HYPERTENSION DEFINITION Hypertension (high BP) is a disease of vascular regulation in which the mechanisms that control arterial pressure within the normal range are altered. Predominant mechanisms of control are the central nervous system (CNS), the renal pressor system (renin-angiotensin-aldosterone system), and extracellular fluid volume. DEFINITION Hypertension, or high blood pressure (BP), is defined as a persistent systolic blood pressure (SBP) greater than or equal to 140 mm Hg, diastolic blood pressure (DBP) greater than or equal to 90 mm Hg, or current use of antihypertensive medication. There is a direct relationship between hypertension and cardiovascular disease (CVD). Contributing factors to the development of hypertension include cardiovascular risk factors combined with socioeconomic conditions and ethnic differences. Hypertension is generally an asymptomatic condition. Individuals who remain undiagnosed and untreated for hypertension present the greatest challenge and opportunity for health care providers. TYPES OF HYPERTENSION PRIMARY HYPERTENSIONSECONDARY HYPERTENSIONACCELERATED HYPERTENSION CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS TO PUT IN WORDS… Hypertension is classified as follows: Prehypertension: BP 120 to 139 / 80 to 89 mm Hg Hypertension, Stage 1: BP 140 to 159 / 90 to 99 mm Hg Hypertension, Stage 2: systolic BP greater than or equal to 160 or diastolic BP greater than or equal to 100 mm Hg. PRIMARY HYPERTENSION Also called as Essential HypertensionApprox. 95% of patients Diastolic -- 90 mm of HgSystolic -- 140 mm of Hg or more CAUSES Idiopathic Hyperactivity of sympathetic vasoconstricting nervesPresence of vasoactive substance on smooth muscleIncreased cardiac output, followed by arteriole constrictionExcessive dietary sodium intake, sodium retention, insulin resistance, and hyperinsulinemia Familial (genetic) tendency PATHOPHYSIOLOGY OF PRIMARY HYPERTENSION The hemodynamic hallmark of hypertension is persistently increased SVR. Water and sodium retention: A high-sodium intake may activate a number of pressor mechanisms and cause water retention. Altered renin-angiotensin mechanism: High plasma renin activity (PRA) results in the increased conversion of angiotensinogen to angiotensin I causing arteriolar constriction, vascular hypertrophy, and aldosterone secretion. Stress and increased SNS activity: Arterial pressure is influenced by factors such as anger, fear, and pain. Physiologic responses to stress, which are normally protective, may persist to a pathologic degree, resulting in prolonged increase in SNS activity. Increased SNS stimulation produces increased vasoconstriction, increased HR, and increased renin release. Insulin resistance and hyperinsulinemia Abnormalities of glucose, insulin, and lipoprotein metabolism are common in primary hypertension. Additional pressor effects of insulin include vascular hypertrophy and increased renal sodium reabsorption.

Endothelial cell dysfunction: Some hypertensive people have a reduced vasodilator response to nitric oxide. Nitric oxide, an endothelium-derived relaxing factor (EDRF), helps maintain low arterial tone at rest, inhibits growth of the smooth muscle layer, and inhibits platelet aggregation. Endothelin produces pronounced and prolonged vasoconstriction. ISOLATED SYSTOLIC HYPERTENSION Systolic BP elevation in the absence of elevated diastolic BP is termed isolated systolic hypertension SECONDARY HYPERTENSION Occurs in approx. 5% of patients with hypertensionRenal pathology:Congenital anomalies, pyelonephritis, renal artery obstruction, acute and chronic glomerulonephritis Reduced blood flow to kidney causes release of renin. Renin reacts with serum protein in liver Coarctation of aortaEndocrine disturbances:Pheochromocytoma Adrenal cortex tumors Cushing’s syndromeHyperthyroidismMedications such as estrogens, sympathomimetics, antidepressants, NSAIDs, steroidsConsequences of HypertensionProlonged hypertension damages blood vessels in the brain, eyes, heart, and kidneys and increases the risk of stroke, angina, MI, blindness, and heart and kidney failureBlood vessel damage occurs through arteriosclerosis in which smooth muscle cell proliferation, lipid infiltration, and calcium accumulation occur in the vascular epitheliumDamage to heart, brain, eyes, and kidneys is termed target organ disease; this is the major object of prevention in patients with high BP Risk Factors Increase in incidence is associated with the following risk factors :-

Age:- between 30 and 70 Race:- Black Overweight, sleep apnea Family history Smoking Sedentary lifestyle Diabetes mellitus Metabolic syndrome

RESEARCH EVIDENCE Prevalence Black -30%Non-hispanic whites-25%Mexicans-Americans-22%Recent data have shown that only 70% of adults with hypertension are aware of it, 59% receive treatment, and only 34% reach BP control (less than 140/90 mm Hg). CLINICAL MANIFESTATIONS Usually asymptomaticMay cause headache, dizziness, blurred vision when greatly elevatedBP readings more than 140/90 mm of Hg CLINICAL MANIFESTATIONS OF HYPERTENSION Often called the “silent killer” because it is frequently asymptomatic until it becomes severe and target organ disease occurs. Target organ diseases occur in the heart (hypertensive heart disease), brain (cerebrovascular disease), peripheral vasculature (peripheral vascular disease), kidney (nephrosclerosis), and eyes (retinal damage). Hypertension is a major risk factor for coronary artery disease (CAD). Sustained high BP increases the cardiac workload and

produces left ventricular hypertrophy (LVH). Progressive LVH, especially in association with CAD, is associated with the development of heart failureHypertension speeds up the process of atherosclerosis in the peripheral blood vessels, leading to the development of peripheral vascular disease, aortic aneurysm, and aortic dissection. Intermittent claudication (ischemic muscle pain precipitated by activity and relieved with rest) is a classic symptom of peripheral vascular disease involving the arteries. Hypertension is one of the leading causes of end-stage renal disease, especially among African Americans. The earliest manifestation of renal dysfunction is usually nocturia. The retina provides important information about the severity and duration of hypertension. Damage to retinal vessels provides an indication of concurrent vessel damage in the heart, brain, and kidney. Manifestations of severe retinal damage include blurring of vision, retinal hemorrhage, and loss of vision. DIAGNOSTIC EVALUATION ECGChest X-ray Proteinuria, elevated serum blood urea nitrogen (BUN), and creatinine levels Serum potassium Urine (24-hour) for catecholamines Renal scan Renal duplex imaging Outpatient ambulatory BP measurementsMANAGEMENT(lifestyle modifications) Lose weight if body mass index is greater than or equal to 25.Limit alcohol Get regular aerobic exercise equivalent to 30 to 45 minutes of brisk walking most days.Cut sodium intake to 2.4 g or less per dayInclude recommended daily allowances of potassium, calcium, and magnesium in diet. Smoking cessationReduce dietary saturated fat and cholesterolConsider reducing coffee intake CONTD… If, despite lifestyle changes, the BP remains at or above 140/90 mm Hg over 3 to 6 months, drug therapy should be initiatedIf BP extremely elevated or in presence of cardiovascular risk factors, single drug therapy may be given CONSIDERATIONS IN SELECTING THERAPY Race:- Blacks respond well to diuretic therapy; Whites respond well to ACE inhibitorsAge:- some adverse effects may not be tolerated well by elderly peopleConcomitant diseases and therapies:- some agents also treat migraines, benign prostatic hyperplasia, heart failureQuality of life impact:- tolerance of adverse effectsEconomic considerations:- newer agents very expensiveANTI-HYPERTENSIVE DRUG GROUPS DiureticsBeta-adrenergic blockers Alpha-receptor blockers Central alpha agonists Peripheral adrenergic agents Combined alpha and beta-adrenergic blockers ACE inhibitors Angiotensin receptor blockers Calcium antagonistsDirect vasodilators Drugs currently available for treating hypertension work by 1) decreasing the volume of circulating blood, and/or (2) reducing SVR.

