HYPERTENSION TREATMENT CASCADE Definition
Stage 1: Clinic BP≥140/90mmHg and subsequent Ambulatory BP Monitoring (ABPM) daytime average or Home BP Monitoring (HBPM) average ≥135/85mmHg. Stage 2: Clinic BP≥160/100mmHg and subsequent ABPM daytime average or HBPM average≥150/95mmHg. Severe hypertension: Clinic systolic BP≥180mmHg or clinic diastolic BP≥110mmHg.
Automated Automated devices may not be very accurate in case of pulse irregularity (eg. atrial fibrillation). Palpate the radial/ brachial devices pulse before measuring BP. If pulse irregularity is present, measure BP manually with auscultation over the brachial artery. Ensure device for measuring BP is properly validated, maintained and regularly recalibrated. Preliminary When measuring BP, standardise the environment providing a relaxed, temperate setting, sitting quietly, and outstretching procedures and supporting the arm. In people with symptoms of postural hypotension (falls or postural dizziness): - measure BP with the person either supine (—) or seated. - measure BP again with the person standing ( | ) for at least 1 minute prior to measurement. Postural - If the systolic BP falls by ≥20mmHg when the person is standing: Hypotension - review medication - measure subsequent blood pressures with the person standing - consider referral to specialist if symptoms of postural hypotension persist. Always measure blood pressure in both arms. If the difference in readings between arms >20mmHg, repeat measurements. If the difference in readings between arms remains >20mmHg, stick to the arm with the higher reading. If blood pressure measured in the clinic ≥140/90mmHg: - Take a 2nd measurement during the consultation. If the 2nd measurement is very from the first, take a 3rd measurement. If the clinic BP≥140/90mmHg, offer ABPM to confirm the diagnosis of hypertension. If a person is unable to tolerate ABPM, then HBPM is a suitable alternative to confirm the diagnosis of hypertension. If the person has severe hypertension, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM. While waiting for confirmation of diagnosis of hypertension, carry out investigations for target organ damage (LV hypertrophy, cKD and hypertensive retinopathy) and calculate cardiovascular risk using QRISK2 tool.
When using ABPM to confirm diagnosis, ensure that: - at least 2 readings/hour were taken during the person's usual waking hours (i.e. between 8am-10pm). - the average of at least 14 measurements is used to confirm diagnosis. When using HBPM to confirm a diagnosis of hypertension, ensure that: - for each recording, two consecutive measurements were taken, at least 1 min. apart and with the person seated, and - readings are recorded twice a day (Morning and Evening), and - readings continue for at least 4 days (ideally 7 days). - disregard measurements made on the 1st day and use the average of all the remaining measurements.
- If diagnosis is not confirmed but there’s evidence of target organ damage (LV hypertrophy, albuminuria or proteinuria) carry out investigations for other causes of the target organ damage. - If diagnosis is not confirmed, measure the person's clinic BP at least every 5 years subsequently, and consider measuring it more frequently if the person's clinic BP is close to 140/90mmHg. Refer to specialist on the same day in case of: - accelerated hypertension, i.e., BP>180/110mmHg with signs of papilloedema and/or retinal haemorrhage, or - suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor and diaphoresis).
Assessing CV risk and target organ damage
Refer to specialist people with signs and symptoms suggesting a secondary cause of hypertension. - Estimate cardiovascular risk in line with the 'Lipid modification' Guideline [NICE CG67] using QRISK2 tool. - For all people with hypertension: - test for proteinuria (urine sample to estimate the Albumin:Creatinine ratio), and test for haematuria using a reagent strip. - take a blood sample to measure plasma Glucose, Electrolytes, Creatinine, eGFR, Total Cholesterol and HDL. - examine the fundi for the presence of hypertensive retinopathy. - arrange for a 12-lead electrocardiogram to be performed. - Ascertain diet and exercise patterns as a healthy diet and regular exercise can ↓BP. - Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes. - Relaxation therapies can ↓BP and people may wish to pursue these as part of their treatment. - Check alcohol consumption and encourage reducing if drinking excessively. This ↓BP and has broader health benefits. - Discourage excessive consumption of coffee and other caffeine-rich products. - Encourage people to keep their dietary Na+ intake low, either by reducing or substituting Na+ salt, as this can ↓BP. - Do not offer Ca2+, Mg2+ or K+ supplements as a method for reducing BP. - Offer advice and help to smokers to stop smoking. - Inform about local initiatives (healthcare teams or patient organisations) that support & promote healthy lifestyle change.
