CARDIOLOGY (/MEDICINE/CARDIOLOGY/NOTES)

Hypertension
NOTES

Definition & classification

Hypertension refers to a persistent elevation of arterial blood pressure.

Prevalence is 30% in the UK (defined as adults with BP >140/90 mmHg). It is higher in men than in
women before 60 years of age, but equal after this point.

Hypertension is a major risk factor for myocardial infarction (MI), stroke and chronic kidney disease
(CKD). It is classified into ‘stages’ to help guide management (Based on NICE NG 136
(https://www.nice.org.uk/guidance/ng136) Hypertension guidelines).

Aetiology

The majority of hypertension is essential (primary), however in a significant number of cases

there may be a secondary cause or contributory factor.
Primary - 95%
No identifiable underlying cause.

Secondary - 5%
Endocrine:
Primary aldosteronism (increasingly recognised as a major cause of hypertension, see notes
(https://app.pulsenotes.com/medicine/endocrinology/notes/primary-aldosteronism) )
Phaeochromocytoma
Cushing’s syndrome (see notes
(https://app.pulsenotes.com/medicine/endocrinology/notes/cushing-s-syndrome))
Acromegaly (see notes
(https://app.pulsenotes.com/medicine/endocrinology/notes/acromegaly))
Renal
Renovascular disease (e.g. atheromatous, fibromuscular dysplasia)
Intrinsic renal disease (e.g. CKD, AKI, glomerulonephritis)
Drugs
Glucocorticoids
Oral contraceptives
SSRIs
NSAIDs
EPO
Coarctation of the aorta (consider in children / young adults with hypertension).
 NOTE: This is an evolving area. It is now thought that a greater proportion of cases of
hypertension have a secondary cause. Some studies indicate primary aldosteronism is
responsible for 5-15% of cases of hypertension.

Clinical features

Hypertension is typically asymptomatic. However, signs and symptoms may reflect underlying
end-organ damage or a potential secondary cause.

Symptoms
Palpitations
Angina
Headaches
Blurred vision
New neurology (e.g. limb weakness, paraesthesia)

Signs
New neurology (e.g. limb weakness, paraesthesia)
Retinopathy
Cardiomegaly
Arrhythmias
Proteinuria
Hypertensive retinopathy

Hypertension may cause progressive retinal microvascular changes.

These changes have been classified by the Keith-Wagener Barker (KWB) grades:

Grade 1: Generalised arteriolar narrowing (silver wiring).

Grade 2: Focal narrowing and arteriovenous nipping.
Grade 3: Retinal haemorrhages, cotton wool spots (retinal nerve fibre layer micro-infarcts leading to
exudation of axoplasmic materials).
Grade 4: Papilloedema

Recently there has been a move away from the KWB grades with a new three stage system proposed.

Investigations

It is important to consider investigations for secondary causes in some individuals.

In the following patients underlying causes should be thoroughly excluded:

 Age < 40 years
Reduced eGFR (suggestive of renal disease)
Proteinuria or haematuria (suggestive of renal disease)
Hypokalaemia and hypernatraemia (suggestive of Conn’s syndrome)
Hypertension that is sudden onset, variable or worsening.

Bedside
Observations
Blood pressure
Urinalysis
Urinary protein creatinine ratio (uPCR)
ECG
Direct ophthalmoscopy

Bloods
FBC
U&Es
Fasting glucose
Cholesterol (CVS risk)
HbA1c

Special tests
Ambulatory BP monitoring (ABPM or HBPM)
Renal USS
Endocrine tests (e.g. aldosterone: renin ratio, if indicated)

Diagnosis

NICE now recommends the use of ambulatory BP measurements (ABPM) for the diagnosis of
Stage 1 & 2 hypertension.

If clinic BP is 140/90 mmHg or higher, ABPM is used to confirm the diagnosis (except in Stage 3
hypertension, in which immediate treatment is initiated). With ABPM, at least two measurements an
hour are taken during the patient's usual waking hours (e.g. 8 am - 10 pm). The average value of
these measurements is used to confirm the diagnosis. Alternative strategies can be considered
including doing a full 24-hour assessment that includes nocturnal readings.

Alternatively, home blood pressure monitoring (HBPM) can be used. This involves taking two
measurements a day (morning & evening) over a period of at least 4 days, ideally 7. At each recording,
two consecutive measurements should be taken at least 1 minute apart when the person is seated. The
readings on the first day are discarded and the average of the following readings are used to confirm a
diagnosis of hypertension.

