The most recent guidelines for adult hypertension investigations and diagnosis in 2023 (part 1)

Recommendations: As stated in NICE's information on making decisions about your care, individuals have the right to participate in discussions and make informed decisions regarding their care.

The suggestions on estimating circulatory strain and diagnosing hypertension in this rule apply to all grown-ups, incorporating those with type 2 diabetes. 

                                      

At points in the care pathway where treatment differs, the treatment and monitoring recommendations are linked to NICE guidelines on chronic kidney disease, type 1 diabetes, and hypertension during pregnancy. 

In NICE's guideline on type 2 diabetes in adults, the recommendations for treating and monitoring adults with type 2 diabetes replace those for diagnosing and managing hypertension.

Measuring blood pressure: 

Ensure that healthcare professionals who take blood pressure readings receive adequate initial training and regular performance evaluations.

 Before measuring blood pressure, palpate the radial or brachial pulse because automated devices may not accurately measure blood pressure if there is a pulse irregularity, such as atrial fibrillation.

 Direct auscultation over the brachial artery should be used to manually measure blood pressure if a pulse irregularity is present.

 Healthcare providers are responsible for ensuring that instruments used to measure blood pressure are properly validated, maintained, and regularly recalibrated in accordance with the instructions provided by the manufacturers.

Ensure that healthcare professionals who take blood pressure readings receive adequate initial training and regular performance evaluations.

 Before measuring blood pressure, palpate the radial or brachial pulse because automated devices may not accurately measure blood pressure if there is a pulse irregularity, such as atrial fibrillation.

 Direct auscultation over the brachial artery should be used to manually measure blood pressure if a pulse irregularity is present.

 Healthcare providers are responsible for ensuring that instruments used to measure blood pressure are properly validated, maintained, and regularly recalibrated in accordance with the instructions provided by the manufacturers.

Ensure that healthcare professionals who take blood pressure readings receive adequate initial training and regular performance evaluations.

 Before measuring blood pressure, palpate the radial or brachial pulse because automated devices may not accurately measure blood pressure if there is a pulse irregularity, such as atrial fibrillation.

 Direct auscultation over the brachial artery should be used to manually measure blood pressure if a pulse irregularity is present.

 Healthcare providers are responsible for ensuring that instruments used to measure blood pressure are properly validated, maintained, and regularly recalibrated in accordance with the instructions provided by the manufacturers.

While estimating pulse in the center or in the home, normalize the climate and give a casual, mild setting, with thei ndividual tranquil and situated, and their arm outstretched and upheld. Make sure your cuffs are the right size for the person's arm.

In individuals who experience postural hypotension (falls or postural dizziness) symptoms:

• Take the person's blood pressure while they are supine or seated

• Take the person's blood pressure again after they have stood for at least one minute prior to the measurement. If a person's standing systolic blood pressure falls by at least 20 mmHg:

1) audit medicine

2)measure resulting blood pressures with the individual standing

3)consider reference to expert consideration in the event that side effects of postural hypotension continue.

Diagnosis of Hypertension:

 When contemplating a hypertension diagnosis, measure blood pressure in both arms:

1) Assuming the distinction in readings between arms is in excess of 15 mmHg, rehash these timations.

2) Measure subsequent blood pressures in the arm with the higher reading if the difference in readings between the arms remains greater than 15 mmHg on the second measurement. Assuming pulse estimated in the center is 140/90 mmHg or higher:

• During the consultation, conduct a second measurement.

• In the event that the subsequent estimation is significantly not the same as the first, take a thirde stimation.

3) Make the clinic blood pressure the lower of the last two measurements. 

4) Provide ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension in patients whose clinic blood pressure is between 140/90 mmHg and 180/120 mmHg. For individuals with a clinic blood pressure of 180/120 mmHg or higher, see the section on determining who to refer.  

3) Provide home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension in the event that ABPM is inappropriate or the individual is unable to tolerate it. 

Ensure that healthcare professionals who take blood pressure readings receive adequate initial training and regular performance evaluations.

 Before measuring blood pressure, palpate the radial or brachial pulse because automated devices may not accurately measure blood pressure if there is a pulse irregularity, such as atrial fibrillation.

 Direct auscultation over the brachial artery should be used to manually measure blood pressure if a pulse irregularity is present.

 Healthcare providers are responsible for ensuring that instruments used to measure blood pressure are properly validated, maintained, and regularly recalibrated in accordance with the instructions provided by the manufacturers.

 Perform the following while awaiting confirmation of a hypertension diagnosis:

1) investigations for damage to the target organ followed by a formal assessment of cardiovascular risk with a cardiovascular risk assessment tool. 

When using ABPM to confirm a hypertension diagnosis, make sure to take at least two measurements per hour during the person's typical waking hours (for instance, between 08:00 and 22:00). To confirm a diagnosis of hypertension, use the average of at least 14 measurements taken during the person's usual waking hours. 

When using HBPM to confirm a hypertension diagnosis, make sure:

1) blood pressure is recorded twice daily, ideally in the morning and evening, and for each blood pressure reading, two consecutive measurements are taken with the patient seated, at least one minute apart.Ensure that healthcare professionals who take blood pressure readings receive adequate initial training and regular performance evaluations.