Diuretics promote sodium and water excretion, reduce plasma volume, decrease sodium in the arteriolar walls, and reduce the vascular response to catecholamines. Adrenergic-inhibiting agents act by diminishing the SNS effects that increase BP. Adrenergic inhibitors include drugs that act centrally on the vasomotor center and peripherally to inhibit norepinephrine release or to block the adrenergic receptors on blood vessels. Direct vasodilators decrease the BP by relaxing vascular smooth muscle and reducing SVR. Calcium channel blockers increase sodium excretion and cause arteriolar vasodilation by preventing the movement of extracellular calcium into cells. Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II and reduce angiotensin II (A-II)–mediated vasoconstriction and sodium and water retention.

A-II receptor blockers (ARBs) prevent angiotensin II from binding to its receptors in the walls of the blood vessels. Thiazide-type diuretics are used as initial therapy for most patients with hypertension, either alone or in combination with one of the other classes. When BP is more than 20/10 mm Hg above SBP and DBP goals, a second drug should be considered. Most patients who are hypertensive will require two or more antihypertensive medications to achieve their BP goals. Side effects and adverse effects of antihypertensive drugs may be so severe or undesirable that the patient does not comply with therapy. Hyperuricemia, hyperglycemia, and hypokalemia are common side effects with both thiazide and loop diuretics. ACE inhibitors lead to high levels of bradykinin, which can cause coughing. An individual who develops a cough with the use of ACE inhibitors may be switched to an ARB. Hyperkalemia can be a serious side effect of the potassium-sparing diuretics and ACE inhibitors. Sexual dysfunction may occur with some of the diuretics. Orthostatic hypotension and sexual dysfunction are two undesirable effects of adrenergic-inhibiting agents. Tachycardia and orthostatic hypotension are potential adverse effects of both vasodilators and angiotensin inhibitors. Patient and family teaching related to drug therapy is needed to identify and minimize side effects and to cope with therapeutic effects. Side effects may be an initial response to a drug and may decrease with continued use of the drug. BEST MANAGEMENT OF HYPERTENSION To use the fewest drugs at the lowest doses while encouraging the patient to maintain lifestyle changes. After BP has been under control for at least 1 year, a slow, progressive decline in drug therapy can be attempted. However, most patients need to resume medication within 1 year. PATIENT EDUCATION GUIDELINES Following the DASH eating planDASHDietary Approaches to Stop HypertensionBased on 2,000 calories per day dietDepending on patient’s caloric needs, the number of daily servings may varyFor more information, log on to http://www.nhlbi.nih.gov/health/public/heart/hbp/dash. DASH WEIGHT REDUCTION Weight reduction. A weight loss of 10 kg (22 lb) may decrease SBP by approximately 5 to 20 mm Hg. Dietary Approaches to Stop Hypertension (DASH) eating plan. Involves eating several servings of fish each week, eating plenty of fruits and vegetables, increasing fiber intake, and drinking a lot of water. The DASH diet significantly lowers BP. Restriction of dietary sodium to less than 6 g of salt (NaCl) or less than 2.4 g of sodium per day. This involves avoiding foods known to be high in sodium (e.g., canned soups)

and not adding salt in the preparation of foods or at meals. Restriction of alcohol HYPERTENSIVE CRISIS Hypertensive crisis is a severe and abrupt elevation in BP, arbitrarily defined as a DBP more than 140 mm Hg. Hypertensive crisis occurs most often in patients with a history of hypertension who have failed to comply with their prescribed medications or who have been undermedicated. Hypertensive crisis related to cocaine or crack use is becoming a more frequent problem. Other drugs such as amphetamines, phencyclidine (PCP), and lysergic acid diethylamide (LSD) may also precipitate hypertensive crisis that may be complicated by drug-induced seizures, stroke, MI, or encephalopathy. Hypertensive emergency develops over hours to days and is defined as BP that is severely elevated (more than 180/120 mm Hg) with evidence of acute target FM organ damage. Hypertensive emergencies can precipitate encephalopathy, intracranial or subarachnoid hemorrhage, acute left ventricular failure with pulmonary edema, MI, renal failure, dissecting aortic aneurysm, and retinopathy. Hypertensive emergencies require hospitalization, intravenous (IV) administration of antihypertensive drugs, and `intensive care monitoring.

COMPLICATIONS CONTD… CONTD… NURSING ASSESSMENT Nursing HistoryFamily history of high BPPrevious episodes of high BPDietary habits and salt intakeCigarette smokingEpisodes of headache, weakness, muscle cramp, tingling, palpitations, sweating, vision disturbancesMedication that could elevate BPHormonal contraceptives, steroidsNSAIDs, Nasal decongestants, appetite suppressantsNURSING ALERT The finding of an isolated elevated BP does not necessarily indicate hypertension. However, the patient should be regarded as at risk for high BP until further assessment through history taking, repeat BP measurements, and diagnostic testing either confirms or denies the diagnosis NURSING DIAGNOSES Deficient Knowledge regarding the relationship between the treatment regimen and control of the disease processIneffective Therapeutic Regimen Management related to medication adverse effects and difficult lifestyle adjustments NURSING INTERVENTIONSProvide basic education Explain the meaning of high BP, risk factorsStress that there can never be total cure, only control can be doneStress the fact that there may be no correlation between high BP and symptomsHave the patient recognize that hypertension is chronic and requires persistent therapy and periodic evaluation.Effective treatment improves life expectancy CONTD… Explain the pharmacologic control of hypertension:-Explain that the drugs used for effective control of elevated BP will likely produce adverse effects.Warn the patient of the possibility that orthostatic hypotension may occur initially with some drug therapyInstruct the patient to get up slowly to offset the feeling of dizziness

Encourage the patient to sit or lie down immediately if he feels faintAlert the patient to expect initial effects, such as anorexia, light-headedness, and fatigue, with many medicationsGERONTOLOGIC ALERT Polypharmacy, cognitive changes, and sensory deficits in the elderly may make dosage adjustment and control of BP difficult. Work with the patient, family, and home care nurse to devise a simple method for the patient to take the proper medications. Elderly patients are also more sensitive to therapeutic levels of drugs and may demonstrate adverse effects while on an otherwise average dosage.They may be more sensitive to postural hypotension and should be cautioned to change positions with great care. ACCELERATED HYPERTENSION DEFINITION Also called as Malignant HypertensionOccurs when B.P. elevates extremely rapidlyThreatens one or more target organs like brain, heart & kidney. PATHOPHYSIOLOGY CLINICAL MANIFESTATIONS Brain effects:EncephalopathyStrokeProgressive headache, stupor, seizuresKidney effects:Decreased blood flow, vasoconstrictionBUN elevatedPlasma renin activity increasedUrine specific gravity loweredProteinuria Renal failureCardiac effects:Left-sided heart failureAcute MIRight-sided heart failureMANAGEMENT Immediate hospitalization and treatment if the following are presentSeizuresAbnormal neurologic signsSevere occipital headachePulmonary edemaThe patient is hemodynamically monitored in the ICUAntihypertensive agents are administered parenterally. Agents include:VasodilatorsAdrenergic inhibitorsshort-acting calcium antagonistDiureticsNURSING ALERT BP should be reduced gradually and wide pressure variations avoided because lowered BP may not be adequate to perfuse vital organs NURSING INTERVENTIONS Record BP frequentlyMonitor for adverse effects of medications: headache, tachycardia, orthostatic hypotensionMeasure urine output accuratelyObserve for hypokalemia, especially if patient is placed on diuretic therapy. Monitor for ventricular dysrhythmias HYPERTENSION DEFINITION ACCORDING TO NICE as of August 2011Stage 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 ABPMdaytime average or HBPM average blood pressure is 150/95 mmHg or higher.Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher, or clinic diastolic bloodpressure is 110 mmHg or higher. Diagnosing hypertension If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring(ABPM) to confirm the diagnosis of hypertension.● When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurementsper hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00).Use the average value of at least 14 measurements taken during the person’s usual waking hoursto confirm a diagnosis of hypertension. Cont… diagnosing hypertension ● When using home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension,ensure that:− for each blood pressure recording, two consecutive measurements are taken, at least 1 minuteapart and with the person seated and− blood pressure is recorded twice daily, ideally in the morning and evening and− blood pressure recording continues for at least 4 days, ideally for 7 days.Discard the measurements taken on the first day and use the average value of all the remainingmeasurements to confirm a diagnosis of hypertension. Initiating and monitoring antihypertensive drug treatment, including bloodpressure targets Initiating treatment● Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertensionwho 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 Cont…initiating treatment Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.● For people aged under 40 years with stage 1 hypertension and no evidence of target organdamage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluationof secondary causes of hypertension and a more detailed assessment of potential target organdamage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime riskof cardiovascular events in these people. Monitoring treatment and blood pressure targets For people identified as having a ‘white-coat effect’1, consider ABPM or HBPM as an adjunct toclinic blood pressure measurements to monitor the response to antihypertensive treatment withlifestyle modification or drugs. ContinuedKey priorities for implementation

