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Hypertension
Short Text
Introduction
This pathway covers the clinical management of primary hypertension in adults.
Hypertension is one of the most important preventable causes of premature morbidity and mortality in the UK, and its management is one of the most common interventions in primary care. This guideline contains new and updated recommendations on blood pressure measurement, the use of ambulatory and home blood pressure monitoring, blood pressure targets and antihypertensive drug treatment.
The original guideline on which this pathway is based was developed by the Newcastle Guideline Development and Research Unit and published in 2004. The guideline was updated by the National Clinical Guideline Centre NCGC (formerly the National Collaborating Centre for Chronic Conditions) in collaboration with the British Hypertension Society in 2006 and 2011.
Source guidance
The NICE guidance that was used to create the pathway.
Hypertension: clinical management of primary hypertension in adults. NICE clinical guideline 127 (2011)
Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. NICE clinical guideline 76 (2009)
WatchBP Home A for opportunistically detecting atrial fibrillation during diagnosis and monitoring of hypertension. NICE medical technology guidance 13 (2013)
Quality standards
Hypertension quality standard
These quality statements are taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care and should be read in full.
Quality statements
Investigations for target organ damage
This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.
Quality statement
People with newly diagnosed hypertension receive investigations for target organ damage within 1 month of diagnosis.
Rationale
Assessment of target organ damage can alert the clinician to possible secondary causes of hypertension, some of which are potentially life threatening and some that may be amenable to potentially curative interventions. It can also support the clinician to decide the appropriate blood pressure threshold at which to consider drug therapy for the treatment of hypertension.
Quality measure
Structure
Evidence of local arrangements for people with newly diagnosed hypertension to receive all investigations for target organ damage within 1 month of diagnosis.
Process
Proportion of people with newly diagnosed hypertension who receive all investigations for target organ damage within 1 month of diagnosis.
Numerator – the number of people in the denominator who receive all investigations for target organ damage within 1 month of diagnosis.
Denominator – the number of people with newly diagnosed hypertension.
Description of what the quality statement means for each audience
Service providers ensure systems are in place for people with newly diagnosed hypertension to receive all investigations for target organ damage within 1 month of diagnosis.
Healthcare professionals carry out all investigations for target organ damage for people with newly diagnosed hypertension within 1 month of diagnosis.
Commissioners ensure they commission services that carry out all investigations for target organ damage for people with newly diagnosed hypertension within 1 month of diagnosis.
People with newly diagnosed hypertension (high blood pressure) receive tests within 1 month of being diagnosed to check for any damage to organs such as their eyes, heart or kidneys.
Source clinical guideline references
NICE clinical guideline 127 recommendations 1.2.6 and 1.3.3.
Data source
Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 127 clinical audit tool: diagnosing hypertension, criterion 3.
Definitions
Investigations for target organ damage
NICE clinical guideline 127 recommendation 1.3.3 recommends that for all people with hypertension, healthcare professionals should offer to:
- test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip
- take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol
- examine the fundi for the presence of hypertensive retinopathy
- arrange for a 12-lead electrocardiograph to be performed.
Target organ damage
NICE clinical guideline 127 recommendation 1.2.6 lists left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy as examples of target organ damage.
Statin therapy
This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.
Quality statement
People with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher are offered statin therapy.
Rationale
Hypertension is associated with a higher risk of cardiovascular events. Primary prevention of cardiovascular disease depends on identification of people who are at risk before disease has become established. Formal cardiovascular risk assessment at the time of diagnosis allows a person's 10-year risk of cardiovascular events, such as coronary heart disease and stroke, to be estimated. Statin therapy is effective in further reducing acute cardiovascular events in people with hypertension.
Quality measure
Structure
Evidence of local arrangements to ensure people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher are offered statin therapy.
Process
a) Proportion of people with newly diagnosed hypertension who receive a formal assessment of their cardiovascular risk.
Numerator – the number of people in the denominator who receive a formal assessment of their cardiovascular risk.
Denominator – the number of people with newly diagnosed hypertension who do not have established cardiovascular disease.
b) Proportion of people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher who are prescribed statin therapy.
