Appendix 2A - Guidance on Management of Hypertension Measurement of blood pressure All adults from 40 years should have blood pressure measured as part of opportunistic cardiovascular risk assessment. Younger adults with a family history of premature artherosclerotic disease should have their cardiovascular risk factors measured. The current British Hypertension Society guidelines for measuring blood pressure should be followed. A minimum of 3-4 pairs of readings should be gathered on separate occasions over 3-4 months. Those with more severe hypertension should be re-evaluated more urgently. Ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring is recommended to confirm the diagnosis of hypertension. It essential that all blood pressure monitoring devices are serviced and calibrated regularly in line with manufacturer s instructions. Lifestyle modifications Salt Intake Reducing dietary sodium intake can reduce blood pressure by 5mmHg, and even more so in some individuals. People with hypertension should be advised to reduce their salt intake as much as possible to lower blood pressure. All individuals should aim to consume less than 6g of salt per day. Salt restriction ameliorates the age related gradual rise in blood pressure. Even in those in whom blood pressure does not respond to salt restriction, it must be pursued for its synergistic effects on pharmacological antihypertensive agents and the relative lack of efficacy of agents in the presence of significant salt intake. Used in combination with ACE inhibitor and diuretic, salt restriction can achieve a further 9/3 mmhg reduction. Independent from blood pressure, salt restriction can improve other patient outcomes e.g. reduction in the incidence of cardiovascular morbidity and mortality; regression of left ventricular hypertrophy; lowering of urinary calcium excretion, which may protect against calcium stones and the development of osteoporosis with age; increased antiproteinuric effect of ACE inhibitors. Consider modifying non-dietary sources of sodium such as soluble medications e.g. co-codamol effervescent. Calcium, magnesium or potassium supplements should not be used as alternatives to salt as a method to reduce blood pressure. Diet A healthy low calorie diet can reduce blood pressure in hypertensive overweight individuals by 5-6 mmhg in both systolic and diastolic blood pressure. Excessive intake of coffee and caffeine-rich products should be avoided as they can be associated with a modest increase in blood pressure. Exercise / Relaxation Regular aerobic exercise can have a modest effect, reducing systolic and diastolic blood pressure by 2-3mmHg. Interventions to reduce stress and promote relaxation can reduce systolic and diastolic by 3-4mmHg.
Alcohol Excessive alcohol consumption (> 14units /week for men and >14units/week for women) is associated with raised blood pressure. Reduction in alcohol consumption to within recommended limits can reduce systolic and diastolic blood pressure by 3-4 mmhg. Smoking Smoking cessation can have beneficial effect on blood pressure and will reduce overall cardiovascular risk - support and advice should be offered. Refer to Appendix 4D of the Fife Formulary NHS Fife Stop Smoking Guidance. Other Medication Consider concomitant medication that may have an impact on blood pressure e.g. NSAIDs, oral steroids, venlafaxine, oral decongestants. Treatment targets The aim is to reduce the blood pressure to 140/90 mmhg or below (150/90 or below in those over 80 years of age). Audit standards target is <150/90mmHg. For those with established cardiovascular disease, diabetes or chronic renal disease the target of <130/80mmHg is appropriate but can be difficult to achieve. Audit standards are <140/80mmHg. In frail/elderly patients the above targets may be difficult to achieve and individual targets should be set based on appropriateness and tolerability. Systolic pressure is often more difficult to control than diastolic and a combination of drugs is often required. If a patient is not at target and further treatment is inappropriate or declined then benefit is still achieved from the drug(s) if they lower blood pressure. Adherence issues should be addressed if a patient is not at target before considering increasing doses or adding in further medication. Management of Hypertension in Asymptomatic Patients >40 years Blood Pressure (mmhg) Action >180/110 Confirm reading over 1-2 weeks then treat. 160/100 180/110 Recheck blood pressure readings over 1-2 months and treat to target (depending on co-morbidities). 140/90 160/100 Recheck blood pressure readings over 1-2 months and undertake CVD risk assessment (ASSIGN risk score). If ASSIGN risk score >20% or target organ damage or patient is diabetic treat to target. If ASSIGN risk score <20% and no target organ damage or diabetes monitor bp and reassess risk score annually. Treat to target (depending on co-morbidities). 130/90 140/90 Reassess blood pressure annually <130/90 Review within 5 years
