Posted in Cardiovascular system, Chronic disease management, Consultation skills, Diagnosis, Hypertension, Uncategorized

Hypertension – the diagnosis

I’m covering this as it’s a common reason for consulting in primary care. What do you do when you pick up a high blood pressure as part of an examination for another presenting complaint? The answer should not be ‘ignore it and hope it goes away’!

As always, you can read the NICE guidance for all the ins and outs of hypertension diagnosis and management. What I’m going to do is give you some tips on what might be helpful during a consultation where someone has a raised blood pressure but no diagnosis of hypertension.

What I will say (and I can imagine this will become a familiar phrase) is that it is not easy to complete all of this in one 10 minute consultation. So it’s worth planning how to tackle this over a couple of consultations.

Most importantly, you need to know what raised blood pressure is. Here are the definitions to guide you:

  • Stage 1 Hypertension – clinic BP 140/90mmHg or higher AND subsequent 24h BP or home monitoring BP 135/85mmHg or higher
  • Stage 2 Hypertension – clinic BP 160/100mmHg or higher AND subsequent 24h BP or home monitoring BP 150/95mmHg or higher
  • Severe Hypertension – clinic systolic BP 180mmHg or higher OR clinic diastolic BP 110mmHg or higher

I think it’s fair to consider their reason for attendance, and whether this may be impacting upon their BP reading. The other important point is that your patient should be relaxed and quiet whilst the measurement is being taken. It’s a good time for you to complete your documentation. It can be hard to convince a patient to sit and say nothing! Also – make sure you’re using the correct cuff size – this really does impact upon the measurement.

If the BP is high on the first reading then measure it on the other arm also. You should have at least two measurements of BP if the initial one is >140/90. You may take a third if there is a significant difference between the first two. Document the lowest reading taken.

Your first consultation is likely to go as follows if you note a raised BP:

  • You will need to organise 24 hour (ambulatory – ABPM) BP monitoring OR home BP monitoring (HBPM). You might want to discuss these options with your patient. The ideal is ABPM.
  • You can also introduce the idea of hypertension and the lifestyle factors that might impact upon the patient’s BP. It gives them a bit of information to digest in the meantime, and it may allow them to consider how they can alter their lifestyle to make improvements.
  • You can also organise further investigations required to assess for target organ damage (kidneys, heart, eyes), and perform a cardiovascular risk assessment:
    • Bloods – renal function, lipids, HbA1c, liver function (if considering statin)
    • ECG – look for LVH, and REALLY helpful to have a baseline ECG
    • Urine – for albumin: creatinine ratio
    • Fundoscopy – you can look yourself but signposting them to an optician for a detailed check is helpful.
  • To complete a CVD risk assessment (a Q-risk in our case) we will need some information regarding family history of CVD, their height and weight (to calculate BMI), their smoking status, and checking their pulse for AF (which should ideally have been done prior to BP measurement since it can affect electronic BP recording)

You can see that after you’ve taken a history and reached the point of diagnosing a raised blood pressure (which may not have been their reason for attendance) there is quite a lot of explanation and planning to get on with! Don’t forget to address their actual reason for attendance if it wasn’t related to blood pressure.

NOTE – If you diagnose someone with severe hypertension, you need to consider starting an anti-hypertensive there and then. You should probably get on and get some bloods taken on the day to facilitate appropriate monitoring of the medications you have started (e.g. unless you have a recent renal function it is good to get one taken prior to starting an ACE inhibitor, since we need to monitor renal function after initiating said medication). You must also consider referral for same day specialist input if they have signs of papilloedema and/or retinal haemorrhage, or if they have symptoms to suggest an underlying cause e.g. phaeochromocytoma, or referral for investigation if this is possibly secondary hypertension.

The follow-up consultation is hopefully going to be straightforward if you have completed all of the above.

You are going to have the BP monitoring results and be able to diagnose hypertension, and which stage. You will also have the investigation results. This, in turn, allows you to manage the condition appropriately.

What are the lifestyle measures patients’ can take to reduce blood pressure? Did they have a think about these after the last consultation? Are there any changes they think they can realistically make?

  • Diet and exercise (including reducing salt intake, and reducing caffeine intake)
  • Quitting smoking
  • Reducing alcohol intake
  • Relaxation therapies

Who are we giving drug treatment to?

  • Stage 1 hypertension and < 80 years old with:
    • target organ damage
    • established CVD
    • 10-year CVD risk > 20%
    • Diabetes
    • Renal impairment
  • All stage 2 hypertension

Consider referral if < 40 years old with stage 1 hypertension and nil other risk factors, since CVD risk may be underestimated in this population. We need to be looking for a secondary cause in these individuals and offering detailed assessment.

Hypertension should be monitored through clinic readings (unless they have white coat hypertension, in which case home monitoring can be used).

Target BP in clinic is <140/90 if <80 years old or <150/90 if 80 year or older. (home monitoring is <135/85 for < 80years and <145/85 if 80 years or older).

I’m going to stop here.

Do you know which antihypertensives should be used in which groups?

Do you know the stepwise treatment for hypertension?

Do you know how different drugs should be monitored, and what common side effects you might experience with the different medications?

Please use the comments section to try answering some of these questions, or if you have any questions regarding what has been discussed above!

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