Numerator – the number of people in the denominator who are prescribed statin therapy.
Denominator – the number of people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher.
Description of what the quality statement means for each audience
Service providers ensure systems are in place to offer statin therapy to people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher.
Healthcare professionals offer statin therapy to people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher.
Commissioners ensure they commission services that offer statin therapy to people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher.
People with newly diagnosed hypertension (high blood pressure) and a 20% (1-in-5) or higher chance of developing cardiovascular disease in the next 10 years are offered a type of drug called a statin.
Source clinical guideline references
NICE clinical guideline 127 recommendations 1.3.1 and 1.3.2 and recommendation 1.5.1 (key priority for implementation).
NICE clinical guideline 67 recommendation 1.4.3 (key priority for implementation).
Data source
Structure
Local data collection.
Process
a) Quality and Outcomes Framework (QOF) indicator PP1 – In those patients with a new diagnosis of hypertension (excluding those with pre-existing coronary heart disease, diabetes, stroke and/or TIA [transient ischaemic attack]) recorded between the preceding 1 April to 31 March: the percentage of patients who have had a face-to-face cardiovascular risk assessment at the outset of diagnosis (within 3 months of the initial diagnosis) using an agreed risk assessment tool.
b) Local data collection. Contained with NICE clinical guideline 127 clinical audit tool: drug treatment, criterion 1.
Local data collection. Contained within NICE clinical guideline 67 audit tool, criterion 3.
Definitions
Clinic blood pressure
Clinic blood pressure refers to blood pressure measured in the clinic.
Formal assessment of cardiovascular risk
NICE does not recommend a particular cardiovascular risk assessment tool. Three commonly used tools validated for use in primary care in England are:
- Framingham
- Joint British Societies' guidelines (JBS2)
- QRISK(2).
Statin therapy
NICE clinical guideline 67 recommendation 1.4.3 recommends statin therapy as part of the management strategy for the primary prevention of CVD (cardiovascular disease) for adults who have a 20% or greater 10-year risk of developing CVD. This level of risk should be estimated using an appropriate risk calculator, or by clinical assessment for people for whom an appropriate risk calculator is not available or appropriate (for example, older people, people with diabetes and people in high-risk ethnic groups). The timeframe from diagnosis to initiation of treatment is anticipated to be no longer than 3 months.
NICE clinical guideline 67 recommends that before people are offered lipid modification therapy for primary prevention, all other modifiable CVD risk factors should be considered and their management optimised if possible.
Equality and diversity considerations
Clinical assessment should be carried out for people for whom an appropriate risk calculator is not available or appropriate (for example, some groups of older people and some younger people) to determine their level of risk.
Younger people are unlikely to have a 10-year cardiovascular disease risk of 20% or higher because risk assessment is strongly influenced by age. This group would still receive statin therapy if they have a specific indication for statin therapy, that is an unequivocally elevated LDL-cholesterol level, for example because of familial hypercholesterolaemia, or if they have clinical evidence of cardiovascular disease.
Blood pressure targets
This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.
Quality statement
People with treated hypertension have a clinic blood pressure target set to below 140/90 mmHg if aged under 80 years, or below 150/90 mmHg if aged 80 years and over.
Rationale
Hypertension is associated with a higher risk of cardiovascular events. Setting blood pressure to recommended levels aims to promote primary and secondary prevention of cardiovascular disease, and to lower the risk of cardiovascular events.
Quality measure
Structure
a) Evidence of local arrangements to ensure people aged under 80 years with treated hypertension have a clinic blood pressure target set to below 140/90 mmHg.
b) Evidence of local arrangements to ensure people aged 80 years and over with treated hypertension have a clinic blood pressure target set to below 150/90 mmHg.
Outcome
People with treated hypertension whose target blood pressure is achieved.
Description of what the quality statement means for each audience
Service providers ensure systems are in place for people aged under 80 years with treated hypertension to have a clinic blood pressure target set to below 140/90 mmHg, and for people aged 80 years and over with treated hypertension to have a clinic blood pressure target set to below 150/90 mmHg.
