e

Dudley Hypertension Pathway

Document Description

Document Type Clinical Pathway

Service Application Diagnosis and Management
Version 2.0
Ratification date May 2016
Review date May 2018
Lead Author(s)
Name Position within the Organisation
Shelagh Cleary Vascular Programme Manager, Lead Vascular Nurse, DMBC
Clair Huckerby Pharmaceutical Advisor- Medicines Optimisation Lead, Dudley
CCG

Presented for discussion, approval and ratification to

Area Clinical Effectiveness Sub Committee

Change History

Version Date Comments

1.0 July 2014 Approved
1.1 April 2016 Updated
2.0 May 2016 Approved

1
 Background

This pathway will cover screening, diagnosis, treatment and referral options for people with, or
suspected of having hypertension, the links to other programmes such as the NHS Health
Checks programme and to the Quality and Outcomes Framework.

The pathway applies directly to all service providers in Dudley who are involved in the
management of people with hypertension and is recommended as good practice guidance for
each of the independent contractor professions.

National and local guidance, policies, reports and/or papers which this particular document
should be read in conjunction with are as follows.

Local Dudley Guidance:

 Best Practice Guidelines for Lifestyle Assessment

 Cardiovascular Risk pathway
 Hyperlipidaemia Guidelines
 Diabetes Adult Management Guidelines

National Guidance: NICE Guidelines for:

 Management of Atrial Fibrillation

 Secondary Prevention of Myocardial Infarction
 Management of Patients with Heart Failure
 Management of Hypertension
 Lipid Modification
 Management of Obesity

2
Contents: Page No.

Pathway Overview ……………………………………………………………………… 5

Introduction …………………………………………………………………….…………6

Signs and Symptoms ………………………………………………………………….. 8

High Risk Groups ……………………………………………………………. ………… 8

Measuring Blood Pressure ……………………………………………………………. 9

Postural Hypotension ………………………………………………………………….. 10

White Coat Hypertension …………………………………………………….………… 11

Diagnosing Hypertension …………………………………………………………….. 11

Ambulatory/Home Blood Pressure Monitoring …………………………………….. 11

Urgent Referral Indications ………………………………………………... ………… 12

Hypertension Stages ………………………………………………………………….. 12

Investigations on diagnosis …………………………………………………………… 13

Initiating Medication …………………………………………………………………… 18

Hypertension Treatment Thresholds ………………………………………………... 18

Blood pressure Targets ………………………………………………………………. 19

Key Points in the Management of People with Hypertension ……………………... 19

Pharmacological Management of Hypertension …………………………………… 20

Logical Therapeutic Combinations …………………………………………………… 21

Annual Review……………………………………………………………………………21

Indications for referral……………………………………………………………………22

References………………………………………………………………………………..23

3
Dudley
Hypertension
Pathway
Pathway for the Diagnosis and
Management of Hypertension:
Including Clinic Reference Guide

4
 Hypertension Pathway Overview

S D
c Introduction i
 Signs / Symptoms Measuring blood pressure
r a
 High Risk Groups  ABPM / HBPM
e  ‘White coat’ hypertension g
e  Hypertension Staging n
n  Diagnostic read codes o
 QOF contract indicators
i s
n i
g s
Investigations on Diagnosis: Initiating Medication:
I  Cardiovascular  Treatment thresholds
o Lipids  Blood pressure targets M
n
o CVD Risk assessment  Key points in the management of
v o Manual Pulse
e
hypertension
e o ECG d
s  Renal The Pharmacological Management of i
o eGFR Hypertension
t c
o Proteinuria  Use of antihypertensive Drugs in
i o Haematuria Concurrent States
a
g  Diabetes  When is it Appropriate to use Beta- t
a o Fasting glucose blockers? i
 Lifestyle
t o
 Eye Dudley Drug Formulary:
i  Other  Drugs approved for the Treatment
n
o o Thyroid function of Hypertension:
n o Phaeochromatocytoma
o Hyperaldosteronism
s
o Cushing’s syndrome
o Obstructive sleep apnoea
o Coartication of aorta
o Acromegaly

M
Useful Links
o R
n
e
i
t f
o e
r  Annual Review
r
I
i  Blood pressure targets r
 Indications for Referral
n 5 a
 Urgent referral
g l
 Community Cardiology Service
Introduction

Based on QOF returns for year end 2015 in Dudley the hypertension prevalence has
increased to 17.7%, compared to Doncaster modeled figures where the expected prevalence
for Dudley is 26%. This would amount to approximately 26,000 people who would be
expected to have hypertension who remain undiagnosed. Despite this statistic Dudley CCG
now has the highest reported to expected hypertension prevalence in England (Atlas of
Variation 2013/14).