Where possible, keep treatment simple with drugs to be taken only ONCE A DAY.
- Teat people with isolated systolic hypertension (systolic BP≥160) or with raised systolic and diastolic BP the same way. Choosing - Treat the elderly aged ≥80 years the same way as people aged 55-80 years, taking into account any comorbidities. treatment - Treat women of child-bearing potential in line with the 'Hypertension in Pregnancy' Guideline [NICE CG107]. People <55yo ,
Step 1 (1 drug)
ACEi or ARA (namely if ACEi not tolerated (eg. dry persistent cough), but NEVER ACEi + ARA to treat BP.
Ca2+ channel blocker (CCB)
β-blockers are NOT a preferred initial therapy for hypertension, but may be considered in younger people, mainly in case of: - intolerance/contraindication to ACEi/ARAs or - women of child-bearing potential or - evidence of increased sympathetic drive (↑vasoconstriction, ↑heart rate, ↑contractility).
People ≥55yo Afro/Caribbean origin
If CCB is unsuitable (eg. due to peripheral edema, intolerance, HF, or high-risk of HF) then offer a Thiazide-like diuretic. If a diuretic is to be initiated or changed, offer a thiazide-like diuretic (Indapamide 1.5mg MR OD or 2.5mg OD or Chlortalidone 12.5-25mg OD) instead of a conventional thiazide. If already taking a thiazide diuretic and BP is stable and well controlled, continue treatment that way.
CCB + β-blocker (rather than adding a thiazide-like diuretic), to reduce the risk of developing diabetes.
Step 2 (2 drugs)
Step 3 (3 drugs)
CCB + ACEi/ARA. If CCB is unsuitable (due to peripheral oedema, intolerance, HF or at high-risk of HF), use a thiazide-like diuretic instead of a CCB.
Before moving on to this step, optimise BP medication.
For Afro/Caribbean patients a CCB + ARA is preferable than CCB + ACEi.
Ensure treatment is already at best tolerated doses.
CCB + ACEi/ARA + Thiazide-like diuretic If clinic BP persists >140/90mmHg after optimal treatment or best tolerated doses of CCB + ACEi/ARA + Diuretic, that is considered RESISTANT HYPERTENSION. a further diuretic like low-dose Spironolactone 25mg OD (unlicensed) if blood K+ level permits (≤4.5mmol/L). Caution in patients with reduced eGFR Increased risk of hyperkalaemia.
Step 4 (4 drugs)
For resistant hypertension, consider seeking expert advice and adding a 4th antihypertensive amongst the following:
a higher-dose thiazide-like diuretic if blood K+ level permits (≤4.5mmol/L).
an -blocker or β-blocker if a further diuretic at this point is not tolerated or ineffective or contraindicated.
If BP remains uncontrolled even at the optimal or maximum tolerated doses of the 4 drugs, refer to specialist if not yet. Step 4 When using a further Diuretic for Resistant Hypertension at Step 4, monitor Na+ & K+ blood levels and renal function within monitoring 1 month of starting Step 4, and repeat as required thereafter. MONITORING - Use clinic BP measurements to monitor the response to antihypertensive treatment with lifestyle modifications or drugs. - The target clinic BP in people aged <80y with treated hypertension is <140/90mmHg. If ≥80y the aim is <150/90. - For people with 'white-coat syndrome', use ABPM or HBPM as an adjunct to clinic BP to monitor response to treatment. - When using ABPM or HBPM to monitor response to treatment, aim for a target average BP during the usual waking hours (8am-10pm): <135/85mmHg for people aged <80 years, or <145/85mmHg for people aged ≥80 years. ADHERENCE TO TREATMENT - PATIENT EDUCATION - Provide guidance about the benefits/side effects of medication in order to help people make informed choices. - Provide an annual review to monitor BP, support and discuss their lifestyle, symptoms and medication. - Evidence supporting interventions to increase adherence is inconclusive. Use interventions to overcome practical problems associated with non-adherence if a specific need is identified. Target the intervention to needs. According to the ‘Medicines Adherence’ Guideline [NICE CG76]), interventions might include: - suggesting that patients record their medicines intake - encouraging patients to monitor their condition - simplifying dosing regimen - using alternative packaging for the medicines - using a multi-compartment medicines system (MDS).