Criteria for referral Investigation prior to referral is essential to focus on secondary causes, other vascular risk factors and evidence of end-organ damage. Test for the presence of blood and protein in urine. Blood sample for plasma glucose, urea & electrolytes, total cholesterol and HDL cholesterol. ECG should be performed. Urgent referral required if patient under 30 years, sudden worsening of condition, accelerated (malignant) hypertension (BP >180/110mmHg) with signs of papilloedema and/or retinal haemorrhage. Elevated creatinine (reduced egfr) may indicate renal disease. Phaeochromocytoma may be indicated by labile or postural hypotension, refractory hypertension, headache, hypokalaemia, palpitations, pallor and diaphoresis (sweating). If patients BP remains uncontrolled whilst on maximally tolerated doses of medication and patient is adherent to medication, the patient should be referred electronically via SCI-Gateway to the renal department for advice or consideration of review. Include minimum dataset of the criteria detailed. Choosing drugs for patients newly diagnosed with hypertension (Adapted from NICE Clinical Guideline 127, August 2011) Black patients are those of African or Caribbean descent and not mixed-race, Asian or Chinese patients Younger than 55 years 55 years or older or black patients of any age Abbreviations (1 st line choices): A = ACE inhibitor (ramipril) (Consider losartan if ACE intolerant) C = calcium-channel blocker (amlodipine) D = thiazide-like diuretic ( bendroflumethiazide) Beta-blockers are not a preferred initial therapy for hypertension but are an alternative to A in patients younger than 55 years in whom A is not tolerated or is contraindicated. Pregnancy ACE inhibitors and A2RAs can cause foetal malformations. Must be used with extreme caution in women of childbearing potential. Beta-blockers should be considered. A C* A + C* A + C + D A+C+ D+ spironolactone 25mg** or higher doses of thiazide-like diuretics. Use doxazosin or atenolol if further diuretic therapy is not tolerated, ineffective or is contra-indicated. Consider seeking specialist advice Step 1 Step 2 Step 3 Step 4 *A CCB is preferred but a thiazide-like diuretic should be considered if a CCB is not tolerated or the person has oedema, evidence of heart failure or is at a high risk of heart failure. **Off-label use
Choice of drug Therapy should be started with the recommended class of antihypertensive for that patient type. When there are no special considerations, the least expensive drug, with the most supportive trial evidence, should be used. Drug choices are the same for those with isolated systolic hypertension. Blood Pressure Lowering Medication ACE inhibitor - 1 st choice Ramipril, 2 nd choice Lisinopril Angiotensin receptor blocker 1 st choice Losartan, 2 nd choice Candesartan (irbesartan 1 st choice for Type 2 diabetics with nephropathy) Beta-blocker - 1 st choice Atenolol, 2 nd choice Bisoprolol Calcium channel blocker (CCB) - 1 st choice Amlodipine, 2 nd choice Felodipine Thiazide diuretic 1 st choice Bendroflumethiazide 2 nd choice Indapamide (standard tablets) Antiplatelets Aspirin and other antiplatelets are not recommended for the primary prevention of cardiovascular disease in patients with hypertension. Patients currently prescribed antiplatelet agents for hypertension should be assessed at their next routine review. Antiplatelet agents should only be continued if the cardiovascular benefits are considered to outweigh the potential risk of side-effects on an individual basis. Statins Hypertensive patients with an ASSIGN risk score >20% should be considered for primary prevention with simvastatin 40mg. Refer to Appendix 2F - NHS Fife Guidance on Management of Cholesterol for further advice. Thiazide Like Diuretics Patients currently taking Thiazide-like diuretics at Step 1/Step 2 Patients who are currently being prescribed a thiazide-like diuretic at Step 1/ Step 2 and whose blood pressure is under control should not be switched to a CCB instead. Patients currently being prescribed indapamide and their blood pressure is under control should not be switched to bendroflumethiazide. Beta-blockers In trials, less effective than comparators in reducing cardiovascular events, in particular stroke. Less effective than ACE inhibitors and calcium-channel blockers in reducing the risk of diabetes, particularly when the beta-blocker is combined with a thiazide. Patients currently taking beta-blockers for hypertension If BP under control, no absolute need to replace the beta-blocker with an alternative agent as risks associated with loss of blood pressure control may outweigh any advantage gained by a change in treatment. A change in therapy may be considered at a routine review due to advantages with other medicines. The beta blocker should not be withdrawn if there is a compelling indication (e.g. angina, previous myocardial infarction). Beta-blockers should be withdrawn by a gradual reduction in dose. Patients with Diabetes ACE inhibitors are considered first choice treatment in both Type 1 and Type 2 diabetes. A low cost Angiotensin-II Receptor antagonist (A2RA) [1 st choice Losartan] should only be considered in patients unable to tolerate an ACE inhibitor.
Patients with diabetic nephropathy should not be co-prescribed an ACE-inhibitor with an A2RA due to the higher risk of developing hyperkalaemia. At step 2 or step 3 a thiazide diuretic is often essential. A high dose loop diuretic may be required in renal failure as thiazides are ineffective at egfr<30ml/min. Elderly Patients The benefits of drug treatment for hypertension, including isolated systolic hypertension have been demonstrated in the elderly up to 80 years. Consideration should be given to the reduction in cognitive impairment which can result from blood pressure treatment. Blood pressure reduction in this age group reduces morbidity and mortality due to stroke and other cardiovascular events. Antihypertensives may be implicated in falls. Doxazosin and nifedipine are particularly problematic. Antihypertensive medication should be reviewed following a fall. In patients with postural hypotension, hypertension may be difficult to manage and require referral. Preventing falls is more important than controlling blood pressure.