Healthcare professionals ensure that people aged under 80 years with treated hypertension have a clinic blood pressure target set to below 140/90 mmHg, and people aged 80 years and over with treated hypertension have a clinic blood pressure target set to below 150/90 mmHg.
Commissioners ensure they commission services that have arrangements for people aged under 80 years with treated hypertension to have a clinic blood pressure target set to below 140/90 mmHg, and for people aged 80 years and over with treated hypertension to have a clinic blood pressure target set to below 150/90 mmHg.
People who are receiving treatment for hypertension (high blood pressure) have a target clinic blood pressure (blood pressure measured in their GP practice or clinic) below 140/90 mmHg if they are aged under 80 years, or a clinic blood pressure below 150/90 mmHg if they are aged 80 years or over.
Source clinical guideline references
NICE clinical guideline 127 recommendations 1.5.5 and 1.5.6.
Data source
Structure
a) and b) Local data collection.
Outcome
Quality and Outcomes Framework (QOF) indicator BP05 – The percentage of patients with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 mmHg or less.
Definitions
Clinic blood pressure
Clinic blood pressure refers to blood pressure measured in the clinic.
For a clinic blood pressure of 140/90 mmHg, the corresponding ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg.
For a clinic blood pressure of 160/100 mmHg or higher, the corresponding ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
Treated hypertension
Treated hypertension includes treatment with antihypertensive drugs.
Equality and diversity considerations
Targets are based on evidence of safe practice. A person aged 80 years or over with treated hypertension would not have a target clinic blood pressure of 150/90 mmHg if their blood pressure was already treated to below this threshold.
Review of cardiovascular disease risk factors
This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.
Quality statement
People with hypertension are offered a review of risk factors for cardiovascular disease annually.
Rationale
People's blood pressure and cardiovascular disease risk will increase over time. A review of risk factors for cardiovascular disease delivered as part of an annual review of care should support identification of increased risk and provide an opportunity to address modifiable risk factors.
Quality measure
Structure
Evidence of local arrangements to ensure people with hypertension are offered a review of risk factors for cardiovascular disease annually.
Process
Proportion of people who have had hypertension for 12 months or longer who have had a review of risk factors for cardiovascular disease within the past 12 months.
Numerator – the number of people in the denominator who have had a review of risk factors for cardiovascular disease within the past 12 months.
Denominator – the number of people who have had hypertension for 12 months or longer who do not have established cardiovascular disease.
Description of what the quality statement means for each audience
Service providers ensure systems are in place to offer people with hypertension a review of risk factors for cardiovascular disease annually.
Healthcare professionals offer people with hypertension a review of risk factors for cardiovascular disease annually.
Commissioners ensure they commission services that offer people with hypertension a review of risk factors for cardiovascular disease annually.
People with hypertension (high blood pressure) are offered a review of risk factors for cardiovascular disease annually.
Source clinical guideline references
NICE clinical guideline 127 recommendation 1.7.3.
Data source
Structure
Local data collection.
Process
Quality and Outcomes Framework (QOF) indicator PP 2 – The percentage of people with hypertension diagnosed after 1 April 2009 who are given lifestyle advice in the last 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet.
QOF indicator SMOKING 6 – The percentage of patients with any or any combination of the following conditions: CHD [chronic heart disease], PAD [peripheral arterial disease], stroke or TIA [transient ischaemic attack], hypertension, diabetes, COPD [chronic obstructive pulmonary disease], CKD [chronic kidney disease], asthma, schizophrenia, bipolar affective disorder or other psychoses who smoke whose notes contain a record of an offer of support and treatment within the preceding 15 months.
QOF indicator BP 4 – The percentage of patients with hypertension in whom there is a record of the blood pressure in the preceding 9 months.
Definitions
Annual review of care
NICE clinical guideline 127 recommendation 1.7.3 recommends that an annual review of care should be provided to monitor blood pressure, provide people with support and discuss their lifestyle, symptoms and medication.
Review of risk factors for cardiovascular disease
Review of risk factors for cardiovascular disease could include:
- smoking status
- alcohol consumption
- blood pressure
- body mass index or other measure of obesity
- total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides
- blood glucose
- renal function
- liver function (transaminases) if receiving statins
- heart rate and rhythm (pulse measurement).
