13 minutes | Apr 8, 2023
Hypertension emergencies - NICE guidance
My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at the NICE guidance on same day referral for hypertension. By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.There is a YouTube version of this and other videos that you can access here:·The NICE GP YouTube Channel: NICE GP - YouTubeThe NICE hypertension flowcharts can be found here:·Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517·Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrnThe full NICE Guideline NG136 can be found here: ·Website: https://www.nice.org.uk/guidance/NG136·Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=JbtgusIntro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-throughTranscriptHello everyone and welcome. My name is Fernando Florido, a GP in the United Kingdom.In today’s episode we will discuss hypertensive emergencies, and the NICE guidance on same day referral for hypertension. Please note, this is my interpretation and not medical advice; it’s intended for health care professionals, and you must use your clinical judgement.Remember that there is also a YouTube version of these episodes so have a look in the episode description.Dealing with hypertension can be challenging, but the good thing is that we often have time to decide on the right treatment. However, in some situations, we do not have the luxury of time due to hypertensive emergencies. Today, we will focus on how to identify and manage these emergencies.Before we start, I would like to share some tips I've learned from my 25 years of experience as a GP.Remember that we are treating the patient, not the blood pressure. The patient that we are going to be talking about today is not your typical happy antihypertensive patient. We are talking about patients who are not well; they are not happy. They will tell us and we will see it. They may have a headache, or chest pains, extreme fatigue, abdominal pain, shortness of breath, visual disturbances etc. And then, their BP is also very high. This situation is when we need to worry.So, if someone comes into our consulting room with a spring on their step, happy and smiling and saying: hello! how are you today? we are not going to be instantly very worried, even if their BP is very high. On the other hand, we may really worry about someone who looks unwell, even if their BP is lower.Also, when we finish the consultation, we like the patient leave happy but we should also feel happy about our management. So, following our instinct, our gut feeling is very important. We shouldn’t let a patient go if we are not entirely happy with their management. It would be better to tell them: I am sorry, I am a little concerned about your BP today and I would like to recheck it in a few minutes. Please sit quietly in the waiting room for 15-20 minutes and then we will recheck it. And then, we can use that time to seek advice. We will normally be working alongside someone else, so maybe we could ask a colleague, or an experienced doctor in the practice. If we happen to be alone or no one is available, then, and I know that this is not going to be popular with hospital doctors, we could just pick up the phone and ask to speak to the medical duty doctor. We will explain why we are worried and we will get their advice and guidance. And in the worst-case scenario, if there is no one around and nobody picks up the phone, it’s probably best just to send the patient to A&E or the emergency department. Feeling a little silly when the patient tells us: why did you send me there? It was a waste of time! Is better than having the patient, or even worse, a relative tell us: why didn’t you? Because something horrible has happened.But don’t worry, all of that comes with experience and our clinical judgement improves all the time. Until then, it is also a good idea to rely on clear NICE guidance, which is what we are now going to look at.So, what do the guidelines actually say:In summary, that we should arrange an urgent or same-day referral in hypertension when we are worried about either the patient’s:·BP levels or·SymptomsLet’s start with when are concerned about BP levels, that is, when the patient’s BP is very high and there are red flags. And this situation would be when the·BP is 180/120mmHg or higher and they have either: osigns of retinal haemorrhage or papilloedemaor onew onset of life-threatening symptoms Let’s look at the retinal haemorrhage and papilloedema first. They are often a sign of accelerated or malignant hypertension which is often when the BP is >220/120 And you are probably screaming at me now saying: I can’t do fundoscopy!And that is fine. Fundoscopy is quite a skill to master and many, if not most doctors will not be trained at a level that makes their examinations reliable.So, what would we do?We should then be guided by the possible symptoms of retinal haemorrhage or papilloedema, which are all of these: ·Blurred or distorted vision·Vision loss, ·Seeing spots or floaters·Reduced peripheral vision·Difficulty seeing in the dark·Eye pain or discomfort·Headaches·Nausea and vomiting·Flashing lights and·Double