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Chronic Care Programme
Treatment guidelines
Hypertension
Chronic condition
Consultations protocols
Preferred treating provider
Notes
 preferred as indicated by
option
 referral protocols apply
Maximum consultations per
annum
 Initial consultation
 Follow-up consultation
Tariff codes
Consultations: Dietician
 Initial consultation
 Follow-up consultation
Tariff codes
Option/plan
Provider
GMHPP
Gold Options
G1000, G500 and
G200.
Blue Options
B300 and B200.
GMISHPP
General Practitioner
Pulmonologist
Physician
Gastroenterologist
Neurologist
Cardiologist
Paediatrician
Surgeon
Thoracic Surgeon
Mild
No target
No target
organ
organ
disease: no
disease:
other risk
no other
risk
New
Existing
Patient
patient
1
0
2
1
0183; 0142; 0187; 0108
Moderate
Blood pressure
controlled on
medication. Minimal
risk factors
Severe/Resistant
Severe and/or
uncontrolled, high
risk factors; on
medication
New
Patient
Existing
patient
New
Patient
Existing
patient
1
3
1
1
1
5
1
5
New
Patient
Existing
patient
New
Patient
Existing
patient
New
Patient
Existing
patient
0
0
0
0
0
0
0
0
1
0
1
0
051
Investigations protocols
Type
Urine dipstick
24 hour
ambulatory blood
pressure
measurement:
hire fee
Microalbuminuria:
thin layer
chromatography
one way
Provider
GP;
Specialist;
Pathologist
GP;
Specialist
(see list)
GP;
Specialist;
Pathologist
Maximum investigations per annum
Tariff
code
New
Patient
Existing
patient
New
Patient
Existing
patient
New
Patient
Existing
patient
4188
2
1
2
2
4
4
1237
0
0
1
0
1
0
4265
0
0
1
1
1
1
Blood glucose
ECG without
effort
Chol/
HDL/LDL/Trig
Total cholesterol
Serum urea
Serum creatinine
Serum potassium
Serum sodium
Aldosterone
Renin activity
(aldosterone:
rennin ratio)
Renal ultrasound
Cardiac
examination:
2 dimensional
Cardiac
examination:
(M mode)
CXR
ICD 10 coding
GP;
Specialist;
Pathologist
GP;
Specialist
(see list)
Pathologist
4057
or
4050
1
1
1
1
1
1
1232
1
1
1
1
1
1
4025
1
0
1
0
1
0
Pathologist
Pathologist
Pathologist
Pathologist
Pathologist
Pathologist
4027
4151
4032
4113
4114
4515
0
0
1
1
0
0
1
0
0
0
0
0
0
1
1
1
1
0
1
1
1
1
1
0
0
1
2
1
1
1
1
1
2
1
1
1
Pathologist
4511
0
0
0
0
1
1
3628
0
0
0
0
1
1
3622
0
0
0
0
1
0
Specialist
(see list)
3621
0
0
0
0
1
0
Radsiologist
3446
0
0
0
0
1
1
Radiologist;
Specialist
(see list)
Specialist
(see list)
I10. - I15.
General
Hypertension, most commonly referred to as "high blood pressure", HTN or HPN, is a medical
condition in which the blood pressure is chronically elevated. It was previously referred to as
nonarterial hypertension, but in current usage, the word "hypertension" without a qualifier
normally refers to arterial hypertension. [1]
Hypertension can be classified either essential (primary) or secondary. Essential hypertension
indicates that no specific medical cause can be found to explain a patient's condition. Secondary
hypertension indicates that the high blood pressure is a result of (i.e., secondary to) another
condition, such as kidney disease or tumors (pheochromocytoma and paraganglioma). Persistent
hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial
aneurysm, and is a leading cause of chronic renal failure. Even moderate elevation of arterial
blood pressure leads to shortened life expectancy. At severely high pressures, defined as mean
arterial pressures 50% or more above average, a person can expect to live no more than a few
years unless appropriately treated.[2]
Hypertension is considered to be present when a person's systolic blood pressure is consistently
140 mmHg or greater, and/or their diastolic blood pressure is consistently 90 mmHg or greater.[3]
Recently, as of 2003, the Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure[4] has defined blood pressure
120/80 mmHg to 139/89 mmHg as "prehypertension." Prehypertension is not a disease category;
rather, it is a designation chosen to identify individuals at high risk of developing hypertension.
The Mayo Clinic website specifies blood pressure is "normal if it's below 120/80" but that "some
data indicate that 115/75 mm Hg should be the gold standard." In patients with diabetes mellitus
or kidney disease studies have shown that blood pressure over 130/80 mmHg should be
considered high and warrants further treatment.
Hypertension is labeled resistant if a person’s blood pressure remains above their target blood
pressure despite taking three or more medications to lower it. The American Heart Association
released a scientific statement[5] in May 2008 with guidelines for treating resistant hypertension.[6]
Classification
Hypertension can be classified either essential (primary) or secondary. Essential hypertension
indicates that no specific medical cause can be found to explain a patient's condition. Secondary
hypertension indicates that the high blood pressure is a result of (i.e., secondary to) another
condition, such as kidney disease or tumors (pheochromocytoma and paraganglioma). Persistent
hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial
aneurysm, and is a leading cause of chronic renal failure. Even moderate elevation of arterial
blood pressure leads to shortened life expectancy. At severely high pressures, defined as mean
