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Hypertension in adults (including Type 2 Diabetes): diagnosis and treatment

- Important instructions and notes - please click to read.
  
  Instructions: Click the links (blue text), icons () and drop-downs (▶) for further information. Select the appropriate clinical scenario to adjust the pathway.
  
  This is an adapted version of the source material referenced/linked below. Please see the original source for full details.
  
  Please read our medical disclaimer - this pathway may not be suitable for your particular patient or healthcare setting/system.
  If you would like to commission a more appropriate localised pathway please get in touch.
  
  This pathway is adapted from NICE NG136: Hypertension in adults: diagnosis and treatment and the Visual summary
  
  Offer lifestyle advice and continue to offer it periodically
- Clinic Blood Pressure Measurement
  Measure standing and sitting BP in people with: type 2 diabetes | symptoms of postural hypotension | aged 80 and over
  - Under 140/90 mmHg
  - 140/90 - 179/119 mmHg
  - ≥ 180/120 mmHg
  When considering a diagnosis of hypertension, measure blood pressure in both arms:
  - 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.
  If blood pressure measured in the clinic is 140/90 mmHg or higher:
  - Take a second measurement during the consultation.
  - If the second measurement is substantially different from the first, take a third measurement.
  Record the lower of the last 2 measurements as the clinic blood pressure.
- ↓
  
  Check BP at least every 5 years and more often if close to 140/90 mmHg
- ↓
  Offer ABPM (or HBPM if ABPM is declined or not tolerated)
  
  Ambulatory Blood Pressure Monitoring
  
  When using ABPM to confirm a diagnosis of hypertension, ensure that at least 2 measurements per hour are taken during the person's usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person's usual waking hours to confirm a diagnosis of hypertension.
  
  Home Blood Pressure Monitoring
  
  When using HBPM to confirm a diagnosis of hypertension, ensure that:
  
  for each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute apart and with the person seated and
  
  blood pressure is recorded twice daily, ideally in the morning and evening and
  
  blood pressure recording continues for at least 4 days, ideally for 7 days.
  
  Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension.
  Investigate for target organ damage
  
  Urine: Dipstick for haematuria and send sample for ACR
  
  Bloods: U+Es inc eGFR | HbA1c | Total cholesterol & HDL
  
  Fundoscopy: for evidence of hypertensive retinopathy
  
  ECG: for evidence of LVH or heart disease
  Assess cardiovascular risk
  
  QRISK®3 risk calculator
  
  Scenario: CVD risk assessment
  
  Scenario: CVD risk less than 10%
  
  Scenario: CVD risk 10% or more
- ↓
  Refer for same-day specialist review if:
  - retinal haemorrhage or papilloedema (accelerated hypertension ^{<div class="redbox">
    <p><b><u>Accelerated hypertension</u></b></p>
    <p>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 progressive target organ damage and is also known as malignant hypertension. </p>
    </div>}) or
  - life-threatening symptoms ^{<div class="redbox">
    <p><b><u>Life-threatening symptoms</u></b> such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. </p>
    </div>} or
  - suspected pheochromocytoma ^{<div class="redbox">
    <p>Refer people for specialist assessment, carried out on the same day, if they have <b><u>suspected phaeochromocytoma</u></b> (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis).</p>
    </div>}
  ↓
  - If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral, carry out investigations for target organ damage as soon as possible:
    
    Urine: Dipstick for haematuria and send sample for ACR
    
    Bloods: U+Es inc eGFR | HbA1c | Total cholesterol & HDL
    
    Fundoscopy: for evidence of hypertensive retinopathy
    
    ECG: for evidence of LVH or heart disease
  - If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
  - If no target organ damage is identified, repeat clinic blood pressure measurement within 7 days.
- ABPM or HBPM
  - Under 135/85 mmHg
    (normal)
  - 135/85 to 149/94 mmHg
    (Stage 1)
  - 150/95 mmHg or more
    (Stage 2)
  Ambulatory Blood Pressure Monitoring
  When using ABPM to confirm a diagnosis of hypertension, ensure that at least 2 measurements per hour are taken during the person's usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person's usual waking hours to confirm a diagnosis of hypertension.
  Home Blood Pressure Monitoring
  When using HBPM to confirm a diagnosis of hypertension, ensure that:
  - for each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute apart and with the person seated and
  - blood pressure is recorded twice daily, ideally in the morning and evening and
  - blood pressure recording continues for at least 4 days, ideally for 7 days.
  Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension.
- ↓
  - Check BP at least every 5 years and more often if clinic BP close to 140/90 mmHg
  - If evidence of target organ damage, consider alternative causes
- ↓
  Offer lifestyle advice.
  
