Hypertension

The link to the Lothian Hypertension Guideline on the main page includes information on assessment, management, thresholds for drug treatment and advice on when to consider referral and emergency admission.

Consultant led email advice

• Can be sought by emailing directly to consultant at balakumar.muthukrishnan2@nhs.scot

Accelerated Hypertension

Consider referral on-call medical team if there is clinical evidence of accelerated hypertension (severe hypertension with symptoms or target organ damage e.g. papilloedema) 

Further qualification of this can be found in current NICE guideline (CG127) 

Refer the person to specialist endocrine care (via SCI gateway urgent outpatient referral, email or endocrine consultant bleep depending on perceived urgency) the same day if they have:

• Suspected phaeochromocytoma (labile hypertension or postural hypotension, headache, palpitations, pallor and diaphoresis). 

Who to refer:

Endocrinology

• Hypertension with features of suspected endocrinopathy – e.g. phaeochromocytoma, hypokalaemia suggesting possible primary hyperaldosteronism, acromegaly, Cushing’s

Metabolic cardiovascular risk

• Young patients <30 years of age with hypertension without clear features of endocrinopathy
• Failure to achieve targets with ≥ 3 drugs on maximal doses
• Multiple drug side effects/intolerance
• Complicated cardiovascular risk assessment
• Target organ damage
• Resistant hypertension

Who not to refer:

• Accelerated hypertension (severe hypertension with target organ damage) –> referral to on call medical team

How to refer: can be made by making SCI Gateway referral via diabetes/endo inbox

Please refer to the latest version of the Lothian Hypertension Guidelines on the main page.

The following is additional information regarding the recommended biochemical tests for new hypertension:

• ACR (albumin:creatinine ratio): This is used to assess for evidence of end organ damage. An ACR persistently > 3 mg/mmol is a sign of chronic kidney disease (CKD) and an indication to start anti-hypertensive medication, even in stage 1 hypertension. If ACR is >30 mg/mmol in a non-diabetic patient, or >3mg/mmol in a Type 2 diabetic patient, an ACE inhibitor should be used as 1^st line therapy for hypertension (rather than a calcium channel blocker). Type 1 diabetics should be prescribed an ACE inhibitor first line for hypertension irrespective of the ACR. [NICE Guidelines NG28, NG203, NG17]

• Creatinine and electrolytes: This is used to assess for evidence of end organ damage and CKD. A baseline measurement is required before starting certain medications such as ACE inhibitors/ARBs where monitoring of renal function is required. Baseline sodium and potassium values are helpful before starting anti-hypertensive medications that can cause derangements in these electrolytes. A low potassium, particularly in a young person, can be suggestive of hyperaldosteronism.  Creatinine and electrolytes should be monitored annually to look for development or progression of CKD in hypertensive patients

• HbA1c or glucose: This is used to assess diabetes status and is required for cardiovascular risk score calculation such as ASSIGN or Q-RISK

• Lipid profile : to assess cardiovascular risk and the need for lipid lowering therapy. This should be monitored on an annual basis

• Liver function tests: To assess for liver disease, in particular fatty liver disease (part of the metabolic syndrome). An isolated, raised GGT can be an indication of alcohol excess, which may be contributing to hypertension.

Cardiac Risk Calculator

• ASSIGN http://assign-score.com/estimate-the-risk/
• QRISK3 https://qrisk.org/

Bor.lipidclinicadvice@borders.scot.nhs.uk