Elevated Blood Pressure (Hypertension)


Screening

1 Indicator

People aged 45 years and over who do not have elevated blood pressure, should have their blood pressure measured yearly.

Updated: 07 December 2018, Version: 2

Diagnosis

9 Indicators

People who have their blood pressure measured as systolic over 130 and/or diastolic over 85 should be diagnosed with elevated blood pressure.

Updated: 07 December 2018, Version: 2

People with suspected elevated blood pressure should have all of their blood pressure measurements taken using:

  • a standardised technique,
  • an appropriate cuff size for their arm, and
  • an electronic oscillometric upper arm device that has been validated independently using established protocols, and maintained and regularly recalibrated to the manufacturers' instructions.

Updated: 07 December 2018, Version: 2

People with suspected hypertension should have

  • three measurements taken during the clinic visit, and
  • the average of the last two readings recorded as the clinic BP.

Updated: 07 December 2018, Version: 2

People who have elevated blood pressure measurements taken multiple times on several separate occasions are diagnosed with hypertension, or suspected hypertension. 

Updated: 07 December 2018, Version: 1

People with hypertension, or suspected hypertension, should be offered:

  • home blood pressure monitoring, or
  • ambulatory blood pressure monitoring.

Updated: 07 December 2018, Version: 2

Home blood pressure monitoring should involve:

  • adequate training and explanation,
  • a relaxed, temperate setting, whilst being quiet and seated, and with their arm outstretched and supported, for at least 5 min before the first reading
  • sets of three consecutive BP measurements taken at least a minute apart,
  • at least in the morning and evening, averaged over at least 4 days.

Updated: 07 December 2018, Version: 2

People with suspected hypertension who are having blood pressure monitoring whilst going about their daily activities should record an average of two measurements at around the same time in the morning and the evening over a seven-day period.

Updated: 07 December 2018, Version: 2

People with hypertension should have their absolute cardiovascular risk calculated using clinic blood pressure measurements.

Updated: 07 December 2018, Version: 2

People who have their blood pressure confirmed (using repeated clinic measurements, home and/or ambulatory monitoring) as at least 140/90 should be diagnosed with hypertension.

Updated: 07 December 2018, Version: 2

Assessment

7 Indicators

People with hypertension have a history taken, including:

  • tobacco use,
  • alcohol consumption,
  • exercise,
  • diet patterns, and
  • medical history, including comorbidities.

Updated: 19 December 2018, Version: 3

People with hypertension have an examination performed, including:

  • pulse rate, rhythm and character,
  • jugular venous pulse and pressure,
  • carotid, femoral and paraumbilical bruits,
  • chest auscultation,
  • abdominal and limb assessment,
  • fundus of both eyes,
  • waist circumference, and
  • height/body weight (body mass index, BMI).

Updated: 19 December 2018, Version: 3

People with hypertension should have the following investigations:

  • urinalysis (albuminuria, proteinuria, haematuria, albumin: creatinine ratio),
  • blood chemistry (potassium, sodium, creatinine, estimated Glomerular Filtration Rate (eGFR)), 
  • fasting blood glucose and/or glycated haemoglobin, 
  • serum total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), non-HDL cholesterol, and triglycerides (lipids may be drawn fasting or non-fasting), and
  • standard 12-lead electrocardiography (ECG).

Updated: 07 December 2018, Version: 2

People with hypertension should not routinely receive echocardiogram evaluation.

Updated: 19 December 2018, Version: 3

People with hypertension with one or more of the following:

  • unexplained spontaneous hypokalaemia (potassium (K+) less than 3.5 mmol/L),
  • marked diuretic-induced hypokalaemia (potassium (K+) less than 3.0 mmol/L),
  • resistant hypertension, or
  • an incidental adrenal adenoma,

should have hyperaldosteronism screening with plasma aldosterone:renin activity ratio.

Updated: 07 December 2018, Version: 2

People with hyperaldosteronism should be referred to a hypertension specialist or endocrinologist.