(adapted from NICE clinical guideline 67 recommendation 1.4.2).
Blood pressure should be measured more frequently than annually for patients who need more frequent monitoring.
Referral to a specialist for people with resistant hypertension
This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.
Quality statement
People with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled are referred for specialist assessment.
Rationale
People with resistant hypertension will usually be at high risk of cardiovascular disease. Specialist assessment and evaluation supports management of their condition.
Quality measure
Structure
Evidence of local arrangements for people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled to be referred for specialist assessment.
Process
Proportion of people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled who are referred for specialist assessment.
Numerator – the number of people in the denominator who are referred for specialist assessment.
Denominator – the number of people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled.
Description of what the quality statement means for each audience
Service providers ensure local arrangements are in place for people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled to be referred for specialist assessment.
Healthcare professionals refer people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled for specialist assessment.
Commissioners ensure they commission services that refer people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled for specialist assessment.
People with resistant hypertension (high blood pressure that is difficult to control) who are receiving 4 antihypertensive drugs (drugs to treat high blood pressure) and whose blood pressure is still high are referred for a specialist assessment.
Source clinical guideline references
NICE clinical guideline 127 recommendations 1.6.18 and 1.6.22.
Data source
Structure
Local data collection.
Process
Local data collection.
Definitions
Referral for specialist assessment
Referral should be to a healthcare professional, usually in secondary care, with specialist expertise in high blood pressure.
Resistant hypertension
NICE clinical guideline 127 recommendation 1.6.18 recommends that clinic blood pressure that remains higher than 140/90 mmHg despite step 3 treatment with the optimal or best tolerated doses of an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) plus a calcium-channel blocker (CCB) plus a diuretic should be regarded as resistant hypertension. People aged 80 years and over are considered to have resistant hypertension if their clinic blood pressure remains higher than 150/90 mmHg despite optimal or best tolerated doses of step 3 treatment.
Recommendation 1.6.22 recommends that expert advice should be sought if blood pressure remains uncontrolled with step 4 treatment of optimal or maximum tolerated doses of 4 drugs if expert advice has not yet been obtained.
Diagnosis – ambulatory blood pressure monitoring
This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.
Quality statement
People with suspected hypertension are offered ambulatory blood pressure monitoring (ABPM) to confirm a diagnosis of hypertension.
Rationale
ABPM is the most accurate method for confirming a diagnosis of hypertension, and its use should reduce unnecessary treatment in people who do not have true hypertension. ABPM has also been shown to be superior to other methods of multiple blood pressure measurement for predicting blood pressure-related clinical events.
Quality measure
Structure
Evidence of local arrangements to ensure people with suspected hypertension are offered ABPM to confirm a diagnosis of hypertension.
Process
Proportion of people with suspected hypertension who receive ABPM to confirm a diagnosis of hypertension.
Numerator – the number of people in the denominator who receive ABPM to confirm a diagnosis of hypertension.
Denominator – the number of people with suspected hypertension.
Description of what the quality statement means for each audience
Service providers ensure systems are in place to offer ABPM to confirm a diagnosis of hypertension.
Healthcare professionals offer ABPM to confirm a diagnosis of hypertension.
Commissioners ensure they commission services that offer ABPM to confirm a diagnosis of hypertension.
People with suspected hypertension (high blood pressure) are offered ambulatory blood pressure monitoring (which involves wearing a blood pressure monitor during their normal waking hours) to confirm whether or not they have hypertension.
Source clinical guideline references
NICE clinical guideline 127 recommendation 1.2.3 (key priority for implementation).
Data source
Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 127 clinical audit tool: diagnosing hypertension, criterion 1.
Definitions
Ambulatory blood pressure monitoring (ABPM)
Clinical guideline 127 Hypertension: full guideline: Ambulatory blood pressure monitoring (ABPM) involves a cuff and bladder connected to electronic sensors which detect changes in cuff pressure and allow blood pressure to be measured oscillometrically. Systolic and diastolic pressure readings are deduced from the shape of oscillometric pressure changes using an algorithm built into the measuring device. A patient's blood pressure can be automatically measured at repeated intervals throughout the day and night, while they continue routine activities. Systolic and diastolic pressure can be plotted over time, with most devices providing average day, night and 24-hour pressures. NICE recommends recording a daytime average to confirm diagnosis.
