Hypertension is defined as:
  • Stage 1 hypertension: clinic BP 140/90 or higher and ambulatory/home BP 135/85 or higher
  • Stage 2 hypertension: clinic BP 160/100 or higher and ambulatory/home BP 150/95 or higher
  • Severe hypertension: clinic systolic BP 180 or higher or clinic diastolic 110 or higher

NICE recommends treatment if:
  • Aged under 80 and stage 1 hypertension with one of the following:
    • Target organ damage
    • Established cardiovascular disease
    • Renal disease
    • Diabetes
    • 10 yr cardiovascular risk of 20% or greater
  • Anyone with stage 2 hypertension
  • Anyone with severe hypertension

NICE recommended management :
  1. Lifestyle interventions (stop smoking, increase exercise, decrease alcohol, coffee and salt)
  2. Medication:

Blood pressure targets:
  • Under 80 years: clinic BP lower than 140/90, ambulatory/home BP lower than 135/85
  • Over 80 years: clinic BP lower than 150/90, ambulatory/home BP lower than 145/85

Secondary hypertension

Secondary hypertension is elevated blood pressure due to an underlying cause. Around 5%-10% of hypertension is secondary. NICE recommends investigating for secondary causes of hypertension in hypertensive patients under 40 years of age.

Secondary causes of hypertension include:
  • Endocrine
  • Renal problems
    • Compromised arterial supply
    • Renal parenchymal disease
  • Drugs
    • Oestrogens – OCP
    • NSAIDs
    • COX2 inhibitors
  • Raised erythropoietin

Investigations for secondary hypertension include:
  • Urinalysis
  • FBC
  • UEs
  • TFTs
  • Calcium
  • 24 hr urinary VMA
  • urinary free cortisol
  • renal ultrasound

Hypertension in pregnancy

In women already on antihypertensives, offer alternatives to ACE inhibitors, angiotensin II receptor antagonists and chlorothiazide as they are associated with increased risk of fetal abnormalities.  With these exceptions, the limited evidence shows no increased risk of abnormalities with other antihypertensive treatments.

New hypertension requiring treatment during pregnancy should be managed with labetalol as first line.  Methyl dopa and nifedipine are other options.

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