arterial pressures 50% or more above average, a person can expect to live no more than a few
years unless appropriately treated.
Signs and symptoms
Hypertension is usually found incidentally - "case finding" - by healthcare professionals during a
routine checkup. The only test for hypertension is a blood pressure measurement. Hypertension in
isolation usually produces no symptoms although some people report headaches, fatigue,
dizziness, blurred vision, facial flushing, transient insomnia or difficulty sleeping due to feeling
hot or flushed, and tinnitus [14] during beginning onset or prior to hypertention diagnosis.
Malignant hypertension (or accelerated hypertension) is distinct as a late phase in the condition,
and may present with headaches, blurred vision and end-organ damage.
Hypertension is often confused with mental tension, stress and anxiety. While chronic anxiety
and/or irritability is associated with poor outcomes in people with hypertension, it alone does not
cause it. Accelerated hypertension is associated with somnolence, confusion, visual disturbances,
and nausea and vomiting (hypertensive encephalopathy). [15]
Diagnosis
Diagnosis of hypertension is generally on the basis of a persistently high blood pressure. Usually
this requires three separate measurements at least one week apart. Exceptionally, if the elevation
is extreme, or end-organ damage is present then the diagnosis may be applied and treatment
commenced immediately.
Obtaining reliable blood pressure measurements relies on following several rules and
understanding the many factors that influence blood pressure reading[17].
For instance, measurements in control of hypertension should be at least 1 hour after caffeine, 30
minutes after smoking or strenuous exercise and without any stress. Cuff size is also important.
The bladder should encircle and cover two-thirds of the length of the arm. The patient should be
sitting upright in a chair with both feet flat on the floor for a minimum of five minutes prior to
taking a reading. The patient should not be on any adrenergic stimulants, such as those found in
many cold medications.
When taking manual measurements, the person taking the measurement should be careful to
inflate the cuff suitably above anticipated systolic pressure. The person should inflate the cuff to
200 mmHg and then slowly release the air while palpating the radial pulse. After one minute, the
cuff should be reinflated to 30 mmHg higher than the pressure at which the radial pulse was no
longer palpable. A stethoscope should be placed lightly over the brachial artery. The cuff should
be at the level of the heart and the cuff should be deflated at a rate of 2 to 3 mmHg/s. Systolic
pressure is the pressure reading at the onset of the sounds described by Korotkoff (Phase one).
Diastolic pressure is then recorded as the pressure at which the sounds disappear (K5) or
sometimes the K4 point, where the sound is abruptly muffled. Two measurements should be
made at least 5 minutes apart, and, if there is a discrepancy of more than 5 mmHg, a third reading
should be done. The readings should then be averaged. An initial measurement should include
both arms. In elderly patients who particularly when treated may show orthostatic hypotension,
measuring lying sitting and standing BP may be useful. The BP should at some time have been
measured in each arm, and the higher pressure arm preferred for subsequent measurements.
BP varies with time of day, as may the effectiveness of treatment, and archetypes used to record
the data should include the time taken. Analysis of this is rare at present.
Automated machines are commonly used and reduce the variability in manually collected
readings [18]. Routine measurements done in medical offices of patients with known hypertension
may incorrectly diagnose 20% of patients with uncontrolled hypertension [19]
Home blood pressure monitoring can provide a measurement of a person's blood pressure at
different times throughout the day and in different environments, such as at home and at work.
Home monitoring may assist in the diagnosis of high or low blood pressure. It may also be used
to monitor the effects of medication or lifestyle changes taken to lower or regulate blood pressure
levels.
Home monitoring of blood pressure can also assist in the diagnosis of white coat hypertension.
The American Heart Association[20] states, "You may have what's called 'white coat
hypertension'; that means your blood pressure goes up when you're at the doctor's office.
Monitoring at home will help you measure your true blood pressure and can provide your doctor
with a log of blood pressure measurements over time. This is helpful in diagnosing and
preventing potential health problems."
Those using home blood pressure monitoring devices are increasingly also making use of blood
pressure charting software.[21] These charting methods provide printouts for the patient's
physician and reminders to take a blood pressure reading.
Distinguishing primary vs. secondary hypertension
Once the diagnosis of hypertension has been made it is important to attempt to exclude or identify
reversible (secondary) causes.

