RTS Hypertension

Question 1

What should a person waiting diagnosis of hypertension be offered?

Answer 1

Target organ damage assessment
cardiovascular risk assessment

Question 2

What are the three classifications of hypertension?

Answer 2

Stage 1 hypertension — clinic blood pressure ranging from 140/90 mmHg to 159/99
mmHg andsubsequent ABPM daytime average or HBPM average blood pressure
ranging from 135/85 mmHg to 149/94 mmHg.
b. Stage 2 hypertension — clinic blood pressure of 160/100 mmHg or higher but less
than 180/120 mmHg andsubsequent ABPM daytime average or HBPM average
blood pressure of 150/95 mmHg or higher.
c. Stage 3 or severe hypertension — clinic systolic blood pressure of 180 mmHg or
higher orclinic diastolic blood pressure of 120 mmHg or higher.

Question 3

What is Accelerated (or malignant) hypertension?

Answer 3

Accelerated (or malignant) hypertension is a severe increase in blood pressure to 180/120
mmHg or higher (and often over 220/120 mmHg) with:
- signs of retinal haemorrhage and/or
- papilloedema (swelling of the optic nerve).
- It is usually associated with new or progressivetarget organdamage.

Question 4

What is white-coat hypertension?

Answer 4

White coat hypertension is blood pressure that is unusually raised when measured during
consultations with clinicians but is normal when measured in other non-threatening situations.

Question 5

What is a white coat effect?

Answer 5

A white-coat effectis a discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.

Question 6

Who should receive referral for same-day specialist assessment?

Answer 6

A clinic blood pressure of 180/120 mmHg and higher with
 signs of retinal haemorrhage or papilloedema (accelerated
hypertension) or
 life-threatening symptoms, such as:
 new onset confusion,
 chest pain,
 signs of heart failure, or
 acute kidney injury.
- Suspected phaeochromocytoma (tumours in adrenal gland), for example:
 labile or postural hypotension,
 headache,
 palpitations,
 pallor,
 abdominal pain, or

 diaphoresis.

Question 7

What is the management for all other people with hypertension?

Answer 7

For all other people with hypertension, management includes:
a. Offering lifestyle advice, including advice on:
- diet and exercise,
- stress management,
- alcohol consumption, and
- smoking cessation (if applicable).
b. Considering the need for antihypertensive drug treatment, which is initiated in a
stepwise approach.
c. Considering the need for antiplatelet or statin treatment.
d. Monitoring response to lifestyle changes and drug treatment.
e. Reviewing the person annually to:
- monitor blood pressure,
- provide support, and
- discuss lifestyle,
- symptoms, and
- treatment(s).

Question 8

What is the definition of hypertension?

Answer 8

Hypertension is persistently raised arterial blood pressure.

Question 9

What is the suspecting threshold for hypertension?

Answer 9

140/90
clinic systolic blood pressure sustained above or equal to 140 mmHg, or
- diastolic blood pressure sustained above or equal to 90 mmHg, or
- both.

Question 10

10. How can we confirm the diagnosis?

Answer 10

The diagnosisis then confirmed with ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM).

Question 11

What is the difference between primary and secondary hypertension?

Answer 11

Primary hypertension(which occurs in about 90% of people) has no identifiable cause.
Secondary hypertension(about 10% of people) has a known underlying cause: such as:
- renal,
- endocrine, or
- vascular disorder, or
- the use of certain drugs.

Question 12

What is masked hypertension?

Answer 12

Masked hypertensionis when clinic blood pressure measurements are normal (less than 140/90 mmHg) but blood pressure measurements are higher when taken outside the clinic using average daytime ABPM or average HBPM blood pressure measurements.

Question 13

14. What is the risk factors for hypertension?

Answer 13

Risk factors for hypertension include:
a. Age — blood pressure tends to rise with advancing age.
b. Sex — Up to about 65 years, women tend to have a lower blood pressure than men.
Between 65 to 74 years of age, women tend to have a higher blood pressure.
c. Ethnicity — people of Black African and Black Caribbean origin are more likely to be diagnosed with hypertension.
d. Genetic factors — research on twins suggest that up to 40% of variability in blood pressure may be explained by genetic factors.
e. Social deprivation — people from the most deprived areas in England are 30% more likely to have hypertension than those from the least deprived.
f. Lifestyle — smoking, excessive alcohol consumption, excess dietary salt, obesity, and lack of physical activity are associated with hypertension.
g. Anxiety and emotional stress — can raise blood pressure due to increased adrenaline and cortisol levels.

