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National Clinical Guideline Centre (UK). Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34 [Internet]. London: Royal College of Physicians (UK); 2011 Aug. (NICE Clinical Guidelines, No. 127.)

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Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34 [Internet].

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10Integrating the assessment of blood pressure, target organ damage and cardiovascular risk assessment and clinical decision making regarding treatment initiation, treatment and targets

The algorithms found in Section 5.1 illustrate the recommended schema for the assessment of blood pressure, clinical decision making regarding initation of treatment and review. Clinic blood pressure is usually measured at scheduled reviews in primary care or on occasions opportunistically during health screening. When clinic blood pressure is <140/90mmHg, further investigation is not usually indicated and clinic blood pressure should be re-measured at least every five years. More frequent review should be considered in people whose clinic blood pressure is close to the 140/90mmHg threshold or in those in whom there is evidence of cardiovascular disease or when their estimated 10 year cardiovascular disease risk is close to, or exceeds 20%.

People with a clinic blood pressure ≥140/90mmHg should be offered ABPM to determine whether their daytime ABPM average is ≥135/95mmHg. If a person’s ABPM daytime average is <135/85mmHg they should be offered annual review. If the ABPM daytime average is ≥135/85mmHg (i.e. stage 1 hypertension), they should be offered lifestyle advice and considered for pharmacological treatment. If their ABPM day time average is ≥150/95mmHg (i.e. stage 2 hypertension), they should be offered lifestyle advice and pharmacological treatment.

All people considered hypertensive should undergo routine clinical evaluation to determine the presence of target organ damage, cardiovascular disease, diabetes or CKD and have their 10 year cardiovascular disease risk estimated. A review of lifestyle factors that may contribute to the development of hypertension and/or increase a patient’s cardiovascular disease risk should also be undertaken. If the initial clinical evaluation suggests the possibility of secondary hypertension, the patient should be referred for specialist review.

If the patient has stage 1 hypertension and evidence of TOD, cardiovascular disease, diabetes, CKD, or their estimated 10 year CVD risk is ≥20%, they should be offered treatment. If not, they should be offered lifestyle advice and annual review as their blood pressure and cardiovascular disease risk will increase over time. For younger people i.e. aged <40 years, special consideration should be given to the possibility of secondary hypertension and the exclusion of target organ damage before deciding not to initatite therapy for stage 1 hypertension and specialist review should be considered. If not offered pharmacological treatment, they should be offered lifestyle advice and annual review.

If the initial clinic blood pressure is ≥180/110mmHg and there is evidence of target organ damage and/or cardiovascular disease, the initiation of pharmacological therapy should not be delayed whilst awaiting the results of ABPM. If the initial evaluation suggests the possibility of accelerated hypertension or phaechromocytoma, the patient should be referred immediately (same day) for specialist care.

When pharmacological treatment is considered, all patients should be offered lifestyle advice (see section 11). People at higher risk, i.e. with target organ damage, established CV disease, diabetes, CKD or an estimated 10 year CVD risk ≥20%, should be considered for additional therapy to reduce their cardiovascular disease risk (e.g. statins and antiplatelet therapy) if not already initiated (see NICE guidance on CVD risk, statins and antiplatelet therapy).

When pharmacological treatment is offered, clinic blood pressure should usually be used to monitor the response to treatment and the target blood pressure is <140/90mmHg in people aged <80 years and <150/90mmHg in people aged ≥80 years.

For people with white coat hypertension (see section 6.4), home blood pressure monitoring (section 9.6) should be considered to monitor the response to treatment - the target blood pressure for optimal treatment is a HPBM average of <135/85mmHg.

Copyright © 2011, National Clinical Guideline Centre.

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Bookshelf ID: NBK83276

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