visionBut we also need to be aware that a retinal haemorrhage can have no symptoms at all!This would be the case, for example, when the bleeding is small or occurs in the periphery of the retinaBut normally that would be spotted because we would:·Always do investigations for target organ damage on initial diagnosis and·These investigations always include fundoscopy, so there will always be opportunities to spot this problem.But you will probably want to shout at me again saying: I told you I can’t do fundoscopy!And basically, what we need to do is refer the patient for fundoscopy to either:·A doctor skilled in fundoscopy or·An optician If we are worried because the BP is 180/120 or higher and the patient has visual symptoms, we could play it safe and send the patient to A&E or the emergency department.However, if they have a BP of 180/120 or higher and they do not have any symptoms, a more sensible approach would be to arrange an oUrgent referral to an optician or a doctor skilled in fundoscopy oWhich should ideally be the same or next dayOne top tip.Even though you say that you can’t do fundoscopy, I would advise you to love your ophthalmoscope and to use it. Look at the fundi every time that an opportunity comes along. We will probably not see anything half of the times and the other half we will not know what we are seeing. It will not change our management and we will still refer the patient for a proper assessment. However, over many years of practice and experience, we may learn to spot something. And even small victories can be satisfying and good for our professional developmentRight, now, if we go to the previous slide, we see that we have dealt with the issue of a high BP and retinal concerns. The next point is to address a high BP of 180/120 or higher with new onset life threatening symptoms. And what are these life-threatening symptoms? They would be new onset: §confusion §chest pain §signs of heart failure, or §acute kidney injury or AKIOK, new onset confusion and chest pain are very clear but, heart failure and AKI?You may be saying now, how can we diagnose new onset heart failure the same day? Organising Blood tests and echocardiograms take time!So, we do what we always do, which is to be guided by the symptoms, which we can also confirm with the physical examination:And we need to remember that we are talking about new onset heart failure, which is basically acute heart failure. So, we are not talking about those patients who have chronic heart failure and have a little bit of shortness of breath or a bit of leg oedema, etc. We are talking about acute heart failure which is when: oThe patient is unwell!So, we are talking about sending to A&E or the emergency department any unwell patient with a BP of 180/120 or higher and with any of the following new symptoms:·Shortness of breath, coughing or wheezing, especially at night or when lying down ·Tachycardia, arrhythmia·Leg/ankle/foot oedema·Fatigue and weakness·Nausea and loss of appetite·Confusion or disorientation and·Chest pain or pressureAnd now you may also be saying, how can we diagnose new onset AKI the same day? Renal function test results take time!So, again, we do what we always do, which is to be guided by the symptoms:And we need to remember that we are talking about acute kidney injury, which is an acute problem. So, we are not talking about those patients who
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FAQs
What is the first line treatment for hypertension NICE guidelines? ›
First-line treatment is now ACEI, ARB, or CCB, with an option of diuretic if CCB is not tolerated or the person has oedema or heart failure, or is at high risk of heart failure. ACEI or ARB should be used for those aged <55 years. The second step is now ACE/ARB with a CCB for most patients.
What is the guideline for hypertensive emergencies? ›The initial goal of therapy is to reduce mean arterial BP by no more than 25% (within minutes to 1 hour). If the patient remains stable, further reduce the BP to 160 mmHg systolic and 100-110 mmHg diastolic within the next 2 to 6 hours. Normal BP may be targeted over the next 24 to 48 hours.
What are the American Family Physicians Guidelines for hypertension? ›First, the AAFP recommends that clinicians treat adults with hypertension to a standard blood pressure target of less than 140/90 mm Hg to reduce the risk of all-cause mortality and cardiovascular mortality. This is a strong recommendation based on high-quality evidence.
What are the guidelines for hypertension in primary care? ›The AAFP strongly recommends a standard blood pressure target of less than 140/90 mm Hg to reduce the risks of all-cause and cardiovascular mortality. The AAFP also recommends that clinicians consider a blood pressure target of less than 135/85 mm Hg to reduce the risk of myocardial infarction.
What is the new guidelines for hypertension stage 1? ›New BP categories are: 1) normal (<120 systolic and <80 mm Hg diastolic), 2) elevated (120–129 systolic and <80 mm Hg diastolic), 3) stage 1 hypertension (130–139 systolic or 80–89 mm Hg diastolic) and stage 2 hypertension (≥140 systolic or ≥90 mm Hg diastolic).