 Before measuring blood pressure, palpate the radial or brachial pulse because automated devices may not accurately measure blood pressure if there is a pulse irregularity, such as atrial fibrillation.

 Direct auscultation over the brachial artery should be used to manually measure blood pressure if a pulse irregularity is present.

 Healthcare providers are responsible for ensuring that instruments used to measure blood pressure are properly validated, maintained, and regularly recalibrated in accordance with the instructions provided by the manufacturers.

2) The recording of blood pressure continues for at least four days, ideally seven.

To confirm a diagnosis of hypertension, discard the measurements taken on the first day and use the average of all subsequent measurements. 

Confirm a hypertension diagnosis in individuals with:

1) Facility pulse of 140/90 mmHg or higher and

2) ABPM daytime normal or HBPM normal of 135/85 mmHg or higher. 

3) Consider conducting investigations for alternative causes of the target organ damage if hypertension is not diagnosed but there is evidence of damage to the target organ (for more information on investigations, see NICE's guidelines on chronic kidney disease and chronic heart failure). 

 

Ensure that healthcare professionals who take blood pressure readings receive adequate initial training and regular performance evaluations.

 Before measuring blood pressure, palpate the radial or brachial pulse because automated devices may not accurately measure blood pressure if there is a pulse irregularity, such as atrial fibrillation.

 Direct auscultation over the brachial artery should be used to manually measure blood pressure if a pulse irregularity is present.

 Healthcare providers are responsible for ensuring that instruments used to measure blood pressure are properly validated, maintained, and regularly recalibrated in accordance with the instructions provided by the manufacturers.

Ensure that healthcare professionals who take blood pressure readings receive adequate initial training and regular performance evaluations.

 Before measuring blood pressure, palpate the radial or brachial pulse because automated devices may not accurately measure blood pressure if there is a pulse irregularity, such as atrial fibrillation.

 Direct auscultation over the brachial artery should be used to manually measure blood pressure if a pulse irregularity is present.

 Healthcare providers are responsible for ensuring that instruments used to measure blood pressure are properly validated, maintained, and regularly recalibrated in accordance with the instructions provided by the manufacturers.

If hypertension is not diagnosed, measure the patient's blood pressure at the clinic at least every five years, and if the patient's clinic blood pressure is close to 140/90 mmHg, consider measuring it more frequently. 

Type 2 diabetes: annual blood pressure measurement.

 Adults with type 2 diabetes who have not previously been diagnosed with hypertension or renal disease should have their blood pressure taken at least annually. Offer and support preventive way of life exhortation. 

 

Specialized investigations for potential secondary causes of hypertension  Take into consideration the need for specialized investigations in individuals who exhibit signs and symptoms that suggest a secondary cause of hypertension.

Assessing cardiovascular risk and damage to the target organs For advice on how to identify and treat chronic kidney disease early, see the NICE guideline on the subject.

When discussing prognosis and healthcare options with hypertensive individuals, use a formal estimation of cardiovascular risk for both elevated blood pressure and other modifiable risk factors. 

 Estimate cardiovascular risk in accordance with the NICE guideline on cardiovascular disease's recommendations for identifying and assessing cardiovascular disease risk. Calculate cardiovascular risk by taking measurements of your blood pressure at the clinic.

 For all individuals with hypertension proposition to:

• send a urine sample to be estimated for albumin in order to check for protein in the urine: Ensure that healthcare professionals who take blood pressure readings receive adequate initial training and regular performance evaluations.

 Before measuring blood pressure, palpate the radial or brachial pulse because automated devices may not accurately measure blood pressure if there is a pulse irregularity, such as atrial fibrillation.

 Direct auscultation over the brachial artery should be used to manually measure blood pressure if a pulse irregularity is present.

 Healthcare providers are responsible for ensuring that instruments used to measure blood pressure are properly validated, maintained, and regularly recalibrated in accordance with the instructions provided by the manufacturers.

• Take a blood sample to measure glycated hemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol, and HDL cholesterol; examine the fundus for hypertensive retinopathy; arrange for a 12-lead electrocardiogram. 

Ensure that healthcare professionals who take blood pressure readings receive adequate initial training and regular performance evaluations.

 Before measuring blood pressure, palpate the radial or brachial pulse because automated devices may not accurately measure blood pressure if there is a pulse irregularity, such as atrial fibrillation.

 Direct auscultation over the brachial artery should be used to manually measure blood pressure if a pulse irregularity is present.

 Healthcare providers are responsible for ensuring that instruments used to measure blood pressure are properly validated, maintained, and regularly recalibrated in accordance with the instructions provided by the manufacturers.

Ensure that healthcare professionals who take blood pressure readings receive adequate initial training and regular performance evaluations.

 Before measuring blood pressure, palpate the radial or brachial pulse because automated devices may not accurately measure blood pressure if there is a pulse irregularity, such as atrial fibrillation.

 Direct auscultation over the brachial artery should be used to manually measure blood pressure if a pulse irregularity is present.

 Healthcare providers are responsible for ensuring that instruments used to measure blood pressure are properly validated, maintained, and regularly recalibrated in accordance with the instructions provided by the manufacturers.

Treatment of hypertension will be talked about in my next blog.