Suspected hypertension
NICE clinical guideline 127 recommendation 1.2.3 describes suspected hypertension as clinic blood pressure of 140/90 mmHg or higher without a confirmed diagnosis of hypertension.
Equality and diversity considerations
ABPM may not be suitable for everyone, for example people with particular learning or physical disabilities. Some people may be unable to tolerate ABPM and some people may decline it.
Home blood pressure monitoring should be offered as an alternative to ABPM in such cases, in line with NICE clinical guideline 127 recommendation 1.2.4. If a person is unable to tolerate ABPM, home blood pressure monitoring (HBPM) is a suitable alternative to confirm the diagnosis of hypertension.
Effective interventions library
Successful effective interventions library details
Implementation
Assessment tools
The baseline and self-assessment tools are Excel spreadsheets that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
Audit support
Audit support provides ready-to-use criteria, including exceptions, definitions, suggested data sources and a data collection tool.
Costing support
Costing support includes national cost impact reports that summarise the national costs and savings and discuss the assumptions used; costing templates to assess the impact on local budgets; and costing statements when the impact is not significant or impossible to quantify at a national level.
Education and learning
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
Learning resources
Learning resources are designed to support people to run workshops and for individual learning. They include clinical case scenarios, presentations for trainers and tests for participants.
Service planning
Providing implementation advice, these tools help people to plan or deliver services. They can include an overview of the key steps and decision points in the care pathway and suggestions for putting the guidance into practice locally.
Slide sets
Slide sets provide a framework for discussion and assist in local dissemination of the guidance. The slides contain the key messages from NICE guidance and can be tailored for local presentations.
Pathway information
Information for patients and the public
NICE produces booklets for patients and the public, called 'Understanding NICE guidance'. They summarise, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written a booklet for patients and the public explaining its guidance on each of the following topics.
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Assembly Government. If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children.
15 January 2013 Medical technology guidance 13 on WatchBP Home A added to measuring blood pressure.
22 January 2013 Added shared learning example to supporting products.
20 March 2013 Added quality standard to pathway.
Supporting information
Glossary
Angiotensin-converting enzyme inhibitor
Angiotensin II receptor blocker
Calcium-channel blocker
Ambulatory blood pressure monitoring
Estimated glomerular filtration rate
Home blood pressure monitoring
Clinic systolic blood pressure 180 mmHg or higher or clinic diastolic blood pressure 110 mmHg or higher
Clinic blood pressure 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring daytime average or home blood pressure monitoring average blood pressure 135/85 mmHg or higher
Clinic blood pressure 160/100 mmHg or higher and subsequent ambulatory blood pressure monitoring daytime average or home blood pressure monitoring average blood pressure 150/95 mmHg or higher
A discrepancy of more than 20/10 mmHg between clinic and average daytime ambulatory blood pressure monitoring or average home blood pressure monitoring measurements at the time of diagnosis
Person having blood pressure measured
Person having blood pressure measured
Diagnosis and assessment of hypertension
View the 'Diagnosis and assessment of hypertension' pathHypertension not diagnosed
Hypertension not diagnosed
Hypertension not diagnosed
If hypertension is not diagnosed and there is evidence of target organ damage such as left ventricular hypertrophy, albuminuria or proteinuria, consider carrying out investigations for alternative causes of the target organ damage.
Source guidance
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Review at least 5-yearly
Review at least 5-yearly
If hypertension is not diagnosed:
- offer to measure the person's blood pressure at least every 5 years
- consider measuring it more often than every 5 years if the person's clinic blood pressure is close to 140/90 mmHg.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeReview annually
Review annually
Review annually
If hypertension is diagnosed offer an annual review of care to monitor blood pressure, provide people with support and discuss their lifestyle, symptoms and medication.
Quality standards
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
Pathway created: August 2011 Last updated: March 2013
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