What is the NICE guideline classification of hypertension? ›| Hypertension stage | CBPM threshold | ABPM/HBPM threshold |
|---|---|---|
| Stage 1 | 140/90 | 135/85 |
| Stage 2 | 160/100 | 150/95 |
| Stage 3 | 180/120 | Does not Require ABPM/HBPM |
Hypertensive emergency is a condition in which there is elevation of both systolic and diastolic blood pressure with the presence of acute target organ disease. Hypertensive urgency is a condition where the blood pressure is elevated (diastolic > 120 mmHg) with the absence of acute target organ disease.
What are the hypertensive emergency parameters? ›Malignant hypertension and accelerated hypertension are both hypertensive emergencies (ie, systolic BP [SBP] >180 mm Hg or diastolic BP [DBP] >120 mm Hg, and acute target organ damage ), with similar outcomes and therapies.
What is the target for hypertensive emergency treatment? ›The goal of therapy for a hypertensive emergency is to lower the mean arterial pressure by no more than 25% within minutes to 1 hour and then stabilize BP at 160/100-110 mm Hg within the next 2 to 6 hours.
What is the CDC recommendation for hypertension? ›| Blood Pressure Levels | |
|---|---|
| Normal | systolic: less than 120 mm Hg diastolic: less than 80 mm Hg |
| At Risk (prehypertension) | systolic: 120–139 mm Hg diastolic: 80–89 mm Hg |
| High Blood Pressure (hypertension) | systolic: 140 mm Hg or higher diastolic: 90 mm Hg or higher |
What are the new vs old blood pressure guidelines? ›
Under the updated AHA/ACC guidelines, if you have systolic blood pressure rates of 130 and higher you are considered to have high blood pressure. The old guidelines set high blood pressure rates at 140 or higher.
What are the new blood pressure guidelines for seniors? ›The new guidelines change nothing if you're younger than 60. But if you're 60 or older, the target has moved up: Your goal is to keep your blood pressure at 150/90 or lower. If you have kidney disease or diabetes, your target used to be 130/80 or lower; now it's 140/90 or lower.
What is Stage 3 hypertension guidelines? ›Stage 3 or severe hypertension — clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.
What are the guidelines for Stage 2 hypertension? ›The recommended action for a patient with stage 2 hypertension—BP readings at or above 140/90 mm Hg—is both nonpharmacological therapy and BP-lowering medication. Patients' blood pressure should be reassessed after one month. If the blood pressure goal has been met, reassess in three to six months.
What is FDA guidance for hypertension? ›Brief rises in blood pressure are normal, but the higher your blood pressure stays, the more at risk you are. If your blood pressure is often greater than 140/90, you may need treatment. If your blood pressure is greater than 120/80, and you have other risk factors, like diabetes, you may need treatment.
Is a hypertension crisis the same as an emergency? ›What is the difference between hypertension crisis and hypertension emergency? A hypertension emergency is a type of hypertension crisis. In addition to very high blood pressure, you have damage to some of your organs. Having very high blood pressure can put you at risk for serious health issues.
Can you code both hypertensive urgency and emergency? ›...
Coding Spotlight: Hypertension, A providers' guide for coding.
| Code | Description |
|---|---|
| I11.0 | Hypertensive heart disease with heart failure |
| I11.9 | Hypertensive heart disease without heart failure |
Hypertensive Emergency
Blood pressure must be reduced immediately to prevent imminent organ damage. Organ damage associated with hypertensive emergency may include: Changes in mental status, such as confusion. Bleeding into the brain (stroke)
The most common presentations of hypertensive emergencies are cerebral infarction (24.5%), pulmonary edema (22.5%), hypertensive encephalopathy (16.3%), and congestive heart failure (12%).
What is the map goal for hypertensive emergency? ›In hypertensive emergencies, BP should almost never be rapidly lowered. Goal of 10-20% reduction of MAP in first hour, and then 5-15% further in next 23 hours. – Usually results in acute target of <180/<120 in first hour, then <160/<110 in next 23 hours.
