CHECKLIST FOR REFERRAL FOR HYPERTENSION



CHECKLIST FOR REFERRAL FOR HYPERTENSION[i]

|Patient name: |Yes/No |

|Prior to referral: | |

|Has routine lifestyle advice been given, especially salt reduction, alcohol moderation and increasing physical activity? | |

|Have the following routine investigations been checked: urine strip for protein & blood, U&E, blood glucose, lipid profile, TFT and ECG? | |

|[ii] | |

|Has the NICE/BHS (ACD) treatment algorithm been followed? | |

|Is urgent treatment needed?: | |

|Accelerated (malignant) hypertension (BP>180/110mmHg) with grade III–IV retinopathy (papilloedema and / or retinal haemorrhage) | |

|Presence of suspected complications (e.g. transient ischaemic attack, left ventricular failure, aortic dissection) | |

|Is a possible underlying cause suspected?: | |

|Suggestion from history of a secondary cause [iii] | |

|eGFR less than 60mls/min/1.73m2 (stage 3 CKD) | |

|Proteinuria or haematuria | |

|Sudden-onset or rapidly worsening hypertension | |

|Is the patient’s hypertension resistant to a multi-drug regimen (3 or more drugs)? [iv] | |

|Is the patient less than 20 years old, or less than 30 years old and needing drug treatment according to NICE/BHS treatment guideline [v] | |

|[vi] ? | |

|Is there any therapeutic problem such as?: | |

|Multiple drug intolerance / Multiple drug contraindications | |

|Persistent non adherence or non compliance | |

|Unusually variable BP, White-coat hypertension, Pregnancy | |

|Reason for referring if not one of the above: | |

Recommendations for best practice guideline – referral letters:

The following should be included in referral letters:

✓ Ethnicity

✓ List of at least three recent BP readings

✓ Results of recommended routine investigations

✓ Currents medications (antihypertensive and others medications)

✓ Antihypertensive medications that have been used in the past and detailed reason(s) for been stopped (e.g., “bendrofluazide was stopped because of symptomatic hyponatraemia of 122 mmol/L” instead of “stopped because of hyponatraemia”)

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[i] Based on BHS guideline, RCP guideline and NICE guideline.

[ii] All hypertensive patients should have a thorough history and physical examination, but need only a limited number of routine investigations. It is important to consider and document the following: the causes of secondary hypertension; contributory factors; complications of hypertension; CVD risk factors, to allow the assessment of CVD risk; CIs to specific drugs. Chest X-ray, urine microscopy and culture and echocardiography are not routinely required.

[iii] e.g. hypokalaemia with increased or high normal plasma sodium - Conn’s syndrome; labile or postural hypotension, headache, palpitations, pallor, excessive sweating – phaeochromocytoma; truncal obesity, moon face, purple striae, muscle weakness, easy bruising, hirsutism, hyperglycaemia, hyperlipidaemia - Cushing)

[iv] The most usual recommended combination is ACE inhibitor + CCB + thiazide diuretic. Before referring a fourth drug could be consider (BB or selective alpha-blocker). If BP remains uncontrolled on adequate doses of four drugs expert advice should be sought.

[v] Secondary causes of hypertension are more common in younger people. Secondary hypertension should, in particular, be suspected if patients do not respond to the initial treatment recommendations for younger patients according to the NICE/BHS treatment algorithm.

[vi] Treatment thresholds:

- therapy should be started in all patients with sustained systolic blood pressures ≥ 160mmHg or sustained diastolic blood pressures ≥100mmHg despite non pharmacological measures

- Drug therapy is also indicated in patients with sustained systolic blood pressures of 140–159mmHg or diastolic blood pressures of 90–99mmHg if target organ damage is present, or there is evidence of established cardiovascular disease, diabetes or the 10-year cardiovascular disease risk is ≥ 20%.

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