need for specialist investigations in people with signs
and symptoms suggesting a secondary cause of hypertension which include:
• Search for exogenous potentially modifiable factors that can induce/aggravate hypertension
– Prescription Drugs:
• NSAIDs, including coxibs
• Corticosteroids and anabolic steroids
• Oral contraceptive and sex hormones
• Vasoconstricting/sympathomimetic decongestants
• Calcineurin inhibitors (cyclosporin, tacrolimus)
• Erythropoietin and analogues
• Antidepressants: Monoamine oxidase inhibitors (MAOIs), SNRIs, SSRIs
• Midodrine
– Other:
• Licorice root
• Stimulants including cocaine
• Salt
• Excessive alcohol use
Assessing cardiovascular risk and target organ
damage
For all people with hypertension offer to:
· Test for the presence of protein in the urine by sending a urine sample forestimation of the albumin:creatinine ratio and test for haematuria using a reagent strip.
· Take a blood sample to measure
o Plasma glucose,
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o Electrolytes,
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o Creatinine,
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o Estimated glomerular filtration rate,
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o Serum total cholesterol
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o HDL cholesterol
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· Examine the fundi for the presence of hypertensive retinopathy.
· Arrange for a 12-lead ECG to be performed.
If hypertension is not diagnosed but there is evidence of target organ damage such as left ventricular hypertrophy, albuminuria or proteinuria, consider carrying out investigations for alternative causes of the target organ damage.
SCORE is a risk estimation system, based on data from 12 European cohort studies and includes 205178 subjects examined at baseline between 1970 and 1988 with 2.7 million years of follow-up and 7934 cardiovascular deaths. The SCORE system estimates the 10 year risk of a first fatal atherosclerotic event, whether heart attack, stroke, aneurysm of the aorta or other. For further information visit http://www.revespcardiol.org/en/global-preventive-policies-strategies-at/articulo/13125894/
TREATMENT
NON PHARMACOLOGIC:
· A healthy diet and regular exercise can reduce blood pressure.
· Encourage a reduced alcohol intake if they drink excessively, because this can reduce blood pressure and has broader health benefits.
· Discourage excessive consumption of coffee and other caffeine-rich products.
· Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure.
· Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure.
· Offer advice and help to smokers to stop smoking.
PHARMACOLOGIC
Initiating treatment
ü Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following:
· target organ damage
· established cardiovascular disease
· renal disease
· diabetes
· a 10-year cardiovascular risk equivalent to 20% or greater.
ü Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.
ü Aim for a target clinic blood pressure below 140/90 mmHg in people aged under 80 years with treated hypertension and a target clinic blood pressure below 150/90 mmHg in people aged 80 years and over, with treated hypertension.
Step 1 treatment
ü Offer people aged under 55 years step 1 antihypertensive treatment with anangiotensin-converting enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB).
ü Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged over 55 years and to black people of African or Caribbean family origin of any age.
ü If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic.
ü If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.
ü Beta-blockers are not a preferred initial therapy for hypertension. However, beta-blockers may be considered in younger people, particularly:
1. Those with an intolerance or contraindication to ACE inhibitors and angiotensin II receptor antagonists or
2. Women of child-bearing potential or
3. People with evidence of increased sympathetic drive.
ü If therapy is initiated with a beta-blocker and a second drug is required, add acalcium-channel blocker rather than a thiazide like diuretic to reduce the person’s risk of developing diabetes.
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