Updated: 07 December 2018, Version: 2

People with hypertension with one or more of the following:

  • signs of possible catecholamine excess
  • paroxysmal, unexplained, labile, and/or severe or sustained hypertension that is treatment resistant,
  • multiple symptoms suggestive of catecholamine excess (e.g., headaches, palpitations, sweating, panic attacks, and pallor),
  • hypertension triggered by b-blockers, monoamine oxidase inhibitors, micturition, changes in abdominal pressure, surgery, or anaesthesia,
  • an incidental adrenal mass, or
  • predisposition to hereditary causes (e.g., multiple endocrine neoplasia 2A or 2B, von Recklinghausen neurofibromatosis type 1, or Von Hippel-Lindau disease),

should be investigated for possible pheochromocytoma or paraganglioma screening.

Updated: 07 December 2018, Version: 2

Acute Care

16 Indicators

People with hypertension receive a written plan of care which includes follow-up, monitoring and care coordination including:

  • pharmacological and non-pharmacological treatments (including weight loss and salt intake),
  • management of comorbid conditions,
  • patient and family education,
  • psychosocial factors,
  • socioeconomic and cultural factors.

Updated: 19 December 2018, Version: 3

People with hypertension should be provided with lifestyle advice including all the following:

  • smoking cessation
  • limiting alcohol to preferably no intake, or at least to no more than 14 standard drinks per week for men and 9 standard drinks per week for women),
  • exercising (30-60 minutes of moderate-intensity dynamic exercise; e.g., walking, jogging, cycling, or swimming 4-7 days per week),
  • healthy and balanced diet (fruit, vegetables, dairy products, dietary and soluble fibre, whole grains, and plant proteins, decreasing sodium intake, increasing potassium intake (if not at risk of hyperkalaemia), avoiding excessive caffeine and caffeine-containing product intake),
  • stress management and/or relaxation therapies, and
  • information about community supports.

Updated: 07 December 2018, Version: 2

People with hypertension who are overweight should be advised to lose weight by:

  • exercising for at least 30-60 minutes on 4-7 days per week, at a moderate-intensity (e.g. working at 3-4 out of 10 maximal effort) while walking, jogging, cycling, or swimming,
  • choosing amounts of nutritious food and drinks to meet your energy needs
  • eating a healthy and balanced diet daily which includes serves of fruit, vegetables, dairy products, dietary and soluble fibre, whole grains, and animal and plant-based proteins)
  • limiting intake of saturated fat, added salt, added sugar and alcohol. 

Updated: 07 December 2018, Version: 2

People with hypertension should have their absolute cardiovascular risk used in discussions about prognosis and decisions about management options.

Updated: 07 December 2018, Version: 2

People with hypertension should be advised not to take non-prescribed supplements or alternative medicines.

Updated: 07 December 2018, Version: 2

People with hypertension who are to take antihypertensive medication should be:

  • educated on the quality use of medicines (including expectations, preferences, comorbidities, balance of side effects, risks and benefits), and
  • prescribed generic medication (where appropriate) taken only once per day (where possible), and
  • commenced on low to moderate dose(s) of first-line drugs with the dose and number of drugs being increased as necessary.

Updated: 07 December 2018, Version: 2

People with essential uncomplicated hypertension can receive first line treatment, either as monotherapy or in combination, with one or more of the following unless contraindicated:

  • Diuretics, including thiazide-like diuretics (e.g. chlorthalidone, indapamide) in preference to thiazides (e.g. bendroflumethiazide, hydrochlorothiazide),
  • Calcium channel blockers (CCB),
  • Angiotensin converting enzyme inhibitors (ACEi) OR Angiotensin II receptor blockers (ARB).

Updated: 07 December 2018, Version: 2

People with hypertension should not normally receive simultaneous Angiotensin converting enzyme inhibitors (ACEi) and Angiotensin II receptor blockers (ARB).

