Hypertension (High BP) ⚠️

  • Treating high BP lessens risk of stroke, heart disease, kidney disease
  • If BP high — may also be other risk factors that need to be managed
  • Person may not know they have high BP until checked
  • All Aboriginal people over 18 years should be offered a BP check at least every 2 years as part of Adult Health Check
  • Target BP — less than 140/90 OR less than 130/80 if diabetes or CKD

Taking BP

  • Take BP while person sitting and rested
    • Use correct-sized BP cuff — always use large cuff for thick arm
    • Use automatic BP machine when possible — person can see numbers
  • Recent alcohol can make BP high for a few days
  • Coffee or tobacco can make BP high for 1–2 hours
  • Diagnosis of high BP needs BP to be high on 4 separate measurements — check BP twice on at least 2 different visits
  • Consider 24 hr home BP monitor and home based BP monitor records if practicable as a more reliable measure
  • Check file notes for
    • Previous records of high BP
    • Existing high BP management plan

Check

  • Do a full review at least once a year. At other visits make relevant to person’s behaviour — focus on agreed changes or highest risk

If new diagnosis of high BP

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • U/A, pregnancy test
  • ECG, if new diagnosis of hypertension

Table 4.17 BP result and action if not already on a BP management plan

Table 4.18 Management of high BP by cardiovascular risk

† See SNAPE — adult health check

See Tobacco, Healthy lifestyle choices, Brief interventions

Medicines for high BP

  • Medical consult
  • ACE inhibitor or ARB mainstay of treatment — maximise dose for best effect
  • May take 4 weeks to see full response to each medicine change
  • Regular review until good blood pressure control — use recall system

Step 1

  • ACE inhibitor, eg ramipril, perindopril
    • If can't take ACE inhibitor (eg cough, angioedema) — give ARB (eg irbesartan) — monitor recurrence of angioedema
    • If elderly or heart failure — start with lower dose
  • Check BP AND  UEC 2 weeks after starting
  • If eGFR decreases by more than 25% OR potassium is more than 5.5mmol —
    • Stop ACE inhibitor or ARB
    • Specialist consult
  • If no side effects — increase dose until target BP reached
  • At all steps — check if taking medicines if BP still above target 

Step 2

  • If BP still above target after 3 months
    • ADD calcium channel blocker (eg amlodipine, felodipine) — medical consult if pregnant

OR if CAD, heart failure — add beta-blocker (eg atenolol, metoprolol). Medical consult if pregnant

Step 3

  • If BP still above target after 3 months — change ACE inhibitor/ARB to combination medicine
    • ACE inhibitor + thiazide diuretic (eg perindopril+indapamide)

OR ARB + thiazide diuretic (eg irbesartan+hydrochlorothiazide)

Step 4

  • If BP still above target — check if taking medicines
    • Make sure all medicines at maximum tolerated doses
  • If still target at maximum tolerated doses — see Resistant high BP

High BP medicine warnings

  • Pregnancy
    • Do not use ACE inhibitor or ARB’s — both contraindicated. Advise all women of childbearing age on ACE inhibitor or ARB of risks AND to use reliable contraception
    • Come to clinic straight away to stop medicine if they could be pregnant — medical consult, see Hypertension (high BP) in pregnancy
  • Do not use ACE inhibitor and ARB together — increased risk of side effects
  • If heart failure or heart block — do not use non-dihydropyridine calcium channel blocker (eg diltiazem, verapamil) — except on specialist advice
  • Do not use alpha-blocker as first line treatment
  • Do not use short-acting nifedipine
  • Do not use beta-blocker and non-dihydropyridine calcium channel blocker (eg diltiazem, verapamil) together
  • Do not use ACE inhibitor/ARB and potassium-sparing diuretic (eg spironolactone) together — except on specialist advice
  • If asthma — avoid beta-blockers, eg atenolol, metoprolol
  • If gout — avoid thiazide diuretics, eg indapamide, hydrochlorothiazide

Table 4.19   Doses of BP control medicines

Resistant high BP

BP above target in person taking 3 or more medicines including a diuretic

  • Make sure person
    • Taking medicines as directed
    • Following lifestyle advice — especially salt restriction
  • Check they are on maximum dose of diuretic
  • Specialist consult