Ratio of reported to expected prevalence of hypertension by CCG (QOF

2013/14 hypertension prevalence / Estimated prevalence modelled by the
former ERPHO
0.70
Ratio of reported to expected prevalence of hypertension by CCG 2013/14

0.60

Dudley CCG
CCGs 5th (Best) Quintile
0.50 CCGs 4th Quintile
CCGs 3rd Quintile
CCGs 2nd Quintile
CCGs 1st (Worst) Quintile

0.40

0.30
CCG

Collaborative working across the Health Economy over the last decade has seen the
Standardised Mortality Rate from hypertension related diseases move from twice the England
average to be in line with the England average.

6
 Directly Standardised Mortality Rates from Hypertensive Disease by Year
3-Year Rates, Dudley, Both Sexes Aged Under 75, 2012
8

Standardised Rate per 100,000 Population 7

0
2001-2003

2002-2004

2003-2005

2004-2006

2005-2007

2006-2008

2007-2009

2008-2010

2009-2011

2010-2012
Continued work to reduce the hypertension prevalence gap is required. It is anticipated that
for every additional 1,000 patients Blood Pressure (BP) controlled, there are £469k of savings
for the NHS over 5 years, or £469 per patient. This would mean a total potential cost saving of
£13m over 5 years for the 27,800 patients missing from hypertension registers in Dudley. In
addition to this we know that by reducing BP from 150/90mmHg to 140/90mmHg, the risk of
CHD is reduced by 22% and the risk of stroke is reduced by 41%.
This pathway will cover screening, diagnosis, treatment and referral options for people with
or suspected of having hypertension, the links to other programmes such as the NHS Health
Checks programme and to the Quality and Outcomes Framework.

Definition of Hypertension
“When blood pressure remains higher than normal over time (at least several months) it is
called variously, high blood pressure, raised blood pressure or hypertension. Hypertension
occurs when the heart has to use more energy to pump against the greater resistance of the
vascular system”

Blood Pressure = Cardiac Output x Peripheral Resistance

Hypertension screening is included in the NHS Health Checks Programme, which seeks to
invite people without a vascular condition or hypertension for a health check.
If blood pressure is found to be raised at the time of the check, this is highlighted to GP
practices who then follow-up these patients following the hypertension diagnostic pathway.
NHS Health Check: Dudley Pathway Vascular Risk Assessment and Management

7
 Signs and Symptoms
Hypertension is usually asymptomatic, but there are some indicators which should prompt a
blood pressure check. These include:
 Headaches
 Dizziness
 Blurred vision
 Epistaxis
 Tinnitus
 Palpitations
 Nocturia
Other symptoms may indicate blood pressure has risen to a dangerously high level. These
include:
 Chest pain
 Sweating
 Shortness of breath
 Wheeze
 Transient vision loss
 Loss of consciousness
 Fits

High Risk Groups

Some co-morbid conditions are more commonly associated with hypertension, these are:
 Cardiovascular:
o Coronary heart disease
o Stroke and TIA
 Renal
o Chronic Kidney disease
o Phaeochromatocytoma
 Endocrine
o Diabetes
o Hyperaldosteronism
o Cushing’s syndrome
o Hyperthyroidism
o Acromegaly
 Pulmonary
o Chronic obstructive pulmonary disease
o Obstructive Sleep apnoea

Some lifestyle behaviours will increase the risk of developing hypertension. These include:
 Smoking
 Hyperlipidaemia
 Alcohol consumption (where this is over recommended limits)
 Obesity
 Physical inactivity
 High salt intake
8
Certain drugs may also affect blood pressure levels. These include:
• Combined oral contraceptives
• Immunosupressants
• NSAIDS
• COX 2
• Stimulants (including caffeine products such as coffee, cola)
• Mineralocorticoids
• Anti-parkinsons drugs
• Monoamine oxidase inhibitors
• Anabolic steroids
• Sympathomimetics

Soluble analgesia and indigestion remedies have a high salt content and should also be
avoided where possible. For further information see the Dudley guideline, Salt Content of
Soluble Analgesics and Indigestions Remedies

Other Determinants

Hypertension is more common in BME groups. African-Caribbean groups have a higher risk
of hypertension and subsequent stroke or renal failure, but not higher levels of coronary
heart disease, whilst South Asians also have a higher risk of hypertension, but tend to have
higher levels of coronary heart disease.
http://qjmed.oxfordjournals.org/content/94/7/391.full.pdf+html

