Primary Care Guidelines

The video version of this podcast can be found here: https://youtu.be/wjIbwy9SdAQ?si=hBe18dtUf_rPtRc8

This video makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode, I go through the NICE guideline [NG136] on Hypertension in adults, always focusing on what is relevant in Primary Care only.

I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.

There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

· Redcircle: https://redcircle.com/shows/primary-care-guidelines

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· Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here:

The Practical GP YouTube Channel:

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The resources consulted can be found here:

Hypertension in adults: diagnosis and management - NICE guideline [NG136]:

· https://www.nice.org.uk/guidance/ng136

Chronic kidney disease: assessment and management - NICE guideline [NG203]:

· https://www.nice.org.uk/guidance/ng203

The NICE hypertension flowcharts can be found here:

· Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517

The Full NICE guideline Hypertension in pregnancy: diagnosis and management [NG133] can be found at:

· https://www.nice.org.uk/guidance/ng133/chapter/Recommendations

The Clinic BP targets tables can be downloaded here:

· https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE

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Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I’m Fernando, a GP in the UK. Today we are going to do an up-to-date review of the NICE guidelines on hypertension, including the changes introduced in November 2023, always focusing on what is relevant in Primary Care only.

Right, so let’s jump into it.

First, this guideline does not cover specific recommendations in CKD, type 1 diabetes, or pregnancy. However, it does cover type 2 diabetes, given that the management of hypertension in type 2 diabetes is no different than in the general population.

Let’s just remind ourselves that, when checking the BP, we should always palpate the pulse first and, if there is pulse irregularity, we should measure the BP manually, because automated devices are not accurate when the pulse is irregular like in AF.

If there are symptoms of postural hypotension, like falls or dizziness:

· We will measure their BP while lying on their back (although we can consider a seated position, if inconvenient)

· And we will measure their BP again after standing for at least 1 minute.

If the systolic BP falls by 20 or more, or their diastolic BP by 10 or more:

· we will consider the causes, and review their medication

· we will manage the risk of falls

· we will check future BP readings with the patient standing and

· we will refer if necessary

Also, in order to diagnose hypertension, we will measure the BP in both arms:

· If the difference is more than 15 mmHg, more than once, we will measure subsequent BPs in the arm with the higher reading.

If BP measured in the clinic is 140/90 mmHg or higher:

· We will take a second measurement.

· If it is substantially different, we will take a third measurement and we will record the lowest of them as the clinic BP.

If clinic BP is between 140/90 mmHg and 180/120 mmHg, we will confirm hypertension by doing ambulatory BP monitoring (ABPM) or, if necessary, home BP monitoring (HBPM). While waiting, we will:

· Estimate the cardiovascular risk using the clinic BP and we will

· Carry out investigations for target organ damage by doing:

o A urine test for a haematuria dipstick and an albumin-creatinine ratio or ACR

o A blood test for HbA1C, renal function, total cholesterol and HDL cholesterol

o A 12‑lead ECG

o And examination of the fundi for the presence of hypertensive retinopathy

If a person has a clinic BP of 180/120 mmHg or higher, we will check for red flags symptoms or signs that would indicate the need for urgent same day assessment in hospital. These are:

· signs of retinal haemorrhage or papilloedema or

· life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury or

· Signs or symptoms suggestive of phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis or excessive sweating).

If there are no symptoms or signs indicating same-day referral, we will carry out investigations for target organ damage as soon as possible and:

· If target organ damage is identified, we will consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

· If no target organ damage is identified, we will confirm diagnosis by:

o Either repeating the BP within 7 days, or

o using ABPM or HBPM, also reviewing the patient within 7 days.

When using HBPM, we will ensure that:

· the BP is checked twice, at least 1 minute apart and

· the BP is recorded twice daily, ideally in the morning and evening and

· the BP checked for at least 4 days, ideally for 7 days

· we will then disregard the BP readings taken on the first day and use the average value of the rest to confirm the diagnosis.

We will confirm the diagnosis of hypertension if:

· the clinic BP is 140/90 mmHg or higher and

· the ABPM daytime average or HBPM average is 135/85 mmHg or higher. As a rule of thumb, the ambulatory or home readings are 5 mmHg lower than for clinic measurements

Obviously, if hypertension is not diagnosed but there is target organ damage, we will investigate further.

If hypertension is confirmed, we will offer lifestyle advice in respect of diet, exercise, smoking and alcohol and we will encourage low caffeine and salt consumption. Salt substitutes containing potassium should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking ACE inhibitors and ARBs.

When it comes to starting antihypertensive medication, we will always use clinical judgement for people with frailty or multimorbidity, but in general:

· At any age, we will start antihypertensives if the clinic BP is 160/100 or higher or ABPM or HPBM is 150/95 or higher

· If the patient is over 80, we will consider antihypertensives if the clinic BP is over 150/90 mmHg

· If the patient is between 60 and 80, we will consider antihypertensives if the clinic BP is 140/90 or higher or ABPM or HBPM is 135/85 or higher but only if there is:

o target organ damage

o established CVD

o renal disease

o diabetes or

o a CV risk of 10% or more

· If the patient is under 60, we will consider antihypertensives if the clinic BP is 140/90 or higher or ABPM or HBPM is 135/85 regardless of the CV risk

· And if the patient is under 40, we should consider referral for investigations of secondary causes.

