1. Clinical Management of primary hypertension
Plus assessment of cardiovascular risk

2. Introduction
Hypertension (high blood pressure) is one of the most important preventable causes of premature morbidity and mortality in the UK.. Raised blood pressure is one of the three main modifiable risk factors for cardiovascular disease, which account for 80% of all cases of premature coronary heart disease 
It increases the risk of atrial fibrillation and is a major risk factor for stroke (ischaemic and haemorrhagic), myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death

3. Definitions From Nice Guidelines August 2011
Stage 1 Hypertension – clinic BP >140/90 or average ABPM/HBPM > 135/85
Stage 2 Hypertension – clinic BP>160/100 or ABPM/HBPM >150/95
Severe Hypertension – clinic BP >180/100
White Coat Hypertension - discrepancy of more than 20/10 mmHg

4. Measuring BP Ensure device is maintained and recalibrated.
Use appropriate cuff size.
Arm outstretched and supported.
Irregular pulse – use non-automated device.
No talking !
Ideally, measure in both arms and if > 140/90 take a 2nd and 3rd , record the lower reading.
Nurse preferable ! See JRCGP April 2014

5. Diagnosing Hypertension
If clinic BP>140/90 offer ABPM ;HBPM is a suitable alternative.
Investigate for target organ damage and an assessment of cardiovascular risk.
Severe hypertension – consider immediate Rx.
Immediate referral – accelerated hypertension plus signs of retinal haemorrhage OR suspected phaeo.

6. Assessing CVD risk and target organ damage
Use a formal tool eg Framingham or Qrisk to estimate 10 year risk.
Urine – blood on dipstick and send ACR.
Blood – glucose/Renal function including eGFR/lipid profile.
12 lead ECG .
Examine fundi.
Age under 40 with stage 1 – consider specialist referral as 10 yr risk can underestimate lifetime risk plus rule out secondary causes.

7. Qrisk or Framingham

8. Lifestyle Interventions
Ask about lifestyle initially and offer advice periodically.
Alcohol – men 3-4 daily, women 1-2, no binging.
Discourage excess caffeine.
Reduce salt intake.
Exercise regularly.
Promote and encourage exercise.
Encourage smoking cessation.
Relaxation therapies can reduce blood pressure and people may wish to try them. However, it is not recommended that primary care teams provide them routinely.

9. Antihypertensive drug treatment
Principles : once daily generic drugs, don’t combine ARB plus ACE. Use a low cost ARB (Losartan) if ACE not tolerated.
Treat all with stage 2 hypertension.
Stage 1 hypertension – treat if additionally : target organ damage, established cardiovascular disease, renal disease, diabetes or CVD risk > 20%

10. Continued - medication
In step 1 – if CCB not tolerated then use a diuretic. When using a D use Indapamide 2.5mg.
Beta Blockers are not preferred. However consider in younger people if ACE/ARB not tolerated or evidence of increased sympathetic drive or for women of child bearing potential.
In Step 2 ARB may be used in preference to an ACE (in combination with CCB) in black people.
In Step 4 , use Spironolactone only if K < 4.5 and caution in reduced eGFR. If K>4.5 then consider higher dose diuretic.
Next step if uncontrolled – alpha or beta blocker.
Younger white patients tend to have high levels of renin and Angiotensin2
Chlortalidone alternative but 25mg starting dose unavailable.
If beta blockers are initiated add CCB as second line as thiazide increase risk of diabetes.
Spironolactone doesn’t have a licence for hypertension.

11. Not NICE Nice doesn’t look at the individual Person centred care
Diabetes/CKD/BPH/Migraine/immediate reduction/increased sympathetic drive/Raynauds/side effects/most hypertensives are on more than one drug traetment

12. BP targets Clinic BP 140/90 if less than 80
Clinic BP 150/90 if over 80.
ABPM/HBPM 135/85 if less than 80
ABPM/HBPM 145/85 if over 80.
BUT QOF: 150/90 or 140/80 diabetes or 140/85 CKD

13. Secondary Hypertension
About 10%
renal disease eg glomerulonephritis, polycystic kidneys, chronic pyelonephritis
Renovascular disease – atheromatous
Pregnancy
Endocrine – Cushings, Conn’s, Phaeo, Acromegaly.
Coarctation.
Drugs – NSAIDs , steroids and alcohol

14. Hypertensive Crisis
Hypertensive urgency:  a systolic blood pressure ≥180 mm Hg or a diastolic blood pressure ≥120 mm Hg without impending end-organ damage
Hypertensive Emergency /Malignant (accelerated) hypertension: this is a syndrome characterised by severe hypertension (eg, systolic >200 mm Hg, diastolic >130 mm Hg) accompanied by end-organ damage -
Treatment should be adjusted to safely reduce BP over a few days.
Eg encephalopathy,, eclampsia, papilloedema. Same day assessment and immediate treatment to reduce the BP within minutes to hour

15. When to consider referral
See previous for accelerated hypertension/suspected phaeo.
At step 4 if BP remains resistant.
Younger patients, especially if suspected secondary cause.
Pregnancy.