Black people (as they are referred to in NICE guidance), i.e. those people of African or
African-Caribbean origin have a much higher prevalence of hypertension. For this reason,
many studies have been conducted looking at their response to anti-hypertensive
medication. Differences were found in response to drug treatment for black people, indicating
treatment with specific anti-hypertensive drugs and combinations.
http://www.york.ac.uk/inst/crd/EHC/ehc84.pdf

People in lower socioeconomic groups also have a higher risk of hypertension and an
increased risk of cardiovascular mortality compared to more affluent groups.
http://journals.lww.com/jhypertension/Abstract/2009/04000/Risks_of_socioeconomic_depriva
tion_on_mortality_in.11.aspx

Measuring Blood Pressure

Devices
• Mercury Sphygmomanometers continue to provide the reference standard for
measurement of blood pressure although, due to their bulk and the fact that they
contain mercury their use is currently being phased out. If using a mercury device,
then a mercury spillage kit should be available at all times and it should not be taken
out of the building. Mercury devices are not available to buy.
• Hybrid devices are available which resemble the mercury sphygmomanometer but
use an LED display in place of a mercury column. They are used in the same way as
the mercury devices by auscultation of the brachial artery.

9
 • Aneroid Sphygmomanometers measure pressure using a bellows system. They
can be less accurate than alternatives, especially over time. For this reason it is
recommended that they are calibrated every 6 months.
• Automated devices are recommended for ease of use in clinic and by patients for
HBPM. However, as the devices work on oscillometry which needs to be in a regular
flow, any irregular pulse will cause an error message on the machine. If error
messages are observed, then a manual pulse should be taken to rule out an irregular
pulse before attempting to measure blood pressure with the automated device again
or with another device

Taking a Blood Pressure Measurement

• Blood pressure (BP) should be measured by a health care professional who has
undergone training, using a machine which is regularly serviced and calibrated. The
patient should be seated comfortably and relaxed.

• Before commencing the blood pressure measurement, manually palpate the radial or
brachial artery and note the pulse rhythm. If there is an irregular pulse present, then
automated devices will not work (they will display an error message) or if readings are
given they will be unreliable. If an irregular pulse is present, blood pressure should be
recorded by direct auscultation of the brachial artery.

• To measure blood pressure the patients arm should be supported at chest level. An
appropriate size cuff should be used for which the inner bladder fits to at least 80% of
the upper arm circumference but not more than 100%, i.e. there is no overlap. Under
cuffing will overestimate blood pressure while over cuffing will underestimate blood
pressure.

• BP should be measured in both arms. If there is a discrepancy of more than

20mmHg, repeat the measurements to confirm. If the discrepancy persists, then the
arm with the higher reading should be used. This arm can then be noted and should
be used for each subsequent visit. (N.B. the arm with the lower pressure indicates
vascular compromise and so examination and appropriate referral is indicated)

• If the BP is above 140/90, (either systolic, diastolic, or both) check the BP again to
confirm. If there is a substantial difference between the first 2 readings take a third
measurement at the end of the consultation or after a short interval of 5 – 10 minutes,
where patient remains seated comfortably.

• The blood pressure should be recorded as the lower of the last 2 readings
taken

N.B. If the BP is > 180/110, urgent (same day) referral /management is needed to
identify other co-morbid conditions and the possibility of accelerated hypertension.

Postural Hypotension

Where postural hypotension is suspected, i.e. in those with dizziness on standing, falls,
people with diabetes or the elderly, according to NICE Clinical Guideline 127: Hypertension:

10
 • Measure the BP with the person seated or lying.
• Ask the person to stand and then measure BP after 1 minute.
• If there is a drop of 20mmHg systolic pressure or more on standing then postural
hypertension is present.

The recommendations for confirming postural hypotension (Consensus Statement on the

Definition of Orthostatic Hypotension, Consensus Committee of the American Autonomic
Society) is:

• To lie the patient flat for 10 minutes

• Measure BP
• Stand the patient
• Measure BP again 1-3 minutes after standing.

White Coat Hypertension

White coat hypertension is defined as those with persistently elevated clinic BP

measurements but normal daytime average BP readings. In patients experiencing white coat
hypertension a difference of at least 10/5 mmHg is observed between home and clinic
measurements. This can be much greater in those with a higher baseline blood pressure and
tends to increase with age. Where white coat hypertension is suspected, a request for
Ambulatory Blood Pressure monitoring (ABPM) or Home Blood Pressure monitoring (HBPM)
should be made when considering a hypertension diagnosis.

‘White coat effect ‘occurs in someone who has hypertension and is on treatment, but has
clinic readings are consistently higher than home readings. This can lead to problems when
titrating medication and lead possibly to over medication. It is suggested that where white
coat effect is suspected that HBPM is considered.

