CLINICAL GUIDELINE. Document No:CG38 *All Sites Management of adult patients referred to South Tees University Hospitals for hypertension.

Transcription

1 GUIDELINE CLINICAL GUIDELINE Document No:CG38 *All Sites Management of adult patients referred to South Tees University Hospitals for hypertension. TITLE Management of adult patients referred to South Tees University Hospitals for hypertension. Version: 2 Approved by: Clinical Standards Sub Group Date: 23 rd September 2014 Author/lead responsible for guideline: Date issued: September 2014 Review date: September 2016 Target audience: Amendments and Additions South Tees Hypertension Service (Revised by Dr N Swanson and Dr A Saif) Doctors referring/reviewing patients with hypertension Replaces/supersedes: CG Associated Policies: N/A

2 Purpose This clinical guideline aims to provide evidence based practice on the investigation and management of patients with hypertension referred as outpatients for specialist assessment to South Tees. Background In light of NICE guidance on hypertension [1], it is anticipated that primary care will refer more complex patients for specialist assessment. Typically, such patients will have one (or more) of the following: 1) Stage 1 hypertension, aged under 40 2) Stage 2 hypertension despite appropriate management as outlined in Steps 1 and 2 of CG127. 3) Where patients cannot access appropriate preliminary assessment in primary care (e.g. unable to get 24 hr BP monitoring) 4) Where patients are intolerant to multiple medications. It is appropriate for patients not meeting these criteria to be managed in primary care. It is expected that this constitutes the large majority of patients with hypertension. Hypertension in childhood or in pregnancy should be referred in the first instance to paediatrics or obstetrics respectively. Guidance: South Tees standard investigation for all patients with resistant/stage 2 hypertension referred for specialist assessment. Take a detailed history A full history should be taken of the condition, specifically covering length of time with hypertension and age of first diagnosis, family history of hypertension, details of current and previous medication regimes used and any side effects encountered. Details of associated risk factors and conditions should be documented (smoking history, lipid disorders, diabetes or endocrine disease, renal impairment/conditions, peripheral vascular disease, impotence, cerebrovascular or cardiac past history). A full drug history (including over the counter/herbal or alternative medications and recreational drug use) should be recorded. Symptoms of phaeochromocytoma should be specifically asked about. Perform an appropriate examination Document BP both arms and lying and standing with appropriate sized cuff. Calculate patients BMI. 24 hour BP (or where unavailable, home monitoring as per NICE guidance) Cardiovascular examination including radiofemoral delay Abdominal examination (specifically for renal disease/bruits) Version: 2 Page 2 of 5

3 Assess for target organ damage 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 (egfr), serum total cholesterol and HDL cholesterol. Examine the fundi for the presence of hypertensive retinopathy if practicable to do so. Arrange for a 12-lead electrocardiograph to be performed. Exclude secondary causes of hypertension This includes (as per NICE CG127 pgs ). Coarctation of the aorta (screened with radiofemoral delay/murmur, confirmed on CT) Hyperaldosteronism - Renin:aldosterone assay. This should be performed on medications. If abnormal, it may need repeated off medications that interfere with the assay. Alcohol excess Screening for renal disease (proteinuria, haematuria, egfr) Hypo/hyperthyroidism Exclude effects of concurrent medications (including decongestant found in inhaled cold remedies, Oral contraceptive pills, immunosuppressive agents, nonsteroidal anti-inflammatory drugs, COX-2 inhibitors, weight loss agents, stimulants (for example, cocaine), mineralocorticoids, antiparkinsonian agents, monoamine oxidase inhibitors, anabolic steroids, sympathomimetics) Where signs/symptoms suggest, or if patient under 40 Exclude Cushing s Exclude phaeochromocytoma (plasma metadrenalines) Exclude acromegaly An ECHO should be requested where clinical assessment has suggested need (i.e. a murmur, features of heart failure) Renal USS with Doppler assessment of renal arteries only for those with proteinuria > trace, haematuria, egfr<60, those resistant to 3 or more drugs and all under 40yrs old at presentation. A chest X ray is not recommended as routine, unless clinical assessment identifies a particular reason to do so. It is not recommended as a screen for coarctation. Measure CVD Risk (from NICE CG181) Use the QRISK2 risk assessment tool to assess CVD risk for the primary prevention of CVD in people up to and including age 84 years. Offer atorvastatin 20 mg for the primary prevention of CVD to people who Version: 2 Page 3 of 5

4 have a 10% or greater 10-year risk of developing CVD. Estimate the level of risk using the QRISK2 assessment tool. [2] Exclude non-compliance Non-compliance should be looked for and excluded, although it is not reasonable in most cases to require admission for observed compliance. Urinary screening for hypertension medications is available on a restricted basis to consultant only requests for patients with apparent resistant hypertension South Tees management for all patients with resistant/stage 2 hypertension referred for specialist assessment. It should be confirmed that appropriate lifestyle changes have been instituted, in line with NICE guidance CG127 Ask people about their diet and exercise patterns, and offer guidance and written or audiovisual materials to promote lifestyle changes. Ask people about their alcohol consumption and encourage them to cut down if they drink excessively. Discourage excessive consumption of coffee and other caffeine-rich products. Encourage people to keep their salt intake low or substitute sodium salt. Offer people who smoke advice and help to stop smoking. Tell people about local initiatives (for example, run by healthcare teams or patient organisations) that provide support and promote lifestyle change. Relaxation therapies can reduce blood pressure and people may wish to try them. However, it is not recommended to provide them routinely. Patients with high blood pressure should pass through steps 1-4 of the NICE guidance on hypertension therapy (see also NICE pathway, Step 4 treatment (from NICE CG127) Consider further diuretic therapy with low-dose (25 mg once daily) spironolactone if blood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a reduced egfr, because they have an increased risk of hyperkalaemia. Consider further diuretic therapy with a higher-dose thiazide-like diuretic if blood potassium level is higher than 4.5 mmol/l. When using further diuretic therapy, monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter. If further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker. Where an underlying endocrine cause has been found, patients should be referred to an appropriately qualified specialist. Version: 2 Page 4 of 5

5 Where an underlying renal cause is found patients with hypertension should be referred to the renal team. Renal referral is indicated in stage IV CRF or proteinuria with albumin: creatinine ratio > 30 mg/mmol. References 1. NICE. CG127 Hypertension [cited 01/04/2011]; Available from: 2. NICE. CG181 Lipid Modification [cited 24/08/2014]; Available from: Version: 2 Page 5 of 5