Hypertension- Notes for PLAB 1 | NICE Guidelines

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Confused about guidelines for Hypertension for PLAB 1 exam? Below we have made them approachable and simpler to memorize and understand. Have a quick read.

Defining Hypertension

20-40-60 rule! (from 120)

Stage 1

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Clinic =140/90 mm Hg or ABPM/HBPM = 135/85 mm Hg

Stage 2

Clinic = 160/100 mm Hg or ABPM/HBPM = 150/95 mm Hg

Stage 3

Clinic = 180/120 mm Hg

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where ABPM= Ambulatory Blood Pressure Monitoring and HBPM= Home Blood Pressure Monitoring, SBP= Systolic Blood Pressure, DBP= Diastolic Blood Pressure

Blood Pressure Targets

For CKD (with DM or Urinary ACR>70)

  • <130/80 mm Hg (120-129 systolic and <80 for diastolic)

For HTN without DM or With DM (Same)

  • Age<80 years- Clinic = 140/90 mm Hg or ABPM/HBPM = 135/85 mm Hg
  • Age>80 years- Clinic = 150/90 mm Hg or ABPM/HBPM= 145/85 mm Hg

Special Scenarios

White-Coat/Masked HTN

Record HBPM/ABPM (same 135/85 for <80 YO and 145/85 for >80 YO)

Postural Hypotension

Always record standing BP

Important Notes

  • Lifestyle Modifications>Any Anti-hypertensive
  • Low salt diet (Salt intake recommendation for adults in the UK is no more than 6 gm per day which is around 1 teaspoon)
  • Always prefer ARB over ACEi in Africo-Carribean
  • Before commencing ACEi- Check eGFR
  • If eGFR is low <30 as in advanced CKD- ACEi and ARBs should be avoided in this case
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Why ACE inhibitors in Diabetic Hypertensives?

  • Reno-protective
  • Protection against diabetic retinopathy
  • Positive effect on glucose metabolism

Hypertension Treatment Protocol

Clinic BP >180/120 mm Hg (Severe HTN)

Symptomatic

  • Life-threatening signs (Confusion, Chest pain, Signs of HF, AKI)
    • Above features present- Refer to A&E

Asymptomatic

  • Fundoscopy- Retinal Haemorrhage, Papilloedema (Accelerated/Malignant HTN)
    • Present- Refer to A&E
    • Absent- Look for Target Organ Damage
      • Present- Start Anti-HTN
      • Absent- Repeat BP in 7 days (without ABPM)
  • Assessing Organ Damage
    • Fundoscopy- Retinal Haemorrhage, Papilloedema
    • Urine ACR
    • HbA1C
    • KFT- CKD
    • ECG- LVH

Clinic BP 140/90 to 179/119

  • Offer ABPM before Anti-HTN
    • ABPM>135/85 mm Hg to 149/94 mm Hg (Stage 1)- Lifestyle changes
    • ABPM>150/95 mm Hg (Stage 2)- Start Anti-HTN

Steps of Mx of HTN

Step 1

  • DM- ACEi or ARB (Africo-Carribean) (race and age is irrelevant)
  • Age <55 years- ACEi or ARBs
  • Age >_55 years/ Afro-Caribbean- CCB
  • ACEi not tolerated (ACE- A- Angioedema, C- Cough, E- Elevated Potassium)- ARB
  • CCB not tolerated (Ankle oedema/Gingival hyperplasia)> Thiazide-like diuretic
  • Evidence of HF- Thiazide like diuretic
  • Thiazide-like diuretic- Indapamide>Bendroflumethiazide (do not change if already on Bendro/HCTZ)

Step 2 (still hypertensive after step 1)

  • CCB/Thiazide- If not controlled on ACEi/ARB
  • ARB- Africo-Carribean without DM and not controlled on CCB

Step 3

  • Add remaining of 3 (CCB, ACEi/ARB, Thiazide-like)

Step 4- Resistant Hypertension

  • Check for Postural Hypotension (?Pheochromocytoma/Addison’s)
  • Add 4th Anti-HTN
  • Potassium levels
    • K+<4.5- Spironolactone (25mg od)
    • K+>4.5- Alpha/Beta Blocker

Step 5

  • Patients who fail to respond to step 4 measures Should be referred to a Specialist
  • NICE recommend- If BP remains uncontrolled with the optimal or maximum tolerated doses of four drugs- Seek Expert Advice
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