Diagnosing Hypertension

1. If the BP recorded after following the procedure above is  140/90, check this reading on
2 more consultations 2 – 4 weeks apart.

2. Exclude the possibility of confounding factors such as white coat hypertension following
the guidance above.

3. If the BP is found to be consistently  140/90, then a diagnosis of hypertension should be

made.

NICE Definition of Hypertension:

Persistently raised BP  140/90 mmHg

Ambulatory BP Monitoring (ABPM) / Home BP Monitoring (HBPM)

11
For all patients with a BP of 140/90 or more, confirmed on a further 2 occasions, offer
ambulatory BP monitoring to confirm the diagnosis of hypertension.
If ABPM is not tolerated then HBPM can be offered as a suitable alternative.

Access to ABPM

ABPM can be accessed by:

• GP practice if equipment and appropriate clinical expertise is available to interpret
results
• Referral to Community Cardiology service
• Referral to Cardiology Dept
ABPM the test
• 2 measurements must be taken per hour during waking hours (08:00 – 22:00)
• Calculate the average value of at least 14 measurements.
• Hypertension is diagnosed if the average BP is  135/85
HBPM
• Suitable equipment must be provided and checked by the issuer.
• Training must be given to the patient to ensure correct measurements are taken
• Measurements must be taken twice a day, morning and evening if possible
• Each reading must be taken with the patient seated and relaxed
• 2 readings must be taken at each occasion with at least a minute apart and the lower
of the 2 recorded.
• Continue recording BP for 7 days (or at least 4 days if this is not possible)
• When analysing results discard the results taken on the first day and calculate the
average of the remaining results.

Hypertension is diagnosed if the average BP is  135/85

If a diagnosis of hypertension is confirmed, then the level of hypertension should be staged
as follows:

Hypertension Stage Criteria

Normotensive < 135/85
1  140/90 or  135/85 ABPM or HBPM average result
2  160/100 or  150/95 ABPM or HBPM average result
Severe  180/110

If hypertension is not diagnosed, BP should be checked every 5 years. Where BP is

borderline, follow-up should be arranged more frequently.

Urgent Referral indications

Arrange urgent referral for:
• Accelerated hypertension -BP  180/110 and papilloedema/retinal haemorrhage
present, arrange urgent referral to cardiology.
• Phaeochromatocytoma - BP  180/110,postural hypertension, headache, palpitation,
sweating.

12
Investigations on Diagnosis

A diagnosis of hypertension should prompt investigation of possible target organ damage,

vascular assessment and investigation of conditions which may cause or contribute to the
progression of the condition. The following investigations should be undertaken.

N.B. For people aged under 40 with stage 1 hypertension and no evidence of target organ
damage, consider specialist referral for more detailed assessment. CVD risk calculators may
underestimate the lifetime risk of CVD events in these people.

Cardiovascular (CVD)

Lipid profile
• Fasting blood samples should be sent requesting a full lipid profile, i.e. total
cholesterol (TC), high density lipoprotein (HDL), low density lipoprotein (LDL) and
triglycerides (TG). Target values for primary prevention are given below:

Lipid Target value / mmol/l

Total Cholesterol 4.0 - 5.0 or less
HDL 1.0 or more (≥1.2 in women and people with diabetes)
Ratio (TC/HDL) 4.0 – 5.0 or less
LDL 2.0 - 3.0 or less
Triglycerides 1.7 or less

If the lipid values are out of normal range, advise a low cholesterol diet and modification of
lifestyle behaviours for at least 3 months and re-check. If lipids remain out of range, consider
further lifestyle modification and initiation of lipid lowering medication according to Dudley
Hyperlipidaemia Guidelines

Familial Hyperlipidaemia (FH)

Familial Hyperlipidaemia should be considered in any patient with:
• TC - 7.5 mmol/l or more, and/or
• LDL – 4.9 mmol/l or more
• In the presence of tendon xanthoma and/or
o Premature CVD (CVD diagnosis in males aged <55, females aged <65)
o Premature familial CVD (1st degree relative with CVD diagnosis in male aged
<55 or female <65)
Follow Dudley Hyperlipidaemia Guidelines where FH is suspected.