1 A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis Key priorities for implementation continued Choosing antihypertensive drug treatment● Offer people aged 80 years and over the same antihypertensive drug treatment as people aged55–80 years, taking into account any comorbidities.Step 1 treatment● Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people agedover 55 years and to black people of African or Caribbean family origin of any age. If a CCB isnot suitable, for example because of oedema or intolerance, or if there is evidence of heart failureor a high risk of heart failure, offer a thiazide-like diuretic. Cont… ● If a diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such aschlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release or 2.5 mg oncedaily) in preference to a conventional thiazide diuretic such as bendroflumethiazide orhydrochlorothiazide.● For people who are already having treatment with bendroflumethiazide or hydrochlorothiazideand whose blood pressure is stable and well controlled, continue treatment with thebendroflumethiazide or hydrochlorothiazide cont… Step 4 treatment● For treatment of resistant hypertension at step 4:− Consider further diuretic therapy with low-dose spironolactone (25 mg once daily)2 if theblood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a reducedestimated glomerular filtration rate because they have an increased risk of hyperkalaemia.− Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higherthan 4.5 mmol/l. Measuring blood pressure ● Healthcare professionals taking blood pressure measurements need adequate initial training andshould have their performance reviewed periodically7.● Devices for measuring blood pressure must be properly validated, maintained and regularlyrecalibrated according to manufacturers’ instructions7.● If using an automated blood pressure monitoring device, ensure that the device is validated8 and anappropriate cuff size for the person’s arm is used. Measuring blood pressure When measuring blood pressure in the clinic or in the home, standardise the environment andprovide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretchedand supported.● Palpate the radial or brachial pulse before measuring blood pressure, since automated devices maynot measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation). If pulse irregularity is present, measure blood pressure manually, using direct auscultationover the brachial artery. Postural hypotension

In people with symptoms of postural hypotension (falls or postural dizziness):− measure blood pressure with the person either supine or seated− measure blood pressure again with the person standing for at least 1 minute priorto measurement.● If the systolic blood pressure falls by 20 mmHg or more when the person is standing:− review medication− measure subsequent blood pressures with the person standing− consider referral to specialist care if symptoms of postural hypotension persist. Diagnosing 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 secondmeasurement, 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. Confirming the diagnosis ● If the clinic blood pressure is 140/90 mmHg or higher, offer ABPM to confirm the diagnosisof hypertension.● If a person is unable to tolerate ABPM, HBPM is a suitable alternative to confirm the diagnosisof hypertension.● While waiting to confirm the diagnosis, carry out investigations for target organ damage and aformal assessment of cardiovascular risk Severe hypertension ● Consider starting antihypertensive drug treatment immediately, without waiting for the results ofABPM or HBPM, for people with severe hypertension. Specialist investigations ● Refer people to specialist care the same day if they have:− accelerated hypertension (blood pressure usually higher than 180/110 mmHg with signs ofpapilloedema and/or retinal haemorrhage) or− suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallorand diaphoresis).● Consider the need for specialist investigations in people with signs and symptoms suggesting asecondary cause of hypertension. Using ambulatory or home blood pressure monitoring Ambulatory blood pressure monitoring● Ensure that at least two measurements per hour are taken during the person’s usual waking hours(for example, between 08:00 and 22:00).● Use the average value of at least 14 measurements taken during the person's usual waking hoursto confirm the diagnosis. Home blood pressure monitoring Home blood pressure monitoring● Ensure that:− for each blood pressure recording, two consecutive measurements are taken, at least 1 minuteapart and with the person seated

− blood pressure is recorded twice daily, ideally in the morning and evening− blood pressure recording continues for at least 4 days, ideally for 7 days.● Discard the measurements taken on the first day and use the average value of all the remainingmeasurements to confirm the diagnosis. If hypertension is not diagnosed ● Offer to measure the person’s blood pressure at least every 5 years.● Consider measuring it more often than every 5 years if the person’s clinic blood pressure is closeto 140/90 mmHg.● If there is evidence of target organ damage such as left ventricular hypertrophy, albuminuria orproteinuria, consider carrying out investigations for alternative causes of the target organ damage. Assessing cardiovascular risk and target organ damage Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with peoplewith hypertension, both for raised blood pressure and other modifiable risk factors9,10.● Estimate cardiovascular risk in line with the recommendations on Identification and assessment ofCVD risk in ‘Lipid modification’11. Cont… ● Assess target organ damage12:− Test for the presence of protein in the urine by sending a urine sample for estimation of thealbumin:creatinine ratio and test for haematuria using a reagent strip.− Take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate (eGFR), serum total cholesterol and HDL cholesterol.− Examine the fundi for the presence of hypertensive retinopathy.− Arrange for a 12-lead electrocardiograph to be performed.● For people aged under 40 with stage 1 hypertension, consider seeking specialist evaluation ofsecondary causes of hypertension and a more detailed assessment of target organ damage. This isbecause 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascularevents in these people. Lifestyle interventions ● Lifestyle advice should be offered initially and then periodically to people undergoing assessment ortreatment for hypertension9,13.● Ask people about their diet and exercise patterns, and offer guidance and written or audiovisualmaterials to promote lifestyle changes9.● Ask people about their alcohol consumption and encourage them to cut down if they drink excessively9.● Discourage excessive consumption of coffee and other caffeine-rich products9.● Encourage people to keep their salt intake low or substitute sodium salt9.● Offer people who smoke advice and help to stop smoking9.● Tell people about local initiatives (for example, run by healthcare teams or patient organisations) thatprovide support and promote lifestyle change9. Cont… Do not offer calcium, magnesium or potassium supplements as a method of reducing blood pressure9.● Relaxation therapies can reduce blood pressure and people may wish to try them. However, it is not recommended that primary care teams provide them routinely9

9 This recommendation was developed for the original 2004 guideline.10 Clinic blood pressure measurements must be used in the calculation of cardiovascular risk.11 NICE clinical guideline 67 (2008), available from www.nice.org.uk/guidance/CG6712 For NICE guidance on the early identification and management of chronic kidney disease see ‘Chronic kidney disease’(NICE clinical guideline 73, 2008), available from www.nice.org.uk/guidance/CG7313 For NICE guidance on the prevention of obesity and cardiovascular disease see ‘Obesity’ (NICE clinical guideline 43, 2006),available from www.nice.org.uk/guidance/CG43, and ‘Prevention of cardiovascular disease at population level’ (NICE publichealth guidance 25, 2010), available from www.nice.org.uk/guidance/PH25 Antihypertensive drug treatment ● If possible, offer drugs taken only once a day14.● Prescribe non-proprietary drugs if these are appropriate and minimise cost14.● Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or higher)the same treatment as people with both raised systolic and diastolic blood pressure14.● Offer people aged over 80 years the same antihypertensive drug treatment as people aged55–80 years, taking into account any comorbidities.● Do not combine an angiotensin-converting enzyme (ACE) inhibitor with an angiotensin II receptorblocker (ARB).● Offer antihypertensive drug treatment to women of child-bearing potential in line with therecommendations on Management of pregnancy with chronic hypertension and Breastfeedingin ‘Hypertension in pregnancy’15. Initiating and titrating antihypertensive drug treatment Step 1 treatment● Offer step 1 treatment to people aged under 80 with stage 1 hypertension and one or more of:− target organ damage− established cardiovascular disease− renal disease− diabetes− 10-year cardiovascular risk equivalent to 20% or more.● Offer step 1 treatment to people of any age with stage 2 hypertension Cont… ● Offer people aged under 55 years an ACE inhibitor or a low-cost ARB. If an ACE inhibitor isprescribed and is not tolerated (for example, because of cough), offer a low-cost ARB.● Offer people aged over 55 years and black people of African or Caribbean family origin of any age acalcium-channel blocker (CCB). 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.● If treatment with a diuretic is being started, or changed, offer a thiazide-like diuretic, such aschlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mgonce daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide orhydrochlorothiazide.