Updated: 07 December 2018, Version: 2

Women who are pregnant and have hypertension are treated with methyldopa, labetolol and nifedipine, singly or in combination.

Updated: 07 December 2018, Version: 2

Women who are pregnant and have hypertensive emergency (pre-eclampsia) should be considered for intravenous labetolol or infusion of nitroprusside.

Updated: 07 December 2018, Version: 2

People with hypertension and ischaemic heart disease should not be prescribed short-acting nifedipine.

Updated: 07 December 2018, Version: 2

People with hypertension should be treated to a target of at least under 140/90 mmHg, preferably 120/80mmHg in some cases, if tolerated.

Updated: 07 December 2018, Version: 2

People with hypertension should have follow-up to confirm hypertension control and to identify hypotension, syncope, electrolyte abnormalities, and acute kidney injury.

Updated: 07 December 2018, Version: 2

People with hypertension who commence treatment, and/or are actively modifying their lifestyle should be seen at least every three months dependent on their cardiovascular risk factors and baseline parameters (e.g. eGFR) until BPs are below target levels (with closer monitoring of patients with impaired renal function).

Updated: 19 December 2018, Version: 3

People with hypertension who have achieved their target blood pressure have an annual review of care to monitor blood pressure, discuss lifestyle, symptoms and medication, and have the following tests repeated as clinically indicated:

  • electrolytes,
  • creatinine,
  • fasting lipids, and
  • fasting glucose.

Updated: 07 December 2018, Version: 2

People with hypertension that remains uncontrolled with the optimal or maximum tolerated doses of the three first line drugs (resistant hypertension) and clinical and/or laboratory features suggestive of secondary causes of hypertension should be considered for referral to specialist care.

Updated: 07 December 2018, Version: 2

Ongoing Care

6 Indicators

People with hypertension who are taking antihypertensive medication should use interventions to overcome practical problems associated with non-adherence, including:

  • suggesting that patients record their medicine-taking,
  • encouraging patients to monitor their BP and condition,
  • simplifying the dosing regimen,
  • using alternative packaging for the medicine,
  • using a multi-compartment medicines system, and/or
  • a combination of two antihypertensive drugs at fixed doses in a single tablet, such as Olmesartan with hydrochlorothiazide, olmesartan with amlodipine, valsartan with hydrochlorothiazide, or valsartan with amlodipine and hydrochlorothiazide.

Updated: 07 December 2018, Version: 2

People with resistant hypertension, who have adverse events, can have the following added or used as substitutes:

  • further diuretic therapy with low-dose spironolactone (from 12.5 mg once daily) if the blood potassium level is 5mmol/L or lower, or
  • higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5mmol/L
  • beta-blockers,
  • alpha-blockers (such as amiloride),
  • centrally acting agents, or
  • nondihydropyridine calcium channel blockers.

Updated: 07 December 2018, Version: 2

People with hypertension are active in shared-decision making with respect to:

  • discussing expectations and preferences when considering recommended treatments
  • potential value and benefits, risks and costs

developing a management plan.

Updated: 07 December 2018, Version: 1

People with hypertension who present with two or more of the following:

  • Sudden onset or worsening of hypertension (age >55 or < 30 years);
  • Abdominal bruit,
  • Resistant hypertension,
  • Increase in serum creatinine level,
  • Recurrent pulmonary oedema,
  • Deterioration in eGFR,
  • Proteinuria,

should be investigated for renovascular hypertension.

Updated: 07 December 2018, Version: 3

People with hypertension attributable to atherosclerotic renal artery stenosis should be primarily medically managed.

Updated: 07 December 2018, Version: 2

People with hypertension attributable to atherosclerotic renal artery stenosis, and uncontrolled hypertension resistant to maximally tolerated pharmacotherapy, progressive renal function loss, and acute pulmonary oedema, can be considered for renal artery angioplasty and stenting.

Updated: 07 December 2018, Version: 2

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