What is the first intervention for hypertensive crisis? ›
The first-line treatment for hypertensive crisis will typically be intravenous antihypertensive medications to lower the person's blood pressure. Healthcare providers usually aim to reduce blood pressure by no more than 25% in the first hour, as rapid decreases in blood pressure can cause other problems.
Where should the patient with hypertensive emergency be managed? ›Patients with hypertensive emergencies should be admitted to an ICU and started on parenteral antihypertensive agents to halt progression of end-organ damage.
Who new guidelines for blood pressure? ›For most people, the goal is to have a blood pressure less than 140/90. There are several common blood pressure medicines: ACE inhibitors relax blood vessels and prevent kidney damage.
What is the first-line agent for hypertensive emergency? ›A first-line medical therapy in this situation is labetalol, an adrenergic receptor blocker with both selective alpha 1-adrenergic and nonselective beta-adrenergic receptor blocking actions. This drug is available in intravenous (I.V.) and oral forms. In a hypertensive emergency, use the I.V. route.
Is lisinopril first-line for hypertension? ›Despite these limitations, both classes are recommended as first-line treatment choices, and ACE inhibitors continue to be far more commonly prescribed in the treatment of hypertension than ARBs, with lisinopril being the most commonly used antihypertensive medication worldwide.
What is first-line hypertension treatment AAFP? ›Thiazide diuretics are first-line therapy for isolated systolic hypertension, and they should be considered in any antihypertensive regimen in older persons.
What is the first choice in the treatment of essential hypertension? ›ACE inhibitors, used alone or in combination with diuretics and digoxin, both prevent congestive heart failure and reduce morbid and mortal events in patients with established failure and therefore are recommended as first-line agents for treating hypertensive patients with this condition.
What is ER treatment for hypertensive urgency? ›Captopril, an angiotensin‐converting enzyme inhibitor, is well tolerated and has effectively reduced blood pressure in hypertensive urgencies. Given by mouth, captopril is usually effective within 15–30 minutes and may be repeated in 1–2 hours depending upon the response.
What is the medical emergency of hypertensive crisis? ›A hypertensive crisis is a sudden, severe increase in blood pressure. The blood pressure reading is 180/120 millimeters of mercury (mm Hg) or greater. A hypertensive crisis is a medical emergency. It can lead to a heart attack, stroke or other life-threatening health problems.
Why are beta-blockers not first line for hypertension? ›In summary, beta-blockers are effective in preventing cardiovascular disease but are no longer suitable for routine initial treatment of hypertension because their cardiovascular protection and metabolic effects are worse than those of other antihypertensive drugs.
When should lisinopril be avoided? ›
You should not use lisinopril if you are allergic to it, or if you: have a history of angioedema; recently took a heart medicine called sacubitril; or. are allergic to any other ACE inhibitor, such as benazepril, captopril, enalapril, fosinopril, moexipril, perindopril, quinapril, ramipril, or trandolapril.
Are ACE inhibitors first line for hypertension? ›Hypertension guidelines recommend initiating ACE inhibitors to manage HTN to lower blood pressure (BP). According to the American College of Cardiology, treatment recommendations exist based on various patient populations.
What is the 1st line treatment in both hypertension and heart failure? ›Thiazides are the first-line drugs in patients with HTN at risk for HF.
What is the first-line treatment for secondary hypertension? ›Thiazide diuretics are often the first — but not the only — choice in high blood pressure medications. Diuretics are often generic and tend to be less expensive than other high blood pressure medications.
What is the first-line therapy for hypertension and diabetes? ›Calcium channel blockers (CCBs)
CCBs are considered a potential first-line treatment for hypertensive diabetics, particularly in the elderly with isolated systolic hypertension [69].
One of the most commonly prescribed thiazide-like diuretics is chlorthalidone. Studies show that it may be the best diuretic to control blood pressure and prevent death. Indapamide is another thiazide-like diuretic.
What is the best hypertension medication for the elderly? ›Angiotensin Receptor Blockers
ARBs are considered the alternative first-line treatment for hypertension in the elderly population when a diuretic is contraindicated. In elderly hypertensive patients with diabetes or HF, ARBs are considered first-line treatment and an alternative to ACE inhibitors.
Thiazide diuretics are recommended as one of the first drug treatments for high blood pressure.