Cont… ● For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide andwhose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide.● Beta-blockers are not preferred in step 1. However, they may be considered for younger people if ACEinhibitors and ARBs are contraindicated or not tolerated or there is evidence of increased sympatheticdrive, and for women of child-bearing potential.● If blood pressure is not controlled by step 1 treatment, offer step 2 treatment. Cont… Step 2 treatment● Offer a CCB in combination with either an ACE inhibitor or an ARB16.● If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heartfailure or a high risk of heart failure, offer a thiazide-like diuretic.● For black people of African or Caribbean family origin, consider an ARB16 in preference to an ACEinhibitor, in combination with a CCB.● If a beta-blocker was used in step 1, add a CCB rather than a thiazide-type diuretic, to reduce theperson’s risk of developing diabetes.● Before considering step 3 treatment, review medication to ensure step 2 treatment is at optimal orbest tolerated doses. Cont… Step 3 treatment● Offer an ACE inhibitor or an ARB16 in combination with a CCB and a thiazide-like diuretic.● Regard clinic blood pressure that remains 140/90 mmHg or higher after step 3 treatment with optimalor best tolerated doses as resistant hypertension. Consider step 4 treatment or seeking expert advice. Cont… Step 4 treatment● Consider further diuretic therapy with low-dose (25 mg once daily) spironolactone17 if bloodpotassium level is 4.5 mmol/l or lower. Use particular caution in people with a reduced eGFR, becausethey have an increased risk of hyperkalaemia.● Consider further diuretic therapy with a higher-dose thiazide-like diuretic if blood potassium level ishigher than 4.5 mmol/l.● When using further diuretic therapy, monitor blood sodium and potassium and renal function within1 month and repeat as required thereafter.● If further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- orbeta-blocker.● If blood pressure remains uncontrolled with optimal or maximum tolerated doses of four drugs, seekexpert advice if it has not yet been obtained.16 Monitoring treatment ● Use clinic blood pressure measurement to monitor the response to treatment.● For people identified as having a ‘white-coat effect’23, consider ABPM or HBPM as an adjunct to clinicblood pressure measurements to monitor the response to treatment. Blood pressure targets Clinic blood pressure● People aged under 80 years: lower than 140/90 mmHg

● People aged over 80 years: lower than 150/90 mmHgDaytime average ABPM or average HBPM blood pressure during the person’s usualwaking hours● People aged under 80 years: lower than 135/85 mmHg● People aged over 80 years: lower than 145/85 mmHg Patient education and adherence to treatment ● Help people to make informed choices by providing guidance and materials about the benefits ofdrugs and the unwanted side effects sometimes experienced24.● Tell people about patient organisations that have forums for sharing views and information24.● Offer an annual review of care to monitor blood pressure, provide people with support and discusstheir lifestyle, symptoms and medication24. Interventions to support adherence to treatment ● Only use interventions to overcome practical problems associated with non-adherence if aspecific need is identified25.● Target the intervention to the need. Interventions might include:− suggesting that people record their medicine-taking− encouraging people to monitor their condition− simplifying the dosing regimen− using alternative packaging for the medicine− using a multi-compartment medicines system25.23 Measuring blood pressure Mercury sphygmomanometers give the most accuratenon-invasive BP readings. Accuracy varies widelybetween other available devices. If a non-mercury(e.g. digital) sphygmomanometer is used, it should bechecked and validated every 6 months to maintainaccuracy. Where possible, validation against amercury sphygmomanometer should be conductedby measuring BP simultaneously with both devices ona single arm using a simple Y-piece connection How to measure BP accurately in the clinic • The patient should be seated and relaxed, preferablyafter several minutes of sitting in a quiet room prior tothe measurement.• The selected arm should be free of constrictingclothing so that the cuff can be wrapped around theupper arm without impediment.• Select the appropriate cuff size. The bladder lengthshould be at least 80% and width at least 40% ofthe circumference of the mid-upper arm. The use of‘standard’-sized cuffs in people with large arms canresult in artificially high BP readings. If an oversizedcuff cannot be satisfactorily fitted on a large arm,consider using an appropriately sized cuff on theforearm and auscultating the radial artery instead.• Wrap the cuff snugly around the upper arm, withthe centre of the cuff bladder positioned over thebrachial artery and the lower border of the cuff about2 cm above the bend of the elbow.• Ensure that the cuff is at heart level by supportingthe arm.• Palpate the radial pulse while inflating the cuff andnote the pressure at which the radial pulse ceases tobe palpable. Continue to inflate the cuff a further 30mmHg above this pressure.• Deflate the cuff at a rate of 2–3 mmHg/beat or lesswhile palpating and note the pressure at which theradial pulse reappears. • Fully deflate the cuff, wait approximately 30 seconds,

then inflate the cuff to at least 30 mmHg above thatat which the radial pulse reappeared.• While deflating the cuff at a rate of 2–3 mmHg/beator less, auscultate over the brachial artery in theantecubital fossa.• Record the result for systolic and diastolic BP tothe nearest 2 mmHg. For the systolic reading,record the level at which the beats (at least twoconsecutive beats) are heard, even if they thendisappear transiently with progressive deflation (the‘auscultatory gap’). For the diastolic reading, usedisappearance of sound (phase V Korotkoff ). Usemuffling of sound (phase IV Korotkoff ) only if soundcontinues to zero.• Wait 30 seconds before repeating the procedure inthe same arm.• Average the readings. If the first two readings differby more than 10 mmHg systolic or 6 mmHg diastolic,or if initial readings are high, have the patient restquietly for 5 minutes then take several readings untilconsecutive readings do not vary by greater thanthese amounts. Common errors in BP measurement The following errors can contribute to undertreatment of hypertension:• cuff placed over clothing• incorrect cuff size• worn cuff• inaccurate sphygmomanometer (e.g. not servicedregularly, not validated correctly)• arm elevated above heart• failure to check that both arms give comparablereadings (e.g. at initial visit)• patient not rested before measurement BP measurements outside the clinic Additional readings may be obtained by 24-hourambulatory BP monitoring or by self-measurement ofBP. It is useful to obtain BP readings outside the clinic,because approximately 15% of the general populationshow elevated BP when measured in the clinic butnot in other settings (‘isolated clinic’ or ‘white coat’hypertension).3 In a similar proportion of people,ambulatory BP may be high while clinic BP is normal(‘isolated ambulatory’, ‘masked’ or ‘reverse white-coat’hypertension.Compare the recorded profile with standardambulatory BP values (Table 1). Note that normalvalues for ambulatory BP differ from clinic-measuredBP normal values. Take into account any patient diaryinformation and time of drug treatment, where relevant.The diagnosis of hypertension is supported if thepatient’s average ambulatory BP reading exceedsstandard values for daytime BP or night-time BP orif ambulatory BP load (area under the BP–time curve)is reported and exceeds the reference range by morethan 20%.Mean night-time ambulatory BP level should be at least10% lower than the daytime level.17 Patients who donot show a night-time lowering of BP (‘non-dippers’)are at increased cardiovascular risk.18 Standard ambulatory BP values Measuring BP – Recommendations Use the recommended technique at every BP readingto ensure accurate measurements and avoid commonerrors. Pay particular attention to the following:

• Measure BP with a regularly serviced mercurysphygmomanometer, or regularly validate yourinstrument against a mercury sphygmomanometer.• At the patient’s first BP assessment, measure BP onboth arms. Thereafter, use the arm with the higherreading.• In patients who may have orthostatic hypotension(e.g. the elderly, those with diabetes), measure BPin sitting position, and repeat after the patient hasbeen standing for at least 2 minutes. Cont… If possible, obtain BP measurements outside the clinic(by ambulatory BP monitoring or self-measurement),particularly for patients with any of the following:• unusual variation between BP readings in the clinic• suspected ‘white coat hypertension’ (e.g. clinichypertension in a person without knowncardiovascular risk factors)• hypertension that is resistant to drug treatment• suspected hypotensive episodes (e.g. in those whoare elderly or have diabetes).Interpret ambulatory BP profiles using standardreference values for daytime (awake), night-time(asleep) and 24-hour means. Diagnosis and classificationof hypertension The diagnosis of hypertension should be based onmultiple BP measurements taken on several separateoccasions, e.g. at least twice, one or more weeks apart(sooner if hypertension is severe).International definitions of hypertension vary. Thesuggested classification system used in this guidelinewas developed following an assessment of the systemsused in the United States and in Europe. Although theterm ‘hypertension’ is potentially misleading becauseBP-related risk is a continuum with no defined lowercut-point, it has been retained in this guideline forpractical reasons, on the understanding that individualcardiovascular risk assessment determines appropriatemanagement in each patient. Evaluation in patients withconfirmed hypertensionHistoryTake a full history with particular attention to thefollowing:• known duration of raised BP and previous levels• ambulatory or self-measured BP levels (if known)• previous antihypertensive therapy, efficacy andadverse effects• past history or current symptoms of ischaemic heartdisease, heart failure, cerebrovascular disease orperipheral arterial disease • past history or current symptoms that suggest CKD,e.g. nocturia, dark urine (suggesting haematuria)• symptoms suggestive of a condition that may causesecondary hypertension, e.g. phaeochromocytoma (paroxysmal headache, sweating, palpitations), sleepapnoea (obesity, snoring)• the presence of asthma, chronic obstructive pulmonarydisease, diabetes, dyslipidaemia, gout, erectiledysfunction, sleep apnoea or other significant illnesses • family history of hypertension, diabetes,dyslipidaemia, stroke, CKD or premature (beforeage 60 years) coronary heart disease• modifiable lifestyle risk factors: obesity, physicalinactivity, smoking, excessive intake of alcohol,

salt or saturated fats, recreational drug use(amphetamines, cocaine)• medications (including complementary medicines)that raise BP Cont… personal, psychosocial and environmental factorsthat could influence the course and outcome ofantihypertensive care e.g. educational background,family situation, work environment and associatedpsychological stress (assess for depression, socialisolation and quality of social support).• history of hypokalaemia or suggestive symptoms(e.g. muscle weakness, hypotonia, muscle tetany,cramps, cardiac arrhythmias). Medications that may increase BP Clozapine • Corticosteroids• Haemopoietic agents (darbepoetin, epoetin)• Immunomodifiers (cyclosporin, tacrolimus)• Leflunomide • Monoamine oxidase inhibitors: reversible(moclobemide), irreversible (phenelzine,tranylcypromine)*• Non-steroidal anti-inflammatory drugs(conventional and cyclooxygenase-2 selective)• Oral contraceptives• Oral decongestants (e.g. pseudoephedrine • Sibutramine • Stimulants (dexamphetamine sulfate,methylphenidate hydrochloride)• Sympathomimetic agents• Venlafaxine (dose-related)Rebound hypertension may occur following abruptwithdrawal of the following:• bromocriptine • clonidine.*The use of monoamine oxidase inhibitors in combinationwith tyramine-rich foods (e.g. matured or out-of-date cheese,fermented or matured meats, yeast and soy bean extracts, andothers) can lead to hypertensive crisis. Complementary medicines that may increase BP • American mistletoe• Angel’s trumpet• Butcher’s broom• Caffeine-containing products(e.g. guarana, black tea, colanut, green tea, mate)• Ephedra (ma huang)• Gentian• Ginger preparations• Ginseng preparations• Liquorice • Melatonin• Peyote• Phenylalanine• Sage• St John’s wort Adapted with Physical examination Perform a physical examination with particularattention to the cardiovascular system, including thefollowing:• pulse rate, rhythm and character• jugular venous pulse and pressure• evidence of cardiac enlargement (displaced apex,extra heart sounds), or evidence of decompensation

(basal crackles or wheeze on lung auscultation,peripheral oedema, abdominal signs, e.g. pulsatile liver)• evidence of arterial disease (e.g. carotid, renal orabdominal bruits, abdominal aortic aneurysm, absentfemoral pulses, radiofemoral delay) Cont… • abnormalities of the optic fundi (e.g. tortuosity,thickening or arteriovenous nipping of retinal arteries,retinal haemorrhages, exudates, diabetic retinopathy,papilloedema)• evidence of CKD (e.g. palpable kidneys)• focal neurological signs• evidence of abnormalities of the endocrine system(e.g. Cushing’s syndrome, thyroid disease)• waist circumference (cm) and/or body mass index(BMI): weight (kg) in light clothing, divided by thesquare of height (m) without shoes. Initial investigations Undertake the following investigations to assess forend-organ disease or associated clinical conditions:• Dip stick testing of urine for blood and protein– If abnormal, proceed to urine microscopy.– If proteinuria detected (≥ 1+ on dip stick),measure 24-hour urinary protein excretion.• Assessment of microalbuminuria (highlyrecommended for all patients and mandatoryfor those with diabetes). Microalbuminuria statuscorrelates with cardiovascular risk and its presenceindicates end-organ damage. Cont… – The most accurate screening test is urinaryalbumin/creatinine ratio on a spot urine sample.Use this method where available.– If albumin/creatinine ratio ≥ 2.0 mg/mmol (males)or ≥ 2.5 mg/mmol (females) is detected, repeat thetest to confirm.– If confirmed, obtain a 24-hour urine collection foraccurate measurement. Cont… Blood analysis (sodium, potassium, chloride,bicarbonate, urea, creatinine, uric acid, haemoglobin,fasting glucose, total cholesterol, LDL-cholesterol,HDL-cholesterol, triglycerides, liver function tests).• Electrocardiogram (ECG) to detect conductiondisturbances, arrhythmias, coronary heart diseaseor left ventricular hypertrophy. The presence ofstrain pattern (ST depression and T-wave inversion)is associated with increased cardiovascular risk inpatients with hypertension. Further investigations Further investigations should be undertaken asindicated on the basis of clinical suspicion following thehistory, physical examination and routine investigations.These may include the following:• Echocardiogram (if available), where the result willaffect treatment decisions. Echocardiography is themost accurate widely available method of detectingleft ventricular hypertrophy. Cont… Ankle-brachial index (ABI) in those with risk factorsfor peripheral arterial disease (e.g. smoking, diabetes,vascular bruits, older age). A finding of < 0.9 isdiagnostic for peripheral arterial disease. For moreinformation on ABI, see the position statement bySociety of Interventional Radiology.20

• Carotid Doppler as indicated (e.g. if bruits detected • Plasma aldosterone/renin ratio. Primary aldosteronismoccurs in 5–10% of patients with hypertension and isnot excluded by normal serum potassium.21 It shouldbe considered in all patients with hypertension,especially those with moderate-to-severe or treatment-resistant hypertension and those withhypokalaemia. For information on testing procedure,including medications that affect the result, see www.heartfoundation.org.au/Professional_Information/Clinical_Practice/Hypertension. Referral to aspecialist for investigation is recommended whenprimary aldosteronism is suspected. Cont… 24-hour urinary catecholamine, metanephrine and normetanephrine excretion (with creatinine)and/or plasma catecholamine, metanephrine* andnormetanephrine* concentration. These tests areindicated by symptoms of episodic catecholamineexcess and/or episodic hypertension (suggestive ofphaeochromocytoma).• Renal artery duplex ultrasound, renal nuclearmedicine imaging, and/or CT angiography–indicatedin young females with hypertension, older patientswho might have atherosclerotic renal artery disease,and patients with a renal bruit. Absolute cardiovascular risk The management plan for a person with hypertensionshould take into consideration the individual’s absoluterisk of cardiovascular disease (see When to intervene,page 12).Absolute cardiovascular risk is the probability (expressedas a percentage) of an individual experiencing acardiovascular event (e.g. myocardial infarction orstroke) during a predefined period of time (e.g. thenext 5 years). Blood pressure is a major determinant ofabsolute cardiovascular risk. Patients at highest absoluterisk include those with existing cardiovascular diseaseor those with multiple risk factors (e.g. diabetes, olderage, overweight/obesity and dyslipidaemia). Cont… The purposes of assessing absolute cardiovascularrisk are:• to identify other modifiable risk factors that requiremanagement• to predict who will benefit most from interventionand determine the appropriate management planto reduce BP • to enable the patient to understand the degree of urgency for reducing BP and correcting other riskfactors. When to intervene in patients with confirmed hypertension – Recommendations The decision to intervene and the development of acomprehensive management plan (including lifestyleadvice and drug treatment) should be based on athorough clinical investigation to identify associatedclinical conditions and/or end-organ damage andassessment of absolute cardiovascular risk.Initiate antihypertensive drug treatment immediatelyin hypertensive patients with any of the following:• grade 3 hypertension or isolated systolichypertension with widened pulse pressure(SBP ≥ 160 mmHg and DBP ≤ 70 mmHg)• associated conditions or evidence of end-organdamage (regardless of BP)• high absolute risk of cardiovascular disease, based