CVD Risk Assessment

An estimation of CVD risk should be calculated using QRISK2 http://qrisk.org/

• The lipid value used to calculate CVD risk is TC:HDL ratio, i.e. TC /HDL
• If the risk score is calculated as high risk, i.e. 20% risk of CVD in the next 10 years or
more then the patient should be added to the practice high risk of CVD register. To do
this, add the read code: 14O70 – High risk of heart disease.
• Lipid lowering medication should be considered for all those at high risk following local
Dudley Hyperlipidaemia Guidelines.
13
 Manual Pulse Palpation
• A manual pulse should be palpated each time blood pressure is measured, especially
in any patient over 50 years of age or experiencing symptoms of atrial fibrillation.
• If an irregular pulse is detected, then an ECG should be performed to detect
abnormality. See NICE guidance

Electrocardiogram (ECG)
• A 12-lead ECG should be performed on diagnosis of hypertension to detect any
undiagnosed conditions, such as left ventricular hypertrophy and also to provide a
baseline.

Renal
Chronic Kidney Disease (CKD) is the most common identifiable cause of hypertension.
Also see Phaeochromatocytoma and primary aldosteronism

Estimated Glomerular Filtration Rate

• Blood specimens should also include a request for estimated glomerular filtration rate
(eGFR), serum creatinine and urea. Any eGFR result of <90 mls/min should be
followed up appropriately using the NICE CG73
Proteinuria
• Proteinuria should be measured by sending early morning urine samples to the
biochemistry laboratory requesting the albumin/creatinine ratio (ACR). Positive
proteinuria is defined by ACR of 30mmol/l or more.
Haematuria
• A dipstick test should be performed for the presence of blood in the urine. The
presence of blood may indicate a urological or a renal origin and should prompt
further investigation. For all positive haematuria and proteinuria tests follow the NICE
CG73

Type 2 Diabetes

Fasting Serum Glucose

• Blood specimens should include a request for fasting serum glucose or HbA1C.
o A fasting serum glucose of 6.1mmol/l to 6.9mmol/l or an HbA1C of 42 to 47
may indicate a diagnosis of non-diabetic hyperglycaemia NDH.
o A fasting serum glucose result of 7.0mmol/l or an HbA1C of 48 or more may
indicate a diagnosis of type 2 diabetes, especially where osmotic symptoms
and /or ketonuria is present.
• See Dudley Diabetes Guidelines

Lifestyle

Smoking
• Smoking status should be recorded. This should be repeated annually except for
those who have never smoked.

14
 • For smokers and those who have quit within the last 5 years, calculate lifetime
tobacco exposure as pack years, http://smokingpackyears.com or use the link on the
LTC template in Emis.
• Assess motivation to quit smoking and offer referral to stop smoking clinic, either in
practice or to Dudley Stop Smoking Service. For information on assessing motivation
and referral see Best Practice Guidelines for Lifestyle Assessment

Healthy Diet
• Assess diet objectively using the Dudley Assessment Questionnaire in Best Practice
Guidelines for Lifestyle Assessment. This will indicate a dietary assessment of good,
average or poor diet. Record the result in the patient medical record.
• Give healthy diet advice for all those with an average or poor score
• Further assessment for progress to improve diet can be made by repeating the score
after a period of time when changes have been made successfully.
• In particular, in addition to healthy diet advice:
o Salt consumption – this should be no more than 6g a day (1 level teaspoon). If
expressed as sodium to maximum daily consumption should be 2.5g. Do not
advise the use of branded salt substitute products as these contain potassium
chloride)
o Caffeine – limit consumption to 5 teacups (200mls each) a day. Advise
particular caution with energy drinks and fizzy drinks containing caffeine.

Weight/Body Mass Index (BMI)

• Measure height and weight and calculate BMI. BMI classification below:

BMI (kg/m2) BMI Classification

< 18.5 Underweight
18.5 – 24.9 (south Asian 18.5 – 23) Healthy weight
25 – 29.9 (south Asian 23 – 27.5) Overweight
 30 (south Asian  27.5) Obese

• For those who are overweight or obese give advice on a reducing diet and consider
referral. See Best Practice Guidelines for Lifestyle Assessment

Waist Measurement
• Body shape and fat distribution gives an indication of CVD risk. A large waist,
especially where the waist measurement is larger than the hip measurement is
associated with increased risk of CVD. It is also associated with the development of
metabolic syndrome and diabetes.
• Waist measurements associated with increased risk are given below:

Gender/Ethnicity Increased Risk

Men  40 inches (102cm)
Women  35 inches (88cm)
Asian men  90cm
Asian women  80cm

• All those with large waist i.e. central visceral fat distribution, should be advised to
reduce weight and increase physical activity if they are inactive.

