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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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There is a YouTube version of this and other videos that you can access here:
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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.
In the last episode we covered the diagnosis and initial assessment and then, we said that we would cover the investigations for target organ damage and the criteria for urgent referral in this episode.
So let’s go through that now.
Right, let’s jump into it.
For all people with hypertension, we should offer the following investigations for target organ damage.
We should test for protein in the urine by sending a urine sample for albumin to creatinine ratio, and test for haematuria using a reagent strip.
We should take a blood sample to measure glycated haemoglobin, electrolytes, creatinine, eGFR, total cholesterol, and HDL cholesterol.
We should examine the fundi for hypertensive retinopathy.
And we should arrange a 12-lead ECG.
Examples of target organ damage include left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy, or an increased urine albumin to creatinine ratio.
Now let’s move on to identifying who to refer for same day specialist review.
We should consider this when a person has severe hypertension, defined as a clinic blood pressure of 180 over 120 or higher. However, referral depends on more than just the blood pressure reading.
So, we should refer people for same day specialist assessment if they have a clinic blood pressure of 180 over 120 or higher together with specific high-risk features.
These include signs of retinal haemorrhage or papilloedema, which indicate accelerated hypertension. Accelerated hypertension refers to a severe increase in blood pressure to 180 over 120 or higher, often above 220 over 120, with signs of retinal haemorrhage or papilloedema. It is usually associated with new or progressive target organ damage and is also known as malignant hypertension.
We should also refer if there are life threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
We should also refer people for same day specialist assessment if phaeochromocytoma is suspected. This may present with features such as labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or sweating.
So, as we can see, not all patients with a blood pressure of 180 over 120 or higher will need urgent specialist referral.
So, what do we do with patients who have severe hypertension, that is, who have a blood pressure of 180 over 120 or higher but do not meet the urgent specialist referral criteria?
Let’s look at this group now.
If a person has severe hypertension but no symptoms or signs indicating same day referral, we should carry out investigations for target organ damage as soon as possible.
If target organ damage is identified, we should consider starting antihypertensive drug treatment immediately, without waiting for the results of ambulatory blood pressure monitoring or home blood pressure monitoring.
If no target organ damage is identified, we should confirm the diagnosis by either repeating the clinic blood pressure within 7 days, or considering ambulatory blood pressure monitoring, or home blood pressure monitoring if ambulatory monitoring is not suitable or not tolerated, and ensuring a clinical review within 7 days.
Before we move on to the final definitions, let’s summarise how to approach severe hypertension in practice.
Severe hypertension is defined as a blood pressure of 180 over 120 or higher.
At this level, the key question is whether there are symptoms or signs that indicate the need for same day specialist referral.
Importantly, not all target organ damage means a hypertensive emergency.
NICE recommends urgent same day referral only when severe hypertension is associated with specific high-risk features, such as retinal haemorrhage or papilloedema, or life-threatening symptoms like chest pain, confusion, heart failure, or acute kidney injury, or when phaeochromocytoma is suspected.
So, in practice, we are not simply looking for any target organ damage, but for features of acute or ongoing organ damage that require immediate assessment.
If these features are present, we call this hypertensive emergency andwe should refer the patient urgently for same day specialist care.
If they are not present, this is often referred to as hypertensive urgency, as opposed to hypertensive emergency.
Hypertensive urgency is more common, and the immediate risk of serious complications is generally low.
In these cases, NICE advises that we should carry out investigations for target organ damage as soon as possible, but this does not necessarily mean hospital admission.
Most patients can be managed safely in Primary Care with prompt investigations, close follow up, and appropriate initiation or adjustment of treatment.
We need to remember that, in the absence of acute organ damage, blood pressure should be reduced gradually rather than rapidly to avoid complications such as cerebral or renal hypoperfusion.
So overall, the main message is to identify red flag features that require urgent referral, and to use our clinical judgement.
Now, before ending this short episode, let’s briefly clarify some definitions used in the guideline.
Stage 1 hypertension is defined as clinic blood pressure between 140 over 90 and 159 over 99, with corresponding ambulatory or home averages between 135 over 85 and 149 over 94.
Stage 2 hypertension is defined as clinic blood pressure of 160 over 100 or higher but below 180 over 120, with ambulatory or home averages of 150 over 95 or higher.
Stage 3, or severe hypertension, is defined as clinic systolic blood pressure of 180 or higher, or diastolic blood pressure of 120 or higher.
White coat effect is when the clinic blood pressure is higher by more than 20 over 10 millimetres of mercury compared with readings taken outside the clinic.
Finally, at the opposite end of the spectrum, masked hypertension occurs when clinic blood pressure is normal, that is, below 140 over 90, but is higher outside the clinic on ambulatory or home monitoring.
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.
