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

• U/A, pregnancy test
• ECG, if new diagnosis of hypertension

† 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

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