15
 • For guidance on measuring waist circumference see Best Practice Guidelines for
Lifestyle Assessment

Physical Activity
The recommendation for physical activity is either:

• 75 minutes of vigorous exercise a week

• 30 minutes of moderate intensity activity on at least 5 days of the week
• 150 minutes of moderate exercise per week
• Or a combination of all of the above

To assess physical activity status use an objective measurement, which reproducible and
can be used to track progress when repeated after changes are made. Use either:

• The Physical Activity Self –Assessment graph

o Anyone with a ‘sedentary’ or ‘not enough’ score should receive advice and
brief intervention

• The GP Physical Activity Questionnaire –GPPAQ

o Anyone with an inactive or moderately inactive score should be offered
physical activity advice and brief intervention

See Best Practice Guidelines for Lifestyle Assessment

Alcohol Consumption
• Assess alcohol consumption and record as number of units consumed per week. The
recommended limits are:
14 units/week - males and females

• Alcohol should also be assessed as to daily consumption. For those with a diagnosis
of hypertension the daily limit is:

1-2 units/day

To include at least 2 alcohol free days a week

• The AUDIT questionnaire should be completed using the Emis template

http://www.alcohollearningcentre.org.uk
• For further information see Best Practice Guidelines for Lifestyle Assessment

Eyes
• The fundi should be examined for the presence of hypertensive retinopathy.

Other Causes

Thyroid Function
Initial blood samples should also include a request for thyroid function.

16
 • The presence of an overactive thyroid – hyperthyroidism, is associated with
hypertension. Treatment should include regulation of the thyroid gland in conjunction
with hypertension therapy. Consideration of referral to specialist management is
indicated.
• The presence of an underactive thyroid – hypothyroidism, is associated with levels of
hyperlipidaemia. The thyroid condition should be treated and fasting lipids repeated
during a state of euthyroid.

Phaeochromatocytoma
A phaeochromatocytoma is a tumour which releases large amounts of adrenaline and
noradrenaline. Patients with signs and symptoms suggestive of a phaeochromatocytoma
should be referred for immediate specialist treatment due to the seriousness of the condition
and the risk it carries. Signs and symptoms include:
• Raised blood pressure 180/110mmHg
• Postural hypotension
• Palpitation and tachycardia
• Headache
• Raised glucose levels
• Facial flushing
• Nervousness
• Sweating
• Decreased gastrointestinal movement
• Oedema

Hyperaldosteronism (primary aldosteronism)

Aldosterone is a hormone which controls sodium and water balance. Typical signs and
symptoms as well as hypertension include:
• Sodium retention
• Low serum potassium
• Possible irregular pulse
• Muscle weakness
Where Hyperaldosteronism is suspected plasma aldosterone: renin ratio should be
requested and referral to specialist considered.

Cushing’s Syndrome
Cushing’s syndrome is caused by excess production of glucocorticoids. Signs and symptoms
including hypertension are:
• Sudden weight gain
• Central obesity
• Striae, thinning and darkening of the skin
• Moon face
• Weakness, muscle atrophy and fatigue
• Osteoporosis
• Backache
• Headache
• Glucose intolerance
• Oligomenorrhoea/amenorrhoea
• Thirst
• Polyuria
• Impotence
17
 • Depression and insomnia
Where Cushing’s syndrome is suspected, referral for specialist treatment should be
considered.

Obstructive Sleep Apnoea (OSA)

Obstructive sleep apnoea is caused by the upper airway becoming obstructed during sleep.
It is more common in men, especially those with a large collar size (17+) or who are obese.
Signs and symptoms including hypertension are:
• Daytime drowsiness
• Snoring
• Oedema to the lower extremities
• Nocturia
• Morning headache
Where OSA is suspected an OSA assessment should be requested and referral to
respiratory specialist considered. For more information on OSA refer to NICE TA 139

Coartication of Aorta
Coartication of the aorta is a congenital condition where a segment of the aorta is narrowed,
reducing oxygenated blood flow around the body. Signs and symptoms in addition to
hypertension are decreased or delayed femoral pulse and abnormal chest X-ray.
Where coartication of the aorta is suspected, refer to cardiology for Doppler or CT imaging.