on the presence of markers of high risk or asestimated using a risk calculator. Advise lifestyle risk reduction for all patients,especially those with high-normal BP or hypertension(see Lifestyle modification, page 13).Also consider drug therapy for:• patients with moderate risk of a cardiovascularevent (10–15% probability within the next 5 years)as estimated using a risk calculator• Aboriginal and Torres Strait Islander adults.Explain the health implications of current risk and thepotential benefits of the recommended treatment Lifestyle modification Lifestyle modification is indicated for all patients withhypertension, regardless of drug therapy. It may reduce,or even abolish, the need for antihypertensive drugs.REGULAR ACTIVITYThere is strong evidence that regular physical activityhas an independent cardioprotective effect.24• Regular aerobic exercise can lower systolic BP by anaverage of 4 mmHg and diastolic BP by an averageof 2.5 mmHg.25People with any the following should defer physicalactivity until medical review:• grade 3 hypertension (systolic BP ≥ 180 mmHgor diastolic BP ≥ 110 mmHg)• unstable angina, uncontrolled heart failure, severeaortic stenosis, resting tachycardia or arrhythmias• symptoms (e.g. chest discomfort, shortness of breath)on low activity• diabetes with poor glycaemic control• other acute illness. Smoking cessation • Smoking cessation may not directly reduce BP, butmarkedly reduces overall cardiovascular risk. Therisk of myocardial infarction is 2–6 times higher 27,28and the risk of stroke is 3 times higher in people whosmoke than in non-smokers.29,30• Advice from health professionals is effective inincreasing quit rates. Even 3–5 minutes taken toencourage smokers to attempt to quit can increase success rates.31 CONT… Pharmacotherapy (nicotine replacement therapy,bupropion, varenicline) is effective. The risk ofadverse effects is small and is generally outweighedby the significant risk of continuing to smoke. Dietary modification There is strong evidence that salt restriction canreduce systolic BP by approximately 4–5 mmHgin hypertensive individuals and 2 mmHg innormotensive individuals.32 Responses vary betweenindividuals–generally greatest among the elderly andthose with severe hypertension.• (Suitable for patients with normal renal functiononly): Increasing dietary potassium can reducesystolic BP by 4–8 mmHg in hypertensive individualsand 2 mmHg in normotensive individuals.32 CONT…A healthy eating pattern includes mainly plant-basedfoods e.g. fruits, vegetables, pulses and a wideselection of wholegrain foods, moderate amountsof low-fat or reduced-fat dairy products, moderateamounts of lean unprocessed meats, poultry andfish, moderate amounts of polyunsaturated andmonounsaturated fats (e.g. olive oil, canola oil,

reduced-salt margarines). Limit salt intake to ≤ 4 g/day (65 mmol/day sodium) by:• choosing foods processed without salt, foodslabelled ‘no added salt’ or ‘low salt’ (or ‘reducedsalt’ products when other options are unavailable)• avoiding high-salt processed foods, salty snacks,takeaway foods high in salt, salt added duringcooking or at the table.Patients with normal renal function only: increasepotassium intake by eating a wide variety of fruitsand vegetables, plain unsalted nuts (limit quantity andfrequency to avoid excess kilojoules), and legumes(e.g. beans, lentils, dried peas).Patients taking potassium-sparing diuretics must limitpotassium intake to avoid severe hyperkalaemia Weight reduction Every 1% reduction in body weight lowers systolic BPby an average of 1 mmHg.33,34• Weight reduction by as little as 4.5 kg reduces BPand/or prevents hypertension in a large proportion ofoverweight people.1 Weight loss of 10 kg can reducesystolic BP by 6–10 mmHgSibutramine may increase BP in some patients,particularly those who are both obese andhypertensive – monitor BP regularly.Assess waist circumference (preferable) and BMI.Targets are:• waist circumference < 94 cm (males); < 80 cm(females)• BMI < 25 kg/m2 (see notes below).Set achievable intermediate goals in consultation withpatients and assess progress regularly.Advise patients on how to reduce kilojoule intakeas well as increase physical activity. Explain that energy input (kilojoules) from food and drinks must be less than the kilojoules expended in daily activities and planned regular physical activity in order to lose weight. To lose weight, most people will need to do more physical activity than the 30 minutes of moderate-intensity physical activity per day recommended for general health benefits.Emphasise that there is no quick solution; lifestylechanges must be practical and able to be maintainedfor a lifetime. Limiting alcohol • Moderate drinking may increase BP38–40 and bingedrinking may increase the risk of hypertension.38,41• Reducing alcohol consumption can substantiallylower BP in some patients.42Advise patients with hypertension to limit their intake to:• a maximum of two standard drinks per day for men• a maximum of one standard drink per day for women.Advise at least two alcohol-free days per week. Supporting long-term lifestyle changes • Tailor advice to individual patient’s needs and setrealistic goals.• Give regular encouragement. Respond positively toany incremental success, even if targets have notbeen achieved (e.g. reduction in smoking or weight).• Provide specific written instructions.• Review progress regularly.• Refer to other health professionals (e.g. accreditedpractising dietitians or exercise professionals) forongoing support and follow-up where appropriate. Lifestyle – Recommendations Manage identified lifestyle risk factors in all patients,whether or not BP is elevated.

Advise patients to aim for healthy targets:• At least 30 minutes of moderate-intensity physicalactivity on most, if not all, days of the week (dailytotal can be accumulated e.g. three 10-minutesessions). Advise patients of all ages to becomemore active.• Smoking cessation. Refer patients to Quitline.Consider recommending nicotine replacementtherapy and/or prescribing oral therapy (bupropion or varenicline) in patients who smoke more than 10cigarettes per day and have no contraindications. CONT…. • Waist measurement < 94 cm for men and < 80 cmfor women, body mass index (BMI) < 25 kg/m2.When recommending weight loss, advise patientson reducing kilojoule intake as well as increasingphysical activity.• Dietary salt restriction: ≤ 4 g/day (65 mmol/daysodium). Recommend low-salt and reduced-saltfoods as part of a healthy eating pattern.• Limited alcohol intake: maximum of two standarddrinks per day for men or one standard drink perday for women. What this presentation coversDefinitionsCase scenario 1 : MaryCase scenario 1 : MaryAnswer 1.1 You would take Mary’s blood pressure a third time during the consultation. Question 1.2The third reading is 149/93 mmHg. You suspect hypertension – what would you do next? Case scenario 1 : MaryAnswer 1.2 Organise for Mary to receive ABPM through your GP practice. If you are responsible for setting up the monitoring device, you ensure that at least two measurements per hour are taken during Mary’s usual waking hours (for example, between 8 am and 10 pm). You would use the average value of at least 14 measurements taken during Mary’s usual waking hours to confirm a diagnosis of hypertension.At the same time you would also carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy). Move to the next slide for a lists of tests and further investigationsCase scenario 1 : MaryAnswer 1.2 (continued)

• test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip

• take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol

• examine the fundi for the presence of hypertensive retinopathy

• arrange for a 12-lead electrocardiograph to be performed.

