Hypertension

A 45-year-old man attends for a BP check. The lowest value of 3 measurements is 150/100 mmHg. What is the preferred next step in confirming a diagnosis of hypertension?

1. Echocardiography to confirm left ventricular hypertrophy

2. Renal function test to confirm renal impairment

3. Serial blood pressure measurement

4. Ambulatory blood pressure measurement (ABPM)

5. ECG to confirm left ventricular hypertrophy

In practice, clinical blood pressure measurement (CBPM) is determined by taking at least 3 measurements, one minute apart, with the patient rested and relaxed. The lowest value from the 2nd or 3rd measurement is usually the most reliable.

• If the CPBM is ≥140/90 mmHg and the patient is not known to be hypertensive, confirm hypertension with ABPM, unless this is not tolerated or not available. If ABPM is not available, home blood pressure monitoring (HBPM) is advised if possible.

• With ABPM there should be at least 2 measurements per hour during the person’s usual waking hours (e.g. 08.00 and 22.00). The average value of at least 14 of these measurements is used to confirm the diagnosis.

• For HBPM, it is recommended that the patient takes 2 resting blood pressures, 2 minutes apart, twice daily. They should do this for 4-7 consecutive days and ignore the readings taken on the 1st day. The average reading will be more accurate with a higher number of readings.

• Chronic poorly controlled hypertension is an important cause of LVH. LVH is often absent in the early stages of hypertensive disease. For this reason ECG and/or echocardiography are not ideal for making the diagnosis of hypertension.

Stage 1

• ≥140/90 clinic or

• ≥135/85 ABPM/HBPM

Stage 2

• ≥160/100 home or

• ≥150/95 ABPM/HBPM

Stage 3

• ≥180 or

• ≥110 diastolic in clinic

Isolated systolic hypertension

• ≥160 systolic

Management

Step 1

ACE or ARB if <55 & not black

References

• Hypertension in Adults: diagnosis and management (NG 136, 2019)

• High blood pressure (hypertension) (NHS Choices)

• Hypertension - not diabetic (CKS)

• Management of Hypertension (Patient.info)

Hypertension in pregnancy

• Hypertension in pregnancy (CKS)

• Hypertension in pregnancy: diagnosis and management (NICE)

Low blood pressure / hypotension:

• Low blood pressure (hypotension) (NHS Choices)