Over 91% of adult hypertension has no clear cause and is therefore called
essential/primary hypertension. Often, it is part of the metabolic "syndrome X" in
patients with insulin resistance: it occurs in combination with diabetes mellitus (type 2),
combined hyperlipidemia and central obesity.

Secondary hypertension is more common in preadolescent children, with most cases
caused by renal disease. Primary or essential hypertension is more common in adolescents
and has multiple risk factors, including obesity and a family history of hypertension. [22]
Investigations commonly performed in newly diagnosed hypertension
Tests are undertaken to identify possible causes of secondary hypertension, and seek evidence for
end-organ damage to the heart itself or the eyes (retina) and kidneys. Diabetes and raised
cholesterol levels being additional risk factors for the development of cardiovascular disease are
also tested for as they will also require management.
Blood tests commonly performed include:

Creatinine (renal function) - to identify both underlying renal disease as a cause of
hypertension and conversely hypertension causing onset of kidney damage. Also a
baseline for later monitoring the possible side-effects of certain antihypertensive drugs.

Electrolytes (sodium, potassium)

Glucose - to identify diabetes mellitus

Cholesterol
Additional tests often include:

Testing of urine samples for proteinuria - again to pick up underlying kidney disease or
evidence of hypertensive renal damage.

Electrocardiogram (EKG/ECG) - for evidence of the heart being under strain from
working against a high blood pressure. Also may show resulting thickening of the heart
muscle (left ventricular hypertrophy) or of the occurrence of previous silent cardiac
disease (either subtle electrical conduction disruption or even a myocardial infarction).

Chest X-ray - again for signs of cardiac enlargement or evidence of cardiac failure.
Treatment

Lifestyle modificatiob (nonpharmacologic testment)

Weight reduction and regular aerobic exercise (e.g., jogging) are recommended as the first
steps in treating mild to moderate hypertension. Regular mild exercise improves blood
flow and helps to reduce resting heart rate and blood pressure. These steps are highly
effective in reducing blood pressure, although drug therapy is still necessary for many
patients with moderate or severe hypertension to bring their blood pressure down to a safe
level.

Reducing sodium (salt) diet is proven very effective: it decreases blood pressure in about
60% of people (see above). Many people choose to use a salt substitute to reduce their salt
intake.

Additional dietary changes beneficial to reducing blood pressure includes the DASH diet
(Dietary Approaches to Stop Hypertension), which is rich in fruits and vegetables and low
fat or fat-free dairy foods. This diet is shown effective based on National Institutes of
Health sponsored research. In addition, an increase in daily calcium intake has the benefit
of increasing dietary potassium, which theoretically can offset the effect of sodium and act
on the kidney to decrease blood pressure. This has also been shown to be highly effective
in reducing blood pressure.

