Hypertension

For adults 18+, hypertension = repeated measurements of diastolic BP >90 mmHg and/or systolic BP >140 mmHg. Never diagnose on a single reading — confirm on at least two further visits within 3 months (average ≥90 diastolic or ≥140 systolic) before labelling someone hypertensive.

• Method, date and levels of initial diagnosis; duration and prior treatment response/side effects
• Symptoms of target organ damage: headache, dyspnoea, chest pain, claudication, ankle oedema, haematuria
• Features suggesting a secondary cause (see table below)
• CV risk factors: smoking, diabetes, dyslipidaemia, family history, abdominal obesity, alcohol, sedentary lifestyle
• Full medication history including OTC/complementary — alcohol, oral contraceptives/HRT, corticosteroids, NSAIDs/COX-2, decongestants/pseudoephedrine, appetite suppressants, amphetamines, MAOIs, ergotamine, ciclosporin/tacrolimus, liquorice, bupropion/clozapine, SNRIs (venlafaxine) can all raise BP or interfere with treatment

• BP: ≥2 seated readings (average), both arms, plus standing in elderly/diabetics
• Fundi — hypertensive retinopathy grading (I-IV)
• Neck — carotid bruits, JVP
• Heart — rate/rhythm, apex beat, murmurs, S3/S4
• Lungs — crackles (LVF), wheeze
• Abdomen — bruits (renal artery), aortic pulsation, kidneys, liver
• Femoral pulses — radiofemoral delay (coarctation)
• Periphery — pulses, trophic changes
• Waist circumference, height, weight, BMI
• Consider BP in the leg / ankle-brachial index if coarctation or PVD suspected

• Validated/calibrated device; patient seated quietly ≥5 min; cuff at heart level; standard bladder 12-13×35cm (larger for big arms)
• At least two readings 60 seconds apart; if first two differ by >6 mmHg systolic or >4 mmHg diastolic, take more
• No caffeine 4-6h, no smoking 2h, no food 30 min before measurement
• Use phase 5 (disappearance of sound) for diastolic, not phase 4 (muffling)
• 'White coat' hypertension may affect up to 25% — home or 24h ambulatory monitoring is the useful discriminator
• Masked hypertension (normal office, high ambulatory BP) carries a relatively poor prognosis — suspect if target organ damage present despite normal office BP

Consider when onset <40y, poor response to drug therapy, accelerated/malignant hypertension, or clinical pointers below. Essential hypertension accounts for 90-95% of cases.

• Chest X-ray — Baseline; cardiomegaly more often reflects chamber dilatation than wall thickness
• Plasma glucose (fasting preferred) — CV risk stratification / diabetes screen
• Total & HDL cholesterol, triglycerides — CV risk stratification
• Serum creatinine / eGFR — Baseline renal function, monitor after starting ACEI/ARB
• Serum uric acid — Baseline — thiazides can raise urate
• Serum potassium and sodium — Baseline before diuretics/ACEI/ARB; screens for secondary causes
• Haemoglobin and haematocrit — Baseline
• Urinalysis (dipstick + microscopy for sediment), urine ACR — Screens for renal disease / target organ damage
• ECG — LVH, ischaemia, arrhythmia
• HbA1c — If fasting glucose ≥6.1 mmol/L
• Fundoscopy — In severe hypertension — grade retinopathy

• Echocardiogram — Not routine — consider for LVH/function assessment
• Carotid (and femoral) ultrasound — Not routine
• Renal doppler ultrasound / isotope scan / arteriography — Suspected renal artery stenosis
• 24h urinary catecholamines — Suspected phaeochromocytoma
• Plasma aldosterone:renin ratio — Suspected primary aldosteronism / refractory hypertension — many antihypertensives affect this ratio, interpretation needs care

Risk should not be based on BP alone — stratify using BP level plus CV risk factors, associated clinical conditions, and target organ damage. Australian guidelines (2023) define absolute 5-year CVD risk: low <5%, moderate 5-<10%, high ≥10%. Use a validated risk calculator / local chapter 74 tables.

• Goal is long-term survival and quality of life, not just a number
• General target: reduce to 140/90 or less (target varies — see treatment targets table)
• Treat non-drug measures first; instruct all patients regardless of whether drugs are also started
• If diastolic 90-100 mmHg at initial visit with no target organ damage, trial non-drug therapy for 3 months before starting drugs
• Avoid excessive/rapid BP lowering — aim for steady, graduated control; watch for postural hypotension
• Remove/revise reversible pressor drugs (NSAIDs, corticosteroids, OCP, HRT) where possible before adding more antihypertensives

• Failed genuine non-pharmacological trial
• High CV risk (>15% 5-year), established CVD, diabetes with age >60 or persistent proteinuria
• 5-year CV risk >10%: treat if SBP >140 or DBP >90
• 5-year CV risk <10%: treat if SBP >160 or DBP >100
• BP >160/100 requires drug treatment regardless of CV risk; consider treatment if consistently >140/90