In terms of monitoring, we will check for postural hypotension if:

· There are symptoms for example falls and dizziness or if

· There is type 2 diabetes or if

· The patient is aged 80 and over.

And if there is postural hypotension or symptoms, we should base the BP target on the standing BP reading.

In straightforward hypertension without any other consideration, the BP targets that we need to remember are:

· If under 80, the target clinic BP is below 140/90 mmHg (or 135/85 if using ABPM or HBPM)

· If aged 80 and over, the target clinic BP is below 150/90 mmHg (or 145/85 if using ABPM or HBPM), always using clinical judgement if there is frailty or multimorbidity.

These targets are for everyone, including type 2 diabetes, but not if the patient is pregnant or has CKD or type 1 diabetes.

NICE has created two tables with BP targets including patients with CKD and type 1 diabetes, so, let’s have a look at them:

· If the person is aged under 80, we have two targets:

o Below 140/90 for general hypertension, with or without type 2 diabetes, or Type 1 diabetes with ACR <70 or CKD with ACR <70; and the second target is

o Below 130/80 in Type 1 diabetes with ACR of 70 or more or CKD with ACR of 70 or more

· If the person is 80 or over, we have three targets:

o Below 150/90 for people with hypertension, with or without type 2 diabetes and also for those with type 1 diabetes regardless of ACR levels, then

o Below 140/90 in CKD with an ACR <70 and the third target is

o Below 130/80 in CKD with an ACR of 70 or more

I have streamlined these two tables into a single flowchart which you will be able to access in the episode description.

Now, to achieve these targets, what antihypertensives should we choose?

And, again, let’s remember that if the patient has certain conditions, we will not follow the hypertension guidelines but the specific guideline for those conditions, such as the guideline on:

· Type 1 diabetes

· CKD

· Cardiovascular disease like heart failure, stable angina and acute coronary syndromes and

· Pregnancy and in particular we will note the MHRA advice to avoid ACEIs and ARBs during pregnancy or breastfeeding or for women planning pregnancy.

Otherwise, the following recommendations apply to everybody else regardless of whether they have type 2 diabetes or not, and treating isolated systolic hypertension (that is a systolic BP 160 mmHg or more) the same way as in both raised systolic and diastolic BP.

Also, when treating patients of Black African or African–Caribbean family origin, we will go for an ARB, in preference to ACE inhibitor. This is because they have a low-renin state and therefore ACEIs and ARBs are less effective for them. However, when they are needed in this group of patients, ARBs are clinically more effective than ACEIs.

The treatment of hypertension comes in 4 steps. Step 1 treatment is with one drug, step 2 treatment with two drugs, step 3 with three and so on.

So, in Step 1 treatment, that is, when we initiate medication for the first time, we will offer an ACE inhibitor or an ARB if:

· They have type 2 diabetes and are of any age or family origin or

· They are aged under 55 but not of Black African or African–Caribbean family origin.

Conversely, we will offer a CCB if:

· They are aged 55 or over and do not have type 2 diabetes or

· are of Black African or African–Caribbean family origin and do not have type 2 diabetes (of any age).

If a CCB is not tolerated, for example because of oedema, we will offer a thiazide-like diuretic. And we should offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.

Step 2 treatment is treatment with two drugs. That is, if hypertension is not controlled with one drug, then, if the patient is taking an ACE inhibitor or ARB, we will offer either:

· a CCB or

· a thiazide-like diuretic

On the other hand, if hypertension is not controlled with a CCB, we will offer either:

· an ACE inhibitor or an ARB or

· a thiazide-like diuretic.

Step 3 treatment is with three drugs so if hypertension is not controlled taking step 2 medication, we will offer a combination of them all, that is:

· an ACE inhibitor or ARB and

· a CCB and

· a thiazide-like diuretic

But if hypertension is not controlled taking these three drugs, we will regard them as having resistant hypertension.

And before considering further treatment:

· We will discuss adherence

· We will confirm it with ABPM or HBPM

· And we will assess for postural hypotension.

If resistant hypertension is confirmed, we may consider:

· either seeking specialist advice

· or adding a fourth antihypertensive drug as step 4 treatment

So, what is step 4 treatment with four drugs? Well, if we decide to give a fourth drug, we will need to look at the potassium level and:

· If the potassium level of 4.5 mmol/l or less we will give further diuretic therapy with low-dose spironolactone, with particular caution if the eGFR is very low because of the risk of hyperkalaemia. When prescribing spironolactone, we will monitor electrolytes and eGFR within 1 month and repeat as needed thereafter.

· If the potassium level of more than 4.5 mmol/l we will give an alpha-blocker or a beta-blocker instead.

If the BP remains uncontrolled with 4 drugs, then we will need to seek specialist advice.

And that is it, a quick summary of the NICE guideline on hypertension.

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.