QuestionSBA
QuestionChoice
Lisinopril is an angiotensin-converting enzyme inhibitor (ACEi) which would be the first choice medication in newly diagnosed hypertensive individuals with type 2 diabetes mellitus and in those who are less than 55 years of age and not of black African or African–Caribbean family origin.
62235
c
Lisinopril
QuestionChoice
Metoprolol is a beta-blocker, usually prescribed following a specialist referral if resistant hypertension is unresponsive to maximum tolerable doses of ACEi/ARB + CCB + thiazide-like diuretic (step-3 treatment).
62236
d
Metoprolol
QuestionChoice
Indapamide, a thiazide-like diuretic, is added in step 2 management of hypertension if it is not controlled with step 1 treatment with either ACEi or ARB; or CCB.
62237
e
Indapamide
QuestionChoice
**Calcium channel blockers (CCB) are the preferred step-1 medication for newly diagnosed hypertension in black African or African-Caribbean ethnicities**, irrespective of age. They tend to develop low renin, salt-sensitive type hypertension for which monotherapy with beta-blockers or ACE inhibitors is less effective than calcium channel blockers in this particular ethnicity.
62233
a
Amlodipine
QuestionChoice
Telmisartan is an angiotensin receptor blocker (ARB) which would be the first choice medication in newly diagnosed hypertensive individuals of any age with type 2 diabetes mellitus. Moreover, an ARB is preferred over an ACE inhibitor in black African or African-Caribbean family origin.
62234
b
Telmisartan
Concept
Chapter
# Summary

Primary hypertension, accounting for approximately 90-95% of cases of hypertension, is characterised by persistently elevated blood pressure due to age-related pathophysiological changes. It is a major risk factor for cardiovascular disease, cerebrovascular disease, chronic kidney disease, and peripheral vascular disease. Diagnosis is based on ambulatory blood pressure monitoring (ABPM) readings of 135/85mmHg or higher. Classification is determined by the severity of the hypertension. Management depends on the classification of the hypertension and involves lifestyle modifications and pharmacological anithypertensives according to NICE guidelines.  Effective management, through lifestyle changes and medications, significantly reduces the associated risks and improves outcomes for individuals with hypertension.

# Definition 

A 'normal' blood pressure ranges between 90/60mmHg to 140/90mmHg. The definition of hypertension is a 24h ambulatory blood pressure average reading (ABPM) that is more than or equal to 135/85mmHg. 

# Epidemiology

In 2015, it was reported that high blood pressure affected more than 1 in 4 adults in England (31% of men; 26% of women). In England, it is estimated that primary hypertension affects around 13.5 million people and contributed to 75,000 deaths.

# Pathophysiology

Primary hypertension is as a result of a series of complex physiological changes as we age. Hypertension often occurs as a result of reduced elasticity of large arteries, age-related and atherosclerosis-related calcification, and degradation of arterial elastin. It may also be present in conditions associated with increased cardiac output, such as anaemia, hyperthyroidism and aortic regurgitation.

Although the risk of cardiovascular disease increases progressively with increasing systolic and diastolic blood pressure, raised systolic pressure is more important than raised diastolic pressure as a risk factor for cardiovascular and renal disease.

# Classification 

Hypertension can be classified according to how high a patient's blood pressure is. 

* Stage 1: Clinic => 140/90mmHg; ABPM => 135/85mmHg 
* Stage 2: Clinic => 160/100mmHg; ABPM =>150/95mmHg 
* Stage 3: Clinic systolic BP (SBP) => 180 or diastolic BP (DBP) =>120mmHg


# Symptoms and Signs

Hypertension, unless malignant, is asymptomatic and does not have any clinical signs. It is diagnosed with ABPM and further investigations should focus on diagnosing end-organ complications of hypertension. 

