Hypertension Protocol

These guidelines have been developed for Newcastle and North Tyneside, based on the British Hypertension Society guidelines for hypertension management 2004 (BHS-IV) and NICE guideline 18 October 2004, updated June 2006. NICE have released a new guideline for hypertension in August 2011, which we will be incorporating into practice.

Diagnosis

• Measure blood pressure (BP) at least every 5 years in adults without hypertension and BP < 135/85 mmHg .
• If BP 135-139/85-89 offer lifestyle advice and measure BP annually.
• Diastolic pressure is recorded as the disappearance of sounds (phase V).
• At least two measurements should be made at each of several visits.

Investigations
On those with a blood pressure > 140 mmHg systolic and/or > 90 mmHg diastolic:-

• test urine for protein and blood on early morning sample
• blood test for electrolytes and creatinine and eGFR (measure of kidney function)
• blood glucose
• serum cholesterol and HDL cholesterol
• record electrocardiograph
• record BMI / waist circumference
• calculate 10 year cardiovascular disease (CVD) risk using hypertension template or cardiovascular risk tables

Blood pressure action levels
Action should be taken on the systolic (upper) or the diastolic (lower) level

target organ damage = kidney impairment, protein in the urine, enlarged heart, eye retina damage, established blood vessel disease.

Non-pharmacological measures
Advice should be offered to all patients with hypertension covering diet, salt reduction, exercise, alcohol, avoiding excess coffee, achieving ideal weight and smoking cessation.

Aim to get blood pressure below 140/90 (130/80 in patients with diabetes or CKD without proteinuria, 125/75 in patients with diabetes with microalbuminuria / nephropathy or patients with CKD with urine protein 2+ or more).

Choice of anti-hypertensive drug treatment
BP lowering is more important than the drug used. Moderate dose of two drugs if preferable to high doses of one. Aim for once daily regimens.

1. ACE inhibitors for patients under 55 yrs eg lisinopril 5-40mg daily (Use as first choice in those with heart failure, left ventricle dysfunction, diabetes with microalbuminuria/nephropathy, most intrinsic renal disease) . Diuretic eg bendroflumethiazide 2.5mg for those 55 yrs or older or black patients of any age.
   
   
2. ACE inhibitor with diuretic.
   
   
3. ACE inhibitor and Calcium antagonists and a diuretic
   
   
4. Consider switching thiazide to loop diuretic (furosemide), add an aldosterone antagonist (spironolactone), add a B blocker (atenolol), alpha-blocker eg doxazosin 1-4 mg daily (max 16mg daily), referral if treated with 4+ drugs
   

Note: High risk of diabetes - strong family history of type 2 diabetes, impaired fasting hyperglycaemia, BMI >= 30, S. Asian or African-Caribbean origin

Other measures to reduce cardiovascular risk

• Patients aged 50 or older whose blood pressure is below 150/90 should have aspirin if there is evidence of target organ damage, diabetes, or a 10 year CHD risk of >20%.
• Patients with vascular disease should have aspirin
• Patients whose cholesterol is >5.0 mmol/l and whose 10 year CVD risk is >20% should have treatment with a statin to reduce cholesterol level according to FATS guidance.

Follow up
If no response to a drug (ie fall in systolic BP < 5mmHg) after 1 month - check usage
If drug is being taken and no response, change to another drug class
Many patients may require combinations of treatment to achieve target BP (lower doses of two drugs lead to more effect and fewer side effects than large doses of one)
Monitor renal function after one month on those taking ACE inhibitors.

Routine follow up for patients with hypertension should be 6 monthly for measurement of BP, and further lifestyle advice as appropriate.
Urinalysis for protein should be done annually.

Side effects
Side effects should be assessed and significant problems referred to the doctor.

Specialist Referral
Should be considered for urgent treatment (malignant hypertension with BP >180/110 with signs of papilloedema and/or retinal haemorrhage, impending complications), to investigate potential underlying causes, for problems or failures of treatment.

Ambulatory BP measurement
This may be indicated for assessment when BP shows unusual variability, when BP is resistant to drug treatment (three or more drugs), when symptoms suggest the possibility of low blood pressure. It is emphasised that even with best management it will not be possible to reach treatment targets in all patients. The aim is to reduce blood pressure as near to target readings as is possible while avoiding side effects and keeping medication levels acceptable to patients.

July 2007