• Weight reduction — every 1kg lost ≈ 2.5 mmHg systolic / 1.5 mmHg diastolic fall; target waist <94cm (M) / <80cm (F) or BMI ~25
• Limit alcohol to 1-2 standard drinks/day (10-20g); reduction can lower BP 5-10 mmHg
• Sodium restriction to ≤4g/day (<100 mmol/day) — put away the salt shaker, caution with processed/takeaway food
• Regular aerobic exercise 150-300 min/week (e.g. walking), build up gradually
• Stress reduction — relaxation/meditation if avoiding stress isn't feasible
• Healthy eating pattern: high vegetables/fruit/wholegrain, lacto-vegetarian patterns, high calcium, low fat/caffeine; avoid/minimise liquorice
• Smoking cessation — doesn't lower BP reliably but critical for overall CV risk; continued smoking can negate antihypertensive CV benefit
• Treat obstructive sleep apnoea (CPAP) — modest BP benefit (2-3 mmHg)

• Build rapport; correct misconceptions (e.g. that treatment can stop once controlled, or that lifestyle alone always suffices)
• Advise on consistent pill-taking routine — a reliable time the patient remembers beats a 'best' time; some evidence bedtime dosing reduces CV events
• Set therapeutic goals, establish a recall system, provide written patient education
• On review: ask about missed doses, review all CV risk factors, ask about side effects

Deprescribing is reasonable once BP has been well controlled for months-years — reduce dose/number of drugs stepwise if expected benefit no longer justifies continuation. Avoid an abrupt 'drug holiday'; monitor carefully as control may only be temporary.

1. 1. ACE inhibitor or ARB (especially if age ≥55) OR calcium-channel blocker OR low-dose thiazide diuretic (if age ≥65)
2. 2. If target not reached after ~3 months: combine ACEI/ARB + CCB, or ACEI/ARB + thiazide, or ACEI/ARB + beta blocker
3. 3. If target still not reached: ACEI/ARB + CCB + thiazide
4. 4. If still not reached: add spironolactone or seek specialist advice
5. Adding a second low-dose drug is usually more effective than maximising the first drug's dose. Do not combine two drugs from the same class. Do not combine ACE inhibitor with ARB.

Distinguish a true hypertensive emergency (BP causing the presenting problem — encephalopathy, stroke, dissection, eclampsia, heart failure, typically ~220/140 with headache/confusion) from an asymptomatic 'random' high reading (≥180/110), which can usually be managed over 1-2 days in the community.

• Upper limits needing evaluation: age 2 → 100/58; age 5 → 105/66; age 13 → 120/80; age 14-17 → 130/80
• Majority of hypertension over age 6 is essential, but secondary causes (renal parenchymal disease, renal artery stenosis) are proportionally more common than in adults
• Use correctly sized cuff — bladder width should cover 75% of upper arm length
• Strongly consider specialist referral. Weight reduction may adequately lower BP in obese children.
• ACE inhibitors are potentially teratogenic — caution in postpubertal females

• Isolated systolic hypertension is worth treating, including >75y in good health — benefits remain significant but weigh against greater harms (e.g. falls risk)
• Start low, go slow — commence at half the normal adult dose
• First-line: indapamide (preferred) or low-dose thiazide; check electrolytes at 2-4 weeks, add a potassium-sparing diuretic (not K supplements) if hypokalaemia develops
• Second-line: ACE inhibitor/ARB, especially with heart failure
• Watch drug interactions: NSAIDs, antiparkinsonian drugs, phenothiazines

• ACE inhibitors and ARBs are contraindicated (avoid)
• Methyldopa and clonidine are the typical agents used, including for pre-eclampsia
• Beta blockers may be used but avoid in late term

• Refractory hypertension — adequate control not achieved after 3-4 months of reasonable treatment and cause not obvious
• Suspected 'white coat' hypertension — refer for ambulatory BP monitoring
• Severe hypertension — diastolic BP >115 mmHg
• Hypertensive emergency
• Ongoing target organ impairment with inadequately controlled BP
• Significant kidney impairment, eGFR <30 mL/min
• A treatable cause of secondary hypertension is found

• Explain hypertension is usually a silent, lifelong condition — asymptomatic status does not mean it is resolved or that treatment can simply stop
• Advise not to stop or alter medication based on how they feel, without discussing with you first
• Arrange a recall/review system; review all CV risk factors and ask about side effects at each visit
• Advise on when to seek urgent review: severe headache, chest pain, visual disturbance, confusion

• Never diagnose hypertension on a single reading — confirm with at least two further measurements
• If hypertension fails to respond to therapy, consider an underlying kidney or adrenal lesion
• The low-pitched bruit of renal artery stenosis is best heard with the diaphragm pressed firmly in the epigastrium
• Beware beta blockers in a patient with a history of wheeze
• Usually add only one new agent at a time; wait about 4 weeks between dose adjustments to let the effect become apparent
• Excess alcohol intake can both cause hypertension and make it harder to control