Acromegaly
Acromegaly is caused by excess production of growth hormone. Signs and symptoms in
addition to hypertension are:
• Cardiomegaly
• Enlarged facial features
• Enlarged jaw
• Headache
• Joint pain
• Excessive hair growth
• Sweating
• Drowsiness, tiredness and weakness
• Impaired glucose tolerance

Initiating Medication:

Hypertension Treatment Thresholds

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 QRISK2 score of 20% or greater

18
 Blood Pressure Targets

Long-term Evidence Based Target

Condition
Primary  140/90 ( 135/85 HBPM)
Hypertension  150/90 If aged over 80 years
CVD  140/90
Diabetes  140/80
 130/80 If eye, kidney or cerebrovascular complications:
CKD 120 – 139/ 90
120 – 129/80 If ACR  70:

Treatment to these targets is essential for reducing the risk of complications

and the development of other co-morbid conditions

Key Points in the Management of Hypertensive Patients

 For blood pressure measurement guidance referring to treatment thresholds and target
ranges it is recommended that NICE guidance is followed. This is available locally in the
Clinical Pathway for the Management of Cardiovascular Risk. Where Chronic Kidney
Disease is present follow the NICE guidance.
 When titrating patients it is imperative that BP readings are taken regularly and treatment
is reviewed at each consultation.
 Where possible take blood pressure readings at the same time of day.
 Robust recall systems need to be in place along with a medication review programme in
order to improve compliance and concordance.
 Patients who do not attend for blood pressure monitoring on 3 separate occasions, or
make a decision that they do not wish to receive blood pressure monitoring, need to fully
understand the decision they are making about their treatment and their health. Once they
understand their decision they can then be recorded as giving informed dissent using the
Read code 8I3Y. They will then be removed from the denominator population for this
indicator in the LTC framework.
 Prior to initiating antihypertensive treatment ensure that non-pharmacological options are
considered and used first, refer to the Clinical Pathway for the Management of
Cardiovascular Risk which includes lifestyle guidance.
 Guidance on the management and limitation of the salt content of medicines is available
following the link. Hypertensive patients prescribed drugs with a high content of salt
should have their treatment reviewed as this could limit the effectiveness of the
antihypertensive.
 Within Dudley Health Economy Practice Based Pharmacists (PBPs) are widely involved in
the management of patients with long term conditions in particular those with
hypertension. A protocol for the management of hypertensive patients as part of a PBP
clinic is available from the Prescribing Team.
 Allow at least 4 weeks at a dose for a full response.
 Treatment should be reviewed if BP falls below the optimal level.
 Refer to the Clinical Pathway for the Management of Cardiovascular Risk for practical
issues and those not covered by this guideline when managing hypertensive patients.

19
 The Pharmacological Management of Hypertension

Patient aged <55 Patient aged ≥55 years or

years black patients of any age

ACE-inhibitor or First line, always consider:

Low cost ARB (A)*
STEP E.g. Ramipril, Lisinopril or
Perindopril
Low cost ARB = Losartan
Check renal function 7-10
1
days post initiation and
each dose up-titration.
Calcium Channel Blocker
(C)
CCB E.g. Amlodipine
contraindicated Unless contraindicated, not tolerated or
or not tolerated person has evidence of oedema, heart
failure or at high risk of heart failure
Thiazide type or like
diuretic (D)
E.g. Bendroflumethiazide 2.5mg daily
or Indapamide 2.5mg daily
Check plasma K+ 3-4 weeks after
start of treatment. Consider social
circumstances.

STEP
2 A+C

STEP
3 A+C+D

STEP Resistant Hypertension

Consider either:
 Spironolactone** 25mg od if K+ ≤4.5mmol/l. Exercise caution in low eGFR as
4 greater risk of hyperkalaemia. Monitor K+ 3-4 weeks after treatment initiation.
 Other high dose thiazide diuretics (stop present D)
 Beta Blocker e.g. Bisoprolol, Atenolol or Labetalol (in pregnancy or child bearing
women)
 Alpha Blocker e.g. Doxazosin immediate release (avoid in heart failure)
 Aliskiren (secondary care nephrology/cardiology initiation only)
Consider seeking specialist advice or opinion

*ARBs (Irbesartan & Candesartan) are appropriate as an alternative

A = ACE I or low cost ARB
C = Calcium Channel Blocker
D = Diuretic (thiazide type or like)
to an ACE-I when an ACE is not tolerated or contra-indicated.
Losartan has been approved for hypertension with diabetic /
nephropathy and Valsartan has been approved for hypertension post
MI.
**Spironolactone not licensed for hypertension so obtain informed
consent and document. 20
Logical Therapeutic Combinations
All combinations of drugs work except:
 Verapamil + BB use is contraindicated (depress cardiac rate and function).
 Diltiazem + BB should be used only under specialist supervision.
 ACE-I + B have opposing modes of action and should be used in patients with IHD
only.
 Do not use BB and D in combination in those at risk of diabetes.

When is it Appropriate to Use Beta-blockers in the Management of

Hypertension?
For new prescriptions – beta blockers are not a preferred initial choice of therapy but may be
considered in younger people, particularly:

• Those with an intolerance or contraindication to ACE-I / ARB

• Women of child bearing potential or in pregnancy (Labetalol)
• Patients with evidence of increased sympathetic drive

Here, D is best avoided (not absolutely contraindicated) to reduce the risk of new onset
diabetes Mellitus.

