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· https://youtu.be/8QEsYYKKGu0
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline 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.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
Primary Care guidelines podcast:
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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 NICE clinical guideline on Hypertension in adults: diagnosis and management [NG136] can be found here:
· https://www.nice.org.uk/guidance/NG136
Transcript
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Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only.
Today, we are focusing on the diagnosis and initial assessment.
In subsequent episodes, we will cover the other sections.
Right, let’s jump into it.
And let’s start about the measurement of blood pressure.
Because automated devices may not measure blood pressure accurately if there is pulse irregularity, for example due to atrial fibrillation, we should palpate the radial or brachial pulse before measuring blood pressure.
If pulse irregularity is present, we should measure blood pressure manually using direct auscultation over the brachial artery.
When measuring blood pressure in the clinic or in the home, we should standardise the environment and provide a relaxed and temperate setting, with the person quiet and seated, and their arm outstretched and supported.
Furthermore, we should make sure that we use an appropriate cuff size for the person’s arm.
Now, let’s look at postural hypotension.
In people with symptoms of postural hypotension, including falls or postural dizziness, we should measure blood pressure with the person lying on their back, although we can consider a seated position if it is inconvenient to measure blood pressure with the person lying down.
We should then measure blood pressure again after the person has been standing for at least one minute.
If the person’s systolic blood pressure falls by 20 millimetres of mercury or more, or their diastolic blood pressure falls by 10 millimetres of mercury or more after standing for at least one minute, we should consider likely causes, including reviewing their current medication.
We should also manage appropriately, for example giving advice on preventing falls, and we should measure subsequent blood pressures with the person standing.
Additionally, we should consider referral to specialist care if symptoms of postural hypotension persist despite addressing the likely causes.
If the drop in blood pressure is smaller than the diagnostic thresholds, and the person still has suggestive symptoms, we should repeat the test. This is especially important if the initial reading was taken from a seated position.
This is because the drop in blood pressure from sitting to standing may be smaller than from lying down to standing, which can lead to false negatives.
So, this time, we should start with the person lying flat, and then measure their blood pressure again after they stand up.
We should then consider specialist referral if blood pressure measurements do not confirm postural hypotension despite suggestive symptoms.
Let’s look at how we make the diagnosis of hypertension.
When considering the diagnosis, we should measure blood pressure in both arms.
If the difference between arms is more than 15 millimetres of mercury, we should repeat the measurements and if the difference remains more than 15, we should use the arm with the higher reading for future measurements.
Now, if clinic blood pressure is 140 over 90 or higher, we should take a second measurement during the same consultation.
If the second reading is substantially different from the first, we should take a third measurement.
We then record the lower of the last two readings as the clinic blood pressure.
If the clinic blood pressure is between 140 over 90 and 180 over 120, we should offer ambulatory blood pressure monitoring to confirm the diagnosis.
If ambulatory blood pressure monitoring is not suitable or not tolerated, we should offer home blood pressure monitoring instead.
While waiting to confirm the diagnosis, we should check their cardiovascular risk assessment using a validated tool and we should also carry out investigations for target organ damage.
If the clinic blood pressure is 180 over 120 or higher, we should consider whether they need urgent referral.
We will cover both the urgent referral criteria and the investigations for target organ damage in the next episode.
When using ambulatory blood pressure monitoring, we should ensure that at least two measurements are taken per hour during the person’s usual waking hours, for example between 8am and 10pm.
We should use the average of at least 14 measurements during waking hours to confirm the diagnosis.
When using home blood pressure monitoring, we should ensure that two consecutive readings are taken for each recording, at least one minute apart, with the person seated and that blood pressure should be recorded twice daily, ideally in the morning and evening and that monitoring should continue for at least four days, but ideally for seven days.
In home blood pressure monitoring we should discard the first day’s readings, and use the average of the remaining measurements to confirm the diagnosis.
We will confirm hypertension if the clinic blood pressure is 140 over 90 or higher, and the ambulatory blood pressure monitoring daytime average or home blood pressure monitoring average is 135 over 85 or higher.
If hypertension is not diagnosed but there is evidence of target organ damage, we should consider investigating for alternative causes.
If hypertension is not diagnosed, we should recheck clinic blood pressure at least every five years, more frequently if readings are close to 140 over 90.
However, we should measure blood pressure at least once a year in adults with type 2 diabetes who do not have previously diagnosed hypertension or renal disease.
Additionally, we should consider the need for specialist investigations in people who have signs and symptoms suggesting a secondary cause of hypertension.
So that is it, a review of a section of the NICE guideline on hypertension.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
