Hypertension Protocol –
These guidelines have been developed for ******* Medical Centre based on
the British Hypertension Society guidelines for hypertension management
2004 (BHS-IV) and NICE guideline 18 October 2004, updated June 2006
Diagnosis
1. Measure blood pressure (BP) at least every 5 years in adults without
hypertension and BP < 135/85 mmHg.
2. If BP 135-139/85-89 offer lifestyle advice and measure BP annually.
3. Diastolic pressure is recorded as the disappearance of sounds (phase
V).
4. 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: 1. Test urine for protein and blood on early morning sample
2. Blood test for electrolytes and creatinine and eGFR (measure of kidney
function)
3. Blood glucose
4. Serum cholesterol and HDL cholesterol
5. Record electrocardiograph
6. Record BMI / waist circumference
7. 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
>200/110
Consider immediate treatment
Admit if retinal
haemorrhage
>160/100
Confirm over 1-12 weeks
Treat
140/90-159/99
If target organ damage (see below)
or
cardiovascular complications or
diabetes or
10 year CVD risk >20%
Treat
If none of above
Annual review
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 e.g. 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 e.g. 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 e.g. 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
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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 (i.e. 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.
All results should be recorded on the computer and in patient’s notes
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.
Ss/feb 2008