Discontinuing tobacco use and alcohol consumption has been shown to lower blood
pressure. The exact mechanisms are not fully understood, but blood pressure (especially
systolic) always transiently increases following alcohol and/or nicotine consumption.
Besides, abstention from cigarette smoking is important for people with hypertension
because it reduces the risk of many dangerous outcomes of hypertension, such as stroke
and heart attack. Note that coffee drinking (caffeine ingestion) also increases blood
pressure transiently, but does not produce chronic hypertension.

Relaxation therapy, such as meditation, that reduces environmental stress, reducing high
sound levels and over-illumination can be an additional method of ameliorating
hypertension. Jacobson's Progressive Muscle Relaxation and biofeedback are also used [1]
particularly device guided paced breathing [2] [3]. Obviously, the effectiveness of
relaxation therapy relies on the patient's attitude and compliance.
Medications
Unless hypertension is severe, lifestyle changes such as those discussed in the preceding section
are strongly recommended before initiation of drug therapy. Adoption of the DASH diet is one
example of lifestyle change repeatedly shown to effectively lower mildly-elevated blood pressure.
If hypertension is high enough to justify immediate use of medications, lifestyle changes are
initiated concomitantly.
There are many classes of medications for treating hypertension, together called
antihypertensives, which — by varying means — act by lowering blood pressure. Evidence
suggests that reduction of the blood pressure by 5-6 mmHg can decrease the risk of stroke by
40%, of coronary heart disease by 15-20%, and reduces the likelihood of dementia, heart failure,
and mortality from vascular disease.
The aim of treatment should be blood pressure control to <140/90 mmHg for most patients, and
lower in certain contexts such as diabetes or kidney disease (some medical professionals
recommend keeping levels below 120/80 mmHg).[4] Each added drug may reduce the systolic
blood pressure by 5-10 mmHg, so often multiple drugs are necessary to achieve blood pressure
control.
Commonly used drugs include:

ACE inhibitors such as creatine captopril, enalapril, fosinopril (Monopril), lisinopril (Zestril),
quinapril, ramipril (Altace)

Angiotensin II receptor antagonists: eg, telmisartan (Micardis, Pritor), irbesartan (Avapro),
losartan (Cozaar), valsartan (Diovan), candesartan (Amias)

Alpha blockers such as doxazosin, prazosin, or terazosin

Beta blockers such as atenolol, labetalol, metoprolol (Lopressor, Toprol-XL), propranolol.

Calcium channel blockers such as nifedipine (Adalat)[23] amlodipine (Norvasc), diltiazem,
verapamil

Direct renin inhibitors such as aliskiren (Tekturna)

Diuretics: eg, bendroflumethiazide, chlortalidone, hydrochlorothiazide (also called HCTZ)

