Hypertension

Data gathering

  • Red flags
    • Visual symptoms, papilloedema, retinal haemorrhages
    • Chest pain
    • Headaches
  • Examine
    • BP, BMI
    • CV
    • Fundoscopy

Clinical management

  • Investigations
    • QRISK2
    • Urine dip
      • Red flag if microscopic haematuria
    • Urinary catecholamines (if young)
  • Treatment
    • Lifestyle
      • Diet (salt), alcohol, smoking, exercise
    • Medications
      • see below
    • Assess for end-organ damage
      • Urine
        • dipstick
        • albumin:creatinine ratio
      • Bloods
        • U+Es, HbA1c, cholesterol
      • ECG
  • Followup / Safety net
    • Annual bloods, BP
    • BP targets
      • Younger than 80 years old: <140/90
      • Older than 80 years old: <150/90
    • Refer
      • Accelerated hypertension (>180/110 with fundoscopy signs)
      • Phaeochromocytoma (headache, palpitations, sweats)
      • < 40 years old

Antihypertensive drug treatments

  • Start if:
    • BP > 140/90 (>150/90 if over 80 years old) and:
      • Target organ damage
      • QRISK > 10%
      • Co-morbidities: CKD, DM, known CVD
    • BP >160/100
  • < 55 years old or T2DM
    • Step 1 ACE-I / ARB
    • Step 2 + CCB
    • Step 3 + Thiazide
    • Step 4 + Spironolactone 20mg OD (if K+ < 4.5) OR alpha blocker (Doxazosin) OR beta blocker (Atenolol)
    • Step 5 Refer
  • T2DM and black person of African or Caribbean origin
    • Step 1 ACE-I / ARB + CCB or Thiazide
  • > 55 years old or black person of African or Caribbean origin
    • Step 1 CCB or Thiazide
    • Steps as above
  • Examples of drugs
    • ACE-I: Ramipril
    • ARB: Losartan
    • CCB: Amlodipine
    • Thiazide: Bendroflumethiazide
    • Potassium sparing diuretic: Spironolactone
    • Alpha blocker: Doxazosin
    • Beta blocker: Atenolol

Patient under 40 years old with newly diagnosed hypertension

  • Differential diagnosis
    • Structural
      • Renal artery stenosis
      • Coarctation
    • Metabolic
      • Phaeochromocytoma
      • Conns – Primary hyperaldosteronism
  • Investigations
    • Bloods – FBC, U+E, LFTs, Fasting glucose, TFTs, Lipids
    • Urine – dipstick
    • Ultrasound KUB
    • 24hour urine metanephrines
  • Management
    • Refer to speciality based on cause
  • Note
    • 10-year CV risk assessments can underestimate the lifetime risk of CV events in this group

Reference