You would also carry out a formal assessment of cardiovascular risk (Mary’s clinic blood pressure must be used in the calculation of cardiovascular risk) using a cardiovascular risk assessment tool, in line with Identification and assessment of CVD risk in ‘Lipid modification’ (NICE clinical guideline 67).Records the results of all investigations

and assessment in Mary’s notes.Case scenario 1 : MaryQuestion 1.3 The result of Mary’s ABPM shows daytime average blood pressure of 145/92 mmHg. What would your diagnosis and your next steps be?Case scenario 1 : MaryAnswer 1.3This result shows that Mary has stage 1 hypertension.If you had not already done so (answer 1.2), you would estimate cardiovascular risk and offer tests for target organ damage. You would use the results of the cardiovascular risk assessment to discuss prognosis and healthcare options with Mary. You would also provide lifestyle advice in accordance with the guideline on areas such as diet (including sodium and caffeine intake) and exercise and alcohol consumption. See the definitions slide for ABPM diagnosis criteria Case scenario 1 : MaryQuestion 1.4 The results of the investigations for target organ damage and formal assessment of cardiovascular risk are:

• no evidence of target organ damage • 10-year cardiovascular risk less than 20%.

Nothing abnormal was detected in the other investigations you organised.What is your next step and what treatment would you offer?Case scenario 1 : MaryAnswer 1.4Further assessment You would consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these peopleTreatment Mary does not have target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater, therefore you would not offer antihypertensive drug treatment. You would provide further lifestyle advice in accordance with the NICE clinical guideline.Case scenario 1 : MaryQuestion 1.5 The results of the specialist assessment identifies that there is no target organ damage and cardiovascular risk remains less than 20%. You would therefore continue not to offer Mary antihypertensive drug treatment and continue to provide advice in line with the lifestyle intervention recommendations 1.4.1-1.4.9 If Mary had been eligible to receive antihypertensive drug treatment, what should you consider when prescribing antihypertensive drugs for a woman of child-bearing potential?Case scenario 1 : MaryAnswer 1.5 There is an increased risk of congenital abnormalities if women take angiotensin-converting enzyme (ACE) inhibitors or angiotensin III receptor blockers (ARBs) during pregnancy, and it is important that women of child-bearing age know this. If the woman is planning a pregnancy she should discuss this with you. If a woman taking ACE inhibitors or ARBs becomes pregnant, these antihypertensive drugs should be stopped and alternatives offered.Link to related recommendations from the ‘Hypertension in Pregnancy’ (NICE clinical guideline 107):

• Management of pregnancy with chronic hypertension

• Breastfeeding Question 1.6 What are the key points to remember when measuring blood pressure to ensure that the reading is as accurate as possible?Case scenario 1 : MaryAnswer 1.6

• Ensure that staff measuring blood pressure are trained.• Ensure the person having their blood pressure

measured has a regular pulse before using an automated blood pressure monitoring device.

• Ensure automated devices are validated, maintained and regularly recalibrated. Although not a NICE recommendation, expert opinion would suggest that devices should be maintained annually and there should be a person accountable for recalibrating the devices in order to ensure consistency.

• Provide a relaxed environment for the person whose blood pressure is being measured.

• Ensure the use of an appropriate cuff size.Link to British Hypertension Societies list of validated blood pressure monitoring devicesCase scenario 2 : DannyPresentationDanny is a 39-year-old black male of Caribbean family origin. He presents to you with a sore ankle after ‘going over’ on it.Medical historyDanny has no significant past medical history. Previous presentations have been related to coughs and colds.He smokes 25 cigarettes a day, alcohol consumption around 20 units/week and has done for 18 years. He works shifts and says that he considers his diet to be unhealthy as a result.On examinationYou conclude that Danny’s ankle is sprained. As part of your routine examination you measure his blood pressure. The first measurement in his left arm is 150/92 mmHg, the second measurement in his right

arm is 149/91 mmHg and the third measurement in his left arm is 151/92 mmHg. Question 2.1 What would you do next? Case scenario 2 : DannyAnswer 2.1 You would record Danny’s clinic blood pressure as 149/91 mmHg. In order to diagnose hypertension, you organise ABPM to confirm a diagnosis of hypertension. When organising this you ensure that at least two measurements per hour are taken during Danny’s usual waking hours. You would use the average value of at least 14 measurements taken during Danny’s usual waking hours to confirm a diagnosis of hypertension.At the same time you would also carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy). Case scenario 2 : DannyAnswer 2.1 (continued) You would:

• test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip

• take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol

• examine the fundi for the presence of hypertensive retinopathy

• arrange for a 12-lead electrocardiograph to be performed.

You would also carry out and a formal assessment of cardiovascular risk (Danny’s clinic blood pressure must be used in the calculation of cardiovascular risk) using a cardiovascular risk assessment tool, in line with the recommendations on Identification and assessment of CVD risk in ‘Lipid modification’ (NICE clinical guideline 67).Record the results of the investigations and assessments in Danny’s notes.Case scenario 2 : DannyQuestion 2.2 ABPM indicates that Danny’s daytime average blood pressure is 147/89 mmHg.There is no evidence of target organ damage, cardiovascular disease, renal disease or diabetes. You identify a 10-year cardiovascular risk equivalent to 12%.With this information, what is your diagnosis and what would you do next?Case scenario 2 : DannyAnswer 2.2 You would diagnose stage 1 hypertension and consider referring Danny for a specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. If you had not already done so (answer 2.1) you would also assess cardiovascular risk and offer to test for target organ damage You would use the results of the initial cardiovascular risk assessment to discuss prognosis and healthcare options with Danny. You would also offer Danny lifestyle advice in accordance with the guideline on areas such as diet (including sodium and caffeine intake), exercise, alcohol consumption and smoking.See the definition slide for ABPM diagnosis criteriaSee section 1.4 of the NICE guideline for recommendations about lifestyle interventionsCase scenario 2 : DannyQuestion 2.3 The results of the tests you arranged (presence of protein in the urine, estimation of the albumin:creatinine ratio, haematuria, plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, cholesterol, hypertensive retinopathy, 12-lead electrocardiograph) have been returned. All are normal with the exception of cholesterol which was total cholesterol = 5.6mmol/L, HDL cholesterol 1.1mmol/L. You decided to refer Danny for the specialist assessment. The results of the specialist assessment are returned. There are no secondary causes of hypertension; however, he was noted to have left ventricular hypertrophy and early evidence of impaired diastolic relaxation on his echocardiogram. The report suggests that these changes are most likely related to hypertension. Thus, Danny has evidence of target organ damage.

What would you do next?Case scenario 2 : DannyAnswer 2.3 You would offer Danny treatment with a calcium-channel blocker, for example amlodipine. You would also offer him appropriate information about the drug and unwanted side effects.You would see the results of the more detailed cardiovascular risk assessment to discuss prognosis and healthcare options with Danny (detailed in answer 2.2). As appropriate, you would repeat the lifestyle advice that was given in answer 2.2 in accordance with the guideline on areas