Combination products (which usually contain HCTZ and one other drug)
Choice of initial medication
Unless the blood pressure is severely elevated, consensus guidelines call for medically-supervised
lifestyle changes and observation before recommending initiation of drug therapy. All drug
treatments have side effects, and while the evidence of benefit at higher blood pressures is
overwhelming, drug trials to lower moderately-elevated blood pressure have failed to reduce
overall death rates.
If lifestyle changes are ineffective or the presenting blood pressure is critical, then drug therapy is
initiated, often requiring more than one agent to effective lower hypertension. Which type of
many medications should be used initially for hypertension has been the subject of several large
studies and various national guidelines.
The ALLHAT study PMID 12479763 showed better cost-effectiveness and slightly better
outcomes for the thiazide diuretic chlortalidone compared with a calcium channel blocker and an
ACE inhibitor in a 33,357-member ethnically mixed study group.[24] The 1993 consensus
recommendation for use of thiazide diuretics as initial treatment stems in part from the ALLHAT
study results, which concluded in 2002 that
Thiazide-type diuretics are superior in preventing 1 or more major forms of CVD and are less
expensive. They should be preferred for first-step antihypertensive therapy. PMID 12479763
A subsequent smaller study (ANBP2) did not show the slight advantages in thiazide diuretic
outcomes observed in the ALLHAT study, and actually showed slightly better outcomes for
ACE-inhibitors in older white male patients.[25]
Thiazide diuretics are effective, recommended as the best first-line drug for hypertension by
many experts, and much more affordable than other therapies, yet they are not prescribed as often
as some newer drugs. Arguably, this is partly because they are off-patent, less profitable, and thus
rarely promoted by the drug industry.[26]
The consensus recommendations of thiazide diuretics as first-line therapy for hypertension stand
against a the backdrop that all blood pressure treatments have side-effects. Potentially serious side
effects of the thiazide diuretics include hypercholesterinemia, and impaired glucose tolerance
with consequent increased risk of developing Diabetes mellitus type 2. The thiazide diuretics also
deplete circulating potassium unless combined with a potassium-sparing diuretic or supplemental
potassium. On this basis, the consensus recommendations to prefer use of thiazides as first line
treatment for essential hypertension have been repeatedly and strongly questioned.[27] [28] [29]
However as the Merck Manual of Geriatrics notes, "[t]hiazide-type diuretics are especially safe
and effective in the elderly."[30]
Medicine formularies
Plan or option
[Link to appropriate Mediscor formulary]
GMHPP
Gold Options
G1000, G500 and
G200
Blue Options
B300 and B200
GMISHPP
Blue Option B100
[Core]
n/a
Epidemiology
The level of blood pressure regarded as deleterious has been revised down during years of
epidemiological studies. A widely quoted and important series of such studies is the Framingham
Heart Study carried out in an American town: Framingham, Massachusetts. The results from
Framingham and of similar work in Busselton, Western Australia have been widely applied. To
the extent that people are similar this seems reasonable, but there are known to be genetic
variations in the most effective drugs for particular sub-populations. Recently (2004), the
Framingham figures have been found to overestimate risks for the UK population considerably.
The reasons are unclear. Nevertheless the Framingham work has been an important element of
UK health policy.
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2. Guyton & Hall. Textbook of Medical Physiology, 7th Ed., Elsevier-Saunders, p220. ISBN
0-7216-0240-1.
3. Hypertension - MeSH
4.
ab
Chobanian AV et al (2003). "The Seventh Report of the Joint National Committee on
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resistant hypertension.
6. Guidelines for treating resistant hypertension.
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9. Harrisons Internal Medicine, online edition (2007-04-14)
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16787251.
12. Johnson JA, Turner ST (June 2005). "Hypertension pharmacogenomics: current status
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15977418.
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"How well do clinic-based blood pressure measurements agree with the mercury
standard?". J Gen Intern Med 20 (7): 647-9. doi:10.1007/s11606-005-0112-6. PMID
16050862.
20. The American Heart Association. Home Monitoring of High Blood Pressure.
21. Blood pressure charting software.
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Physician 73 (9): 1558-68. PMID 16719248.
23. Kragten JA, Dunselman PHJM. Nifedipine gastrointestinal therapeutic system (GITS) in
the treatment of coronary heart disease and hypertension. Expert Rev Cardiovasc Ther 5
(2007):643-653. FULL TEXT!
24. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group (Dec
18 2002). "Major outcomes in high-risk hypertensive patients randomized to
angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The
Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
(ALLHAT)". JAMA 288 (23): 2981-97. PMID 12479763.
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angiotensin-converting--enzyme inhibitors and diuretics for hypertension in the elderly".
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1985–1996". Circulation 99: 2055-2057. PMID 10209012.
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doi:10.1016/S0140-6736(76)90359-7. PMID 55840.
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30. Section 11. Cardiovascular Disorders Chapter 85. Hypertension Topic: Hypertension topic
was last updated July 2005 http://www.merck.com/mkgr/mmg/sec11/ch85/ch85a.jsp
31. Sheetal Ladva (28/06/2006). NICE and BHS launch updated hypertension guideline.
National Institute for Health and Clinical Excellence. Retrieved on 2006-09-30.
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Institute for Health and Clinical Excellence. Retrieved on 2006-09-30.