Stage 1
ABPM ≥ 135/85, or
Clinic BP ≥ 140/90 (must be confirmed by ABPM)

Stage 2
ABPM ≥ 150/95, or
Clinic BP ≥ 160/100 (must be confirmed by ABPM)

Stage 3
Clinic BP ≥ 180/120

White coat hypertension

This refers to an elevated blood pressure above the normal range in a clinical setting (e.g. GP
appointment, hospital outpatients). It is defined as a discrepancy of > 20/10 mmHg between clinic and
average ABPM/HBPM

In white coat hypertension, blood pressure is thought to be artificially elevated due to the stress of
being in a clinical setting. Patients with suspected white coat hypertension should have ABPM
monitoring prior to a diagnosis of hypertension, unless blood pressure is dangerously elevated (i.e.
stage 3).

Management

​Management of hypertension is based upon NICE guidelines.

Modifiable risk factors
Lifestyle modification & patient education are important in treating hypertension.

Offer advice that targets the patient's modifiable risk factors.

Discourage excessive caffeine and alcohol, if appropriate offer smoking cessation advice.
Consider the need for anti-platelets or a statin.

Whom to treat
If clinic BP < 140/90 mmHg or ABPM < 135/85 mmHg, check BP at least every 5 years or more often if
clinic BP close to 140/90 mmHg. If evidence of end-organ damage, consider other causes.

Antihypertensive drug therapy is initiated in patients:

Aged < 80 years with stage 1 hypertension and with one of the following; end organ damage,
cardiovascular disease, renal disease, diabetes or 10-year cardiovascular risk ≥10%.
of any age with stage 2 hypertension
of any age with stage 3 hypertension (consider immediate treatment)

Consider treatment in patients > 80 years old with stage 1 hypertension if clinic BP is > 150/90 mmHg.
However, take into account frailty and co-morbidities. Patients < 60 years with stage 1 hypertension can
be considered for antihypertensive therapy even if the 10-year cardiovascular risk < 10%.

Specialist assessment
Patients with stage 3 hypertension (≥ 180/120 mmHg) should be referred for same-day specialist
assessment if any features of accelerated hypertension are identified:

New onset confusion

Chest pain
Signs of heart failure (e.g. shortness of breath, fluid overload)
Acute kidney injury
Papilloedema
Retinal haemorrhage

In addition, any patient with suspected phaeochromocytoma needs same day assessment. If none of
these features are present, patients should be urgently assessed for end-organ damage. If present,
treatment should be considered immediately before ABPM/HBPM. If absent, blood pressure should be
reviewed within 7 days in clinic.

Any patient aged < 40 years should be considered for specialist assessment to exclude a secondary
cause of hypertension.

Medical therapy
Hypertension is managed in a step-wise fashion. If blood pressure is not controlled with each step,
medication should be reviewed to ensure that the treatment is optimal before moving onto the next
step.

For patients aged > 80 years, offer the same anti-hypertensive therapies as for people aged 55-80
years, however take into consideration comorbidities.
A = ACE-inhibitor / Angiotensin receptor blocker (ARB)
C = Calcium channel blocker (CCB)
D = Thiazide-like diuretic
T2DM = Type 2 diabetes mellitus

NOTE: if patients do not tolerate an ACE-inhibitor (e.g. dry cough), offer an ARB. A combination of
ACE-inhibitor and ARB should NOT be used to manage hypertension.

Blood pressure targets

Patients < 80 years: clinic BP < 140/90 mmHg / ABPM < 135/85 mmHg
Patients ≥ 80 years: clinic BP < 150/90 mmHg / ABPM < 145/85 mmHg

For management of blood pressure in chronic kidney disease (CKD). See the NICE guidelines
(https://www.nice.org.uk/guidance/ng203) on CKD.

Hypertensive emergencies

Hypertensive emergencies occur when high BP results in acute end-organ damage.

The term malignant (or accelerated) hypertension is typically reserved for when papilloedema is
present and is defined by NICE as:

A BP >180/120 with signs of papilloedema and/or retinal haemorrhage.

It is a severe condition resulting in neurological, renal and cardiac damage, requiring admission and
immediate management.

Treatment attempts to reduce BP over 24-48hrs. This is to prevent hypoperfusion. Changes may have
occurred to autoregulatory mechanisms of blood pressure control. Therefore, a rapid reduction in blood
pressure, even to normal levels, may result in profound organ hypoperfusion.

Therapies include:

IV Nitroprusside (a nitric oxide releasing drug), labetalol and glyceryl trinitrate infusions are
options.
Phentolamine (alpha-adrenergic antagonist) also used in phaeochromocytoma crisis.
 Last updated: November 2021

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