# Investigations

[lightgallery]

* Hypertensive patients are commonly first identified at GP appointments or during hospital admissions. Due to the prominence of 'white coat hypertension', ABPM is now required for the diagnosis of hypertension. 
* Hypertension should be suspected in a patient who has a clinic blood pressure of =>140/90mmHg. 
* **1st line: ABPM** or home blood pressure monitoring if ABPM is not tolerated or declined. 
* Alongside ABPM: assessment for end-organ damage and assessment of cardiovascular risk (QRISK2 scores). 
  * Urine dip and albumin:creatinine level
  * Blood glucose, lipids and renal function
  * Fundoscopy for evidence of hypertensive retinopathy
  * ECG: look for evidence of LV hypertrophy


N.B. if presentation is suspicious for secondary hypertension refer and investigate as appropriate (see section). 

N.B. Referral for same-day specialist assessment should be arranged for people with: 

* Clinic blood pressure of 180/120mmHg and higher with signs of retinal haemorrhage or papilloedema (accelerated hypertension) or life-threatening symptoms (e.g. new onset confusion, chest pain, heart failure signs or AKI). 

# Management

## Principles of Management 

### Conservative Management 

Controlling risk factors for cardiovascular disease:

* Weight loss
* Healthy diet (reduce salt and saturated fats)
* Reduce alcohol and caffeine
* Reduce stress
* Stop smoking

### Medical Management

Indications to start pharmacological management of primary hypertension:

* Stage 1 hypertensive patients who are <80 years old with end organ damage, CVS disease, renal disease, diabetes or 10-year CVS risk >10% OR
* Anyone with stage 2 hypertension

### 2019 NICE Guidelines for Pharmacological Management of Primary Hypertension 

[lightgallery1]

* Step 1: 
	* **ACE-inhibitor** (e.g. Ramipril) if <=55 years old
	* **DHP-Calcium Channel Blocker** (e.g. Amlodipine) if >55 years old OR African or Caribbean ethnicity
	* If unable to tolerate ACE-inhibitor then switch to _Angiotensin Receptor Blocker_ (e.g. Candesartan)
* Step 2: 
	* (If maximal dose of Step 1 has failed or not tolerated)
	* **Combine CCB and ACE-I/ARB**
* Step 3:
	* (If maximal doses of Step 2 has failed or not tolerated)
	* **Add thiazide-like diuretic** (e.g. Indapamide)
* Step 4: *Resistant Hypertension*
	* If blood potassium <4.5mmol/L then add **spironolactone**
	* If >4.5mmol/L **increase thiazide-like diuretic dose**
	* Other options at this point if the potassium is >4.5mmol/L include:
		* Alpha blocker (e.g. Doxazosin)
		*  Beta blocker (e.g. Atenolol)
		*   Referral to cardiology for further advice

**ABPM Targets:**
 
* Age <80 ABPM target <135/85
* Age >80 ABPM target <145/85 (due to risk of postural drop and falls)
* T1DM with end-organ damage <130/80

# Complications

* Increased risk of morbidity and mortality from all causes
* Coronary artery disease
* Heart failure
* Renal failure
* Stroke
* Peripheral vascular disease

# Prognosis 

Hypertension remains one of the biggest risk factors for cardiovascular disease and its associated disabilities. Management of hypertension (with lifestyle modifications or pharmacological therapies) has been shown to reduce these risks significantly. 

# NICE Guidelines
> <https://cks.nice.org.uk/topics/hypertension/> 

# References 

<https://patient.info/heart-health/high-blood-pressure-hypertension>
<https://www.ahajournals.org/doi/full/10.1161/01.CIR.101.3.329> 
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A 45-year-old Nigerian man presents to the GP clinic complaining of persistent headaches and fatigue. He has no significant medical history and has never been diagnosed with hypertension before. On physical examination, his clinic blood pressure is 170/110 mmHg. A diagnosis of hypertension is confirmed as his ambulatory blood pressure monitoring reveals similar BP reading of 168/112 mmHg.

What is the first-line management of his condition?
a