The Oakwood Surgery
Clinical Protocols
Hypertension
QoF topic
Based upon NICE guidelines August 2011
http://www.nice.org.uk/nicemedia/live/13561/56015/56015.pdf
Author
Created
Reviewed
Review Date
Dr Dean Eggitt
October 2012
November 2014 (Dr Alsindi)
November 2015
Background
Hypertension is raised systemic blood pressure. Blood pressure changes all the time and is
easily raised, but is difficult to reduce. Consequently, blood pressure needs to be measured
on several occasions before a true interpretation can be made.
Sustained raised blood pressure damages all of the body’s organs and consequently increases
the chances of other disease such as stroke, heart attacks and kidney failure.
There are several targets for blood pressure depending upon your past medical problems.
This protocol relates to patients above 40 years of age with no predisposing disease states. If
hypertension is suspected in a patient less than 40 years of age, then they should be seen by a
GP.
Diagnosis
The diagnosis of hypertension is made by demonstrating sustained high blood pressure. This
is done both in the surgery and by home blood pressure monitoring, or by a 24 hour blood
pressure monitor.
If hypertension is suspected
1) Confirm the diagnosis, by one of several methods (the choice is up to clinician and
patient preference)
Record and code the BP during the consultation (in the template “OAKWOOD
Lifestyle”)
a. add to the waiting list for ambulatory BP monitoring (ABPM)
i. Minimum of 14 readings 30 minutes apart.
b. OR offer home BP monitoring (HBPM)
i. Minimum of 2 readings whilst sat for 4-7 days (disregard first day)
2) Organise investigations to look for both the cause, consequence and other risk
factors surrounding high blood pressure. These include
FBC, UE, LFT, Glucose, Cholesterol
ECG
Urine dipstick for blood and protein. If dipstick +ve for protein then send off urine
for ACR
3) Bring the patient back to see them with the results of the investigations
DO NOT CODE HYPERTENSION AT THIS STAGE [code as Raised BP]
IF THE BLOOD PRESSURE IS ≥180/≥110 – THIS REQUIRES IMMEDIATE
TREATMENT
Interpreting the readings and confirming the diagnosis
Stage 1
≥140/90 in clinic
AND HBPM/ABPM daytime average is ≥135/85
Stage 2
≥160/100 in clinic
AND HBPM/ABPM daytime average is ≥150/95
Severe
≥180/≥110 in clinic
***Requires immediate treatment and should be discussed with a GP
before the patient leaves***
HBPM/ABPM and bloods/urine/ECG should still be arranged
When the patient returns to be seen with the results of their investigations, use the guide
above to decide whether they do or do not suffer from hypertension.
If it is demonstrated that the patient has either systolic, diastolic, or combined hypertension
then complete the “OAKWOOD NEW hypertension” template. Use the updated blood test
results and HBPM/ABPM averages to calculate an up-to-date QRISK2 score. The patient can
then be coded as suffering from “Essential Hypertension” in the problem list, assuming that
no other cause for hypertension is found.
When to offer treatment of confirmed hypertension
Stage 1 (<150/95):
If under 80 y.o
& with no history of diabetes
& QRISK2 score <20%
& no end organ damage (i.e normal U+Es, no blood on urine dip,
normal urine ACR, normal ECG)
→DO NOT offer treatment, should have annual recall only (if under
40 discuss with GP if should have specialist referral)
Stage 1 (<150/95):
If under 80 y.o
& QRISK2 score≥20%
OR any end organ damage (i.e abnormal U+Es, blood on urine dip,
abnormal urine ACR, abnormal ECG)
OR diabetic
→offer treatment (if under 40 then discuss with GP as should have
specialist referral)
Stage 1 (<150/95):
If over 80 y.o
→DO NOT offer treatment, should have annual recall only
Stage 2 (≥150/95):
→Offer treatment (regardless of age/QRISK2 score/investigation
results/diabetic status)
(if under 40 discuss with GP as should have specialist referral)
Treatment
Over 55’s and Black/Caribbean groups
1. Amlodipine (Causes leg swelling. Caution in heart failure)
a. Start at 5mg ON and review BP at 1 month
b. Titrate to 10mg ON, if needed and tolerated
c. NOTE – interacts with simvastatin. If on Simvastatin 40mg, need to change to
Atorvastatin 20mg ON.
2. Ramipril (consider Losartan if not tolerated or instead of Ramipril in Black/Caribbean
groups) (Monitor renal function)
a. Start at 1.25mg OD and titrate to maximum of 10mg OD
b. UE 2 weeks after each dose change
c. Dose change monthly during titration
d. Will need UE annually with this drug
3. Indapamide 1.5mg MR OD
a. No dose changes, titration or monitoring required
4. Discuss with GP if still not controlled
Under 55’s and Diabetics (any age)
1. Ramipril (Losartan if not tolerated)
a. Start at 2.5mg OD and titrate to maximum of 10mg OD
b. UE 2 weeks after each dose change
c. Dose change monthly during titration
d. Will need UE annually with this drug
2. Amlodipine
a. Start at 5mg ON and review BP at 1 month
b. Titrate to 10mg ON, if needed and tolerated
c. NOTE – interacts with simvastatin.
3. Indapamide 1.5mg MR OD
a. No dose changes, titration or monitoring required
4. Discuss with GP if still not controlled