such as diet (including sodium and caffeine intake), exercise, alcohol consumption and smoking. As Danny’s cholesterol level is marginally elevated, you would also enquire about the fat content of his diet and recommend that he reduces his fat intake. You would note that his cholesterol needs rechecking.You would ask Danny to return to your practice in 4 weeks for a review of his blood pressure and for the results of the tests you have arranged.Case scenario 2 : DannyQuestion 2.4 You have previously concluded that Danny’s sprained ankle has healed and all swelling had cleared. Danny returns to the clinic and you notice both ankles are very swollen, which are new to him. This is likely to indicate that he is not tolerating his calcium-channel blocker.His clinic blood pressure is 135/86 mmHg.Would you consider that his blood pressure has been controlled? What would you do next?Case scenario 2 : DannyAnswer 2.4 Danny’s blood pressure has been controlled as his clinic blood pressure is now below 140/90 mmHg which is what you were aiming for. However, he was not tolerating the calcium channel blocker. You would change the calcium-channel blocker to a thiazide like diuretic such as indapamide 2.5 mg once daily. You would arrange for him to return to clinic to check his blood pressure again in 4 weeks.Case scenario 3 : DorisPresentationDoris is an 81-year-old female non-smoker. She was diagnosed with stage 2 hypertension, by a practice colleague 1 month ago. It is thought the cause is probably arterial stiffening. Her clinic blood pressure was 174/52 mmHg and her ABPM average was 170/50 mmHg She was not identified as having ‘white-coat’ hypertension. She has now returned to the practice after your colleague requested she return for a follow up appointment.Medical historyDoris has no significant medical history. Question 3.1What would you have expected your colleague to have initiated with Doris?Case scenario 3 : DorisAnswer 3.1 You would have expected your colleague to have:Arranged and reviewed the results of all appropriate tests for target organ damage and cardiovascular risk assessment in line with the NICE guideline.Started treatment with a calcium-channel blocker.Offered Doris information and guidance about her diagnosis and treatment options.Asked Doris to return to your practice clinic in 1 month to check her blood pressure (this is the purpose of her current visit to you).Please note some cardiovascular risk assessments have a maximum age and may not be applicable for use with Doris. Additionally, given her age, Doris will score very highly in all cardiovascular risk assessments.Case scenario 3 : Doris Question 3.2 Doris’s total cholesterol is 4.8mmol/L and her HDL is 1.6mmol/L. Glucose is normal. There is no left ventricular hypertrophy or atrial fibrillation on ECG. Her 10-year cardiovascular risk is 27% (using QRISK2).You measure her clinic blood pressure and it is 165/100 mmHg.What would you do next?Case scenario 3 : DorisAnswer 3.2

Doris’s blood pressure is not controlled. You would check adherence with step 1 treatment. Identify if there is anything you can do (modify dosing regimen, provide a record for her to monitor her medicine taking) to help enhance adherence. You would offer step 2 hypertensive treatment with the addition of an ACE inhibitor. Link to Medicines adherence (NICE clinical guideline 76) Question 3.3 Doris returns to the clinic after a further month. Her clinic blood pressure is 154/90 mmHg. What would you do next?Case scenario 3 : DorisAnswer 3.3 You would review Doris’s antihypertensive medication and ensure that it is at the optimal or best tolerated dose.You would also consider her adherence to the drug regimen and ensure that any factors that may reduce her adherence are managed. You would arrange for a blood test to check her electrolytes around 2 weeks after starting the ACE inhibitor and ask her to return to the practice in 1 month for the results of the electrolyte test and a further review of her blood pressure. At her next clinic appointment Doris’s blood pressure is 145/85 mmHg.. This is an acceptable blood pressure for a person over 80. Doris can stay on current treatment. Case scenario 4 : DerekPresentation Derek is a 53-year-old male who has been diagnosed with stage 2 hypertension. You confirmed diagnosis one month ago. On examinationDuring Derek’s diagnosis and assessment his clinic blood pressures was 176/108 mmHg. Additionally, you identified left ventricular hypertrophy on ECG. You were unable to confirm the diagnosis with ABPM because Derek refused it because he is a bus driver and it would interfere with his driving. Question 4.1 What alternative test could you have used to diagnose hypertension?Case scenario 4 : DerekAnswer 4.1 You could offer Derek home blood pressure monitoring (HBPM). Question 4.2 When instructing Derek in how to use HBPM, what instructions did you have to give him and what measurements would you base your diagnosis on? Case scenario 4 : DerekAnswer 4.2You would have ensured that each blood pressure recording was based on two consecutive measurements taken at least one minute apart with Derek seated.You would have asked Derek to record his blood pressure twice daily for at least four days and ideally for seven days. To diagnose hypertension based on HBPM, you discard the measurements taken on the first day and take an average of all of the remaining measurements.Question 4.3 The average home blood pressure result was 155/97 mmHg. With this result you noted that Derek had a ‘white-coat effect’. However despite this, his HBPM measurements indicated a diagnosis of stage 2 hypertension and he had target organ damage. You made this diagnosis one month ago. You offered lifestyle interventions in line with recommendations 1.4.1 to 1.4.9 in the guideline nd started Derek on step 1 treatment. What drug regimen would you

have offered Derek and how would you monitor his response to treatment?Case scenario 4 : DerekAnswer 4.3 You would have offered offer Derek treatment with an ACE inhibitor and HBPM to monitor his response to treatment.Question 4.4 Derek has returned to you with the results of his monitoring HBPM. During the past week, his average blood pressure was 150/94 mmHg. What is the target blood pressure for HBPM when monitoring response to treatment and what would you do about this result?Case scenario 4 : DerekAnswer 4.4 For people aged under 80 the target HBPM blood pressure is below 135/85 mmHg. Derek’s blood pressure is not controlled so you would offer him step 2 treatment with a calcium-channel blocker in addition to his current ACE inhibitor.Question 4.5 When he returns to you 1 month later, Derek’s HBPM result is still above 135/85 mmHg. What would you do next?Case scenario 4 : DerekAnswer 4.5 You would check Derek’s adherence to treatment in line with recommendations 1.7.1 to 1.7.4 of the guideline.You would review his medication to ensure that step 2 treatment is optimal.Question 4.6 Derek’s medication adherence is good and step 2 treatment is optimal. What would you do next?Case scenario 4 : DerekAnswer 4.6 You would offer Derek a thiazide-like diuretic in addition to his ACE inhibitor and calcium-channel blocker.Question 4.7 Derek returns to your clinic and his blood pressure is still not controlled. What would you do next?Case scenario 4 : DerekAnswer 4.7

• Check that Derek has received optimal medication at step 3 and reassess his adherence to his antihypertensive medication.

• Ensure that Derek has been involved in treatment decisions throughout his care and that you have adapted your consultation style in order to facilitate this involvement.

• Review Derek’s knowledge, understanding and concerns about his antihypertensive medication and .explore whether or not Derek believes that he needs the medication.

Link to Medicines adherence (NICE clinical guideline 76)Case scenario 4 : DerekAnswer 4.7 (continued)

• If you identify practical problems, consider interventions such as suggesting Derek records his medicine-taking and monitors his condition, simplifying the dosing regimen, using alternative packaging for the medicine or using a multi-compartment medicines system.

• Ensure that Derek has received appropriate guidance and materials about the benefits of the drugs and unwanted side effects.

• Repeat all of these actions on a regular basis when reviewing or prescribing antihypertensive drug treatment for Derek.

Question 4.8 You conclude that Derek is adherent to his medication regime and that he is on the optimal doses of the ACE inhibitor, calcium channel blocker and thiazide-like diuretic. What would you do next?Case scenario 4 : DerekAnswer 4.8 You seek a specialist opinion for Derek. You anticipate he will be started on step 4 treatment.Case scenario 5 : PhilipPresentationPhilip is a 56-year-old male who presents to you with feelings of dizziness every time he stands up.Medical historyPhilip has migraines and takes propranolol modified-release 160 mg daily, which has reduced the frequency.He attends the GP surgery’s weight loss clinic. He has lost five stones in 12 months and his BMI is now 29.On examinationPhilip’s ECG is normal and his blood pressure is 126/82 mmHg.Question 5.1 What would you do next to investigate the cause of Philip’s dizziness?Case scenario 5 : PhilipAnswer 5.1 As he was seated for the first readings, you would ask Philip to stand up for one minute and then measure his blood pressure again.Question 5.2 Philip’s standing blood pressure is 90/50 mmHg.What would you do next?Case scenario 5 : PhilipAnswer 5.2 You would review Philip’s medication. His recent weight loss may mean that the dose of beta-blocker needs to be reduced You would note the postural hypertension in Derek’s records so that colleagues measuring his blood pressure in the future are aware that they should measure his standing blood pressure, as wellIf changes to the migraine prophylaxis do not relieve Derek’s dizziness you would consider referral to a specialist.Find out moreVisit www.nice.org.uk/guidance/CG127 for:the guideline the quick reference guide‘Understanding NICE guidance’costing report and statementaudit support and electronic audit toolbaseline assessment toolImplementation advicepodcastawareness raising slide setTHANKS