  In addition, for the following groups:
  - Age > 80 with clinic BP > 150/90 mmHg:
    
    Consider drug treatment
  - Age < 80 with target organ damage, CVD, renal disease, diabetes or 10-year CVD risk ≥ 10%:
    
    Discuss starting drug treatment
  - Age < 60 with 10-year CVD risk < 10%:
    
    Consider drug treatment
  - Age < 40:
    
    Consider specialist evaluation of secondary causes and assessment long-term benefits and risks of treatment
  ↓
  Discuss the person’s CVD risk and preferences for treatment, including no treatment.
  
  See NICE’s patient decision aid for hypertension
  
  See below for choice of drug, monitoring and BP targets.
  - Offer annual review
  - Support adherence to treatment
- ↓
  Offer lifestyle advice and drug treatment
  
  Age < 40:
  - Consider specialist evaluation of secondary causes and assessment long-term benefits and risks of treatment
  ↓
  Discuss the person’s CVD risk and preferences for treatment, including no treatment.
  
  See NICE’s patient decision aid for hypertension
  
  See below for choice of drug, monitoring and BP targets.
  - Offer annual review
  - Support adherence to treatment
- Select clinical scenario for treatment options
  - Hypertension with type 2 diabetes
  - Hypertension without type 2 diabetes
- Patient demographics
  - Age < 55 and not of black African
    or African–Caribbean family origin
  - Age 55 or over
  - Black African or African–Caribbean
    family origin (any age)
- ↓
  
  Offer lifestyle advice and continue to offer it periodically
  
  Use clinical judgement for people with frailty or multimorbidity
  ACEi or ARB
  
  ↓
  
  ACEi or ARB
  +
  CCB or thiazide-like diuretic
  
  ↓
  
  ACEi or ARB + CCB + thiazide-like diuretic
  
  ↓
  Confirm resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypotension and discuss adherence
  
  Consider seeking expert advice or adding a:
  - low-dose spironolactone if blood potassium level is ≤ 4.5 mmol/l
  - alpha-blocker or beta-blocker if blood potassium level is > 4.5 mmol/l
  Seek expert advice if BP is uncontrolled on optimal tolerated doses of 4 drugs
- ↓
  
  Offer lifestyle advice and continue to offer it periodically
  
  Use clinical judgement for people with frailty or multimorbidity
  CCB
  
  ↓
  
  CCB
  +
  ACEi or ARB or thiazide-like diuretic
  
  ↓
  
  ACEi or ARB + CCB + thiazide-like diuretic
  
  ↓
  Confirm resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypotension and discuss adherence
  
  Consider seeking expert advice or adding a:
  - low-dose spironolactone if blood potassium level is ≤ 4.5 mmol/l
  - alpha-blocker or beta-blocker if blood potassium level is > 4.5 mmol/l
  Seek expert advice if BP is uncontrolled on optimal tolerated doses of 4 drugs
- ALTERNATIVE GUIDELINES
  
  For women considering pregnancy or who are pregnant or breastfeeding, see NICE’s guideline on hypertension in pregnancy.
  
  For people with chronic kidney disease, see NICE’s guideline on chronic kidney disease.
  
  For people with heart failure, see NICE’s guideline on chronic heart failure.
  BP TARGETS
  
  Reduce and maintain BP to the following targets:
  - Age < 80 years:
    
    Clinic BP < 140/90 mmHg
    
    ABPM/HBPM < 135/85 mmHg
  - Age ≥ 80 years:
    
    Clinic BP < 150/90 mmHg
    
    ABPM/HBPM < 145/85 mmHg
  - Postural hypotension:
    
    Base target on standing BP
  - Frailty or multimorbidity:
    
    Use clinical judgement
  Advise people who want to self-monitor to use HBPM. Provide training and advice.
  
  Consider ABPM or HBPM, in addition to clinic BP, for people with white-coat effect or masked hypertension.
  MONITORING TREATMENT
  
  Use clinic BP to monitor treatment.
  
  Measure standing and sitting BP in people with:
  - type 2 diabetes or
  - symptoms of postural hypotension or
  - aged 80 and over.
  Advise people who want to self-monitor to use HBPM. Provide training and advice.
  
  Consider ABPM or HBPM, in addition to clinic BP, for people with white-coat effect or masked hypertension.