When reviewing those on existing beta blocker therapy, if:

• BP is not well controlled (≥140/90mmHg) treatment should be revised according to

the algorithm.
• BP is well controlled (≤140/90mmHg) long-term management should be considered
as part of the routine review, there is no absolute need to replace the beta-blocker
with an alternative agent.

Dudley Drug Formulary:

Drugs approved for the Treatment of Hypertension

(Refer to current BNF for latest prescribing information)

Please refer to the local Dudley Drug Formulary

Annual Review

Annual review should be carried out for all those with hypertension, GP contract indicators
stipulate at least 6 monthly monitoring of blood pressure.

The annual review should include:

• Measurement of blood pressure and review of home monitoring
• Medication review and treatment to target (see blood pressure targets)
• Bloods:
o Urea and electrolytes, eGFR
21
 o Lipid profile
o Fasting serum glucose
o Liver function (if taking lipid lowering medication or other indication)
• Review of symptoms, including identification of new onset suggestive of CVD event or
diagnosis:
o Chest pain
o Shortness of breath
o Fatigue
o Oedema
o Manual pulse
o Headache
o TIA
• Review and revision of lifestyle goals, assessment of motivation

Blood Pressure Targets (mmHg)

Primary  140/90 ( 135/85 HBPM)

Hypertension If aged over 80 years:  150/90
CVD  140/90
Diabetes  140/80
If eye, kidney or cerebrovascular complications:  130/80
CKD 120 – 139/ 90
If ACR  70: 120 – 129/80

Indications for Referral

See urgent referral

General Referral Indications

• Poor response to treatment. Where Blood pressure remains uncontrolled despite 3

antihypertensive agents:
o Check patient concordance with treatment
o Where possible use once daily preparations
o Allow at least 4 weeks for therapeutic effect
N.B. It is extremely rare for intolerance to all major drug classes. Discuss hypertension risks
and agree a management plan. Seek advice from practice based pharmacist before
considering referral.

• Suspected renal artery stenosis:

o A rise of >30% in creatinine or fall of >25% eGFR from baseline
o BP >150/90 mmHg despite 3 antihypertensives
o Unexplained hypokalaemia
o Flash pulmonary oedema

• Investigate and treat secondary causes. refer following indications Dudley pathway
guidance (see useful links)

22
References

National Clinical Guideline Centre (2011) Clinical Guideline 127. Hypertension: The Clinical
Management of Primary Hypertension in Adults. http://guidance.nice.org.uk/CG127

British Hypertension Society http://www.bhsoc.org/

National Institute for Clinical Excellence (2006). Hypertension: Management of Hypertension

in Adults in Primary Care. London

Dudley Formulary www.dudleyformulary.nhs.uk

23
Abbreviations (main pathway and clinic guide)

A Angiotensin Converting Enzyme Inhibitor

ABPM Ambulatory Blood Pressure Monitoring

ACE Angiotensin Converting Enzyme

ACEI Angiotensin Converting Enzyme Inhibitor

ACR Albumin:Creatinine Ratio

ARB Angiotensin Receptor Blocker

B Beta Blocker

BB Beta Blocker

BMI Body Mass Index

BP Blood Pressure

C Calcium Channel Blocker

CCB Calcium Channel Blocker

CHD Coronary Heart Disease

CKD Chronic Kidney Disease

COX2 Cyclooxygenase 2

CVD Cardiovascular Disease

COPD Chronic Obstructive Pulmonary Disease

CT Computerised Tomography

D Diuretic

DAQ Dudley Assessment Questionnaire

DES Designated Enhanced Service

ECG Electrocardiogram

Echo Echocardiogram

eGFR Estimated Glomerular Filtration Rate

GP General Practitioner

GPPAQ General Practice Physical Activity Questionnaire

HBPM Home Blood Pressure Monitoring

HDL High Density Lipoprotein

ISH Isolated Systolic Hypotension

JBS2 Joint British Societies 2

K+ Potassium
24
LDL Low Density Lipoprotein

LV Left Ventricular

MI Myocardial Infarction

mmHg Mini-moles of Mercury

mmol/l Mini-moles per Litre

NHS National Health Service

NICE National Institute for Clinical Excellence

NSAIDs Non-Steroidal Anti-Inflammatory Drugs

QOF Quality and Outcomes Framework

QRISK2 QResearch CVD Risk Calculator

TC Total Cholesterol

TG Triglycerides

TIA Transient Ischaemic Attack

UE Urea and Electrolytes

25