Question 14

15. What are the complications of hypertension?

Answer 14

Heart failure.
b. Coronary artery disease.
c. Stroke.
d. Chronic kidney disease.
e. Peripheral arterial disease.
f. Vascular dementia.

Question 15

What is the prognosis of hypertension?

Answer 15

Can be successfully managed when medication is used

Question 16

How should you measure blood pressure in someone with suspected hypertension?

Answer 16

Measure blood pressure in a relaxed, temperate setting, with the person quiet and seated and
their arm outstretched and supported.
Measure blood pressure in both arms using an appropriate cuff size.

• If the difference in readings between arms is more than 15 mmHg, repeat the
  measurements.
• If the difference in readings between arms remains more than 15 mmHg on the
  second measurement, measure subsequent blood pressures in the arm with the
  higher reading.
  Be aware that automated devices may not measure blood pressure accurately if there is
  pulse irregularity (for example due to atrial fibrillation).
  Palpate the radial or brachial pulse before measuring blood pressure.
  If pulse irregularity is present, measure blood pressure manually using direct auscultation
  over the brachial artery.

Question 17

How do you measure blood pressure In people with symptoms of postural hypotension?

Answer 17

In people with symptoms of postural hypotension (falls or postural dizziness), measure blood
pressure with the person either supine or seated.
Measure blood pressure again with the person standing for at least 1 minute before
measurement.
If the systolic blood pressure falls by 20 mmHg or more when the person is standing,
measure subsequent blood pressures with the person standing.

Question 18

What should you do if the person’s blood pressure is between 140/90 mmHg and 180/120mmHg?

Answer 18

offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.
If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM).
- When using ABPM, ensure that at least 2 measurements per hour are taken during the person’s usual waking hours (for example between 8am and 10pm).
- Use the average value of at least 14 measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension.

Question 19

When should we confirm the diagnosis of hypertension in people?

Answer 19

A clinic blood pressure of 140/90 mmHg or higher and ABPM daytime average or HBPM average of 135/85 mmHg or higher.

Question 20

When should you suspect masked hypertension?

Answer 20

i. if clinic blood pressure measurements are normal (less than 140/90 mmHg)
but
ii. blood pressure measurements are higher when taken outside the clinic
using average daytime ABPM or average HBPM blood pressure
measurements.

Question 21

What should you do If hypertension is not diagnosed and there is evidence of target organ damage?

Answer 21

consider carrying out investigations for alternative causes of the target organ damage.
Take a blood sample to measure plasma glucose, electrolytes, creatinine, eGFR, serum total cholesterol and HDL cholesterol

Question 22

What should you do if If hypertension is not diagnosed and there is no evidence of target organ damage?

Answer 22

measure the person’s clinic blood pressure at least every 5 years subsequently, and
- consider measuring it more frequently if the person’s clinic blood pressure is close to 140/90 mmHg.

Question 23

What investigations can be done for someone with hypertension?

Answer 23

Assess for target organ damage.
i. Test for haematuria.
ii. Arrange measurement of:
1. Urine albumin:creatinine ratio (to test for the presence of protein in
the urine).
2. HbA1C (to test for diabetes).
3. Electrolytes, creatinine, and estimated glomerular filtration rate (to
test for chronic kidney disease).
iii. Examine the fundi (for the presence of hypertensive retinopathy).
iv. Arrange for a 12-lead electrocardiograph to be performed (to assess
cardiac function and detect left ventricular hypertrophy).
1. Consider the need for specialist investigations in people with signs
and symptoms suggesting target organ damage or a secondary
cause of hypertension.

b. Assess cardiovascular risk.
i. Arrange measurement of serum total cholesterol and high-density
lipoprotein (HDL) cholesterol.
ii. Estimate the person’s 10-year risk of developing cardiovascular disease
(CVD) using the QRISK assessment tool.
1. For information on the management of people with a 10-year
cardiovascular risk of 10% or more (including prescribing statins and
anti-platelet therapy),
2. See the CKS topics on CVD risk assessment and management, Lipid
modification - CVD prevention, and Antiplatelet treatment.