How do you diagnose Hypertension❓ 

 Measure blood pressure (BP) using a suitably sized cuff 

 Measure the BP in both arms for comparison (if difference >15mmHg, repeat and if difference is still >15mmHg, use arm with higher BP going forward) 

 If the BP is ≥140/90, repeat a 2nd time and a 3rd time if significant difference (lowest of final 2 readings is the relevant measurement) 

What is the criteria for patient referral❓ 

 Same day referral: accelerated hypertension/ phaeochromocytoma suspected 

 Routine referral: patients <40 with hypertension/ secondary hypertension suspected/ no response to step 4 of treatment ❌ 

How is Postural Hypotension diagnosed❓ 

 Check BP when patient is seated, then repeat when standing 

 If systolic BP is >20mmHg lower, it indicates postural hypotension 

 Patients who are ≥80, have type 2 diabetes or symptoms such as dizziness should be tested for postural hypotension 

 If postural hypotension is diagnosed, review patient’s drugs and use standing BP going forwards 

Management of Hypertension 

First line drugs: 

 First line drug is chosen depending of 3 factors: type 2 diabetes, ethnicity and age: 

     Type 2 diabetes: for ALL type 2 diabetes patients, use ACE inhibitor unless contraindicated 

     African/African Caribbean ethnicity: for all patients excluding those with type 2 diabetes, use a calcium channel blocker unless contraindicated (if heart  failure/oedema, use thiazide-like diuretic for BP control instead) 

     Patients <55 not of African/African Caribbean ethnicity: ACEi or ARB is ACEi is not tolerated 

     Patients ≥55 who are not type 2 diabetics: thiazide-like diuretics 

Second line drugs: 

 Any 2 of: ACE/ARB, CCB, thiazide-like diuretic 💊

 Heart failure/oedema: ACE and thiazide-like diuretic should be used to control BP 💊

 African/African Caribbean ethnicity: ARB instead of ACE

Third line drugs: 

 ACE/ARB and CCB and thiazide-like diuretic 

Fourth line drugs:

 Resistant Hypertension: BP still not within target range, even after third line drugs ❌

 Confirm elevation of BP with ABPM/HBPM 

 Assess for postural hypotension (as described above) 

 Patient potassium ≤4.5: add spironolactone 25mg/d 💊

 Patient potassium >4.5: consider addition of alpha/betblocker 💊

What are the targets of treatment❓

 Patients <80: clinic (140/90), ABPM/HBPM (<135/85) 

 Patients ≥80: clinic (<150/90), ABPM/HBPM (<145/85) 

 If BP still not controlled after fourth line therapy: REFER the patient ❌