Detection and diagnosis

·        GPs measure the blood pressure of all patients between 40 and 80 years of age consulting for other reasons and/or within the framework of high blood pressure monitoring (GRADE 1C). Measurements are performed in the conventional manner. If blood pressure is increased when performing a conventional measurement, it is preferable to check the results by self-measurement. Also when self-measurement reveals high blood pressure, this should preferably be verified by conventional measurement. The lowest of these two measurements will determine blood pressure interpretation (GRADE 1B).

·        Conventional blood pressure measurements are performed in accordance with WHO/ISH and ESH criteria, using a validated aneroid sphygmomanometer. This is the standard technique (GRADE 1B).

·        Self measurement of the blood pressure by the patient or a relative is a first-choice alternative (GRADE 1C). Self-measurements should always be performed complementary to conventional blood pressure measurements by the doctor. The doctor should never initiate treatment based on self-measurements only (GRADE 1B).

·        Ambulant 24-hour blood pressure monitoring is performed only in the event of a major discrepancy between the various measurement methods. In this case, specialist advice can also be sought. Ambulant 24-hour blood pressure monitoring is no routine examination that has to be performed by GPs (GRADE 1C).

·        After diagnosis of hypertension, management consists of three major objectives: active detection of secondary hypertension; looking for present and/or impending  the organ damage; estimating the overall cardiovascular risk profile (GRADE 1C). For this, the GP takes a personal history, remains vigilant for specific clinical signs of secondary hypertension, takes blood samples (to determine blood glucose, serum creatinine, total cholesterol), performs a urine stick test (to detect proteinuria, haematuria) and performs an ECG (to detect left ventricular hypertrophy) (GRADE 1C).

Therapeutic approach

·        In persons with very high blood pressure values, the GP will commence treatment regardless of the cardiovascular risk (immediately if systolic is >180 mm Hg or diastolic is >110 mm Hg, or - if the impact of non-pharmacological advice is insufficient - after several months in patients with systolic >160 mm Hg and diastolic >100 mm Hg) (GRADE 1C).

·        For all other patients, the GP will first determine the cardiovascular risk (GRADE 1B):

o   In high-risk patients (SCORE>10%) and in patients with a cardiovascular history or organ damage: prompt initiation of treatment and efforts to achieve strict blood pressure control (<140/90 mm Hg; for type 2 diabetes <130/80 mm Hg).

o   In persons with a SCORE risk between 5 and 10%: treatment (or not) will depend on a number of other factors: family history (for a first-degree relative experiencing a cardiovascular event at age < 65 years (female) or < 55 years (male), the SCORE risk is multiplied by 1.5) and the extent of sedentary behaviour and (abdominal) obesity.

o   In persons with a SCORE risk of <5%: start drug therapy  only if blood pressure values are extremely high.

·        Target blood pressure for the treatment of middle-aged hypertensive patients without comorbidity is <140/90 mmHg (conventional measurement) (GRADE 1B). The target blood pressure in cases of diabetes without nephropathy is 130/80 mmHg; in cases of diabetes with nephropathy: 125/75 mmHg; in cases of renal disease without proteinuria 130/80 mmHg; in cases of renal disease with proteinuria < 125/75 mmHg (GRADE 1B).

·        In healthy subjects over 80 years without major comorbidity, we advise a target blood pressure of 150-80 mmHg. In this fragile population, the GP should weigh up the benefit of antihypertensive treatment against the potential risks (GRADE 2B).

·        For the GP, non-pharmacological measures are always the first and often the only treatment required in patients with mild, uncomplicated essential hypertension (GRADE 1C).

·        The GP should consider drug treatment if the patient has a persistently high arterial blood pressure of ≥160/100 mmHg, or if there is an increased cardiovascular risk with an arterial blood pressure of 140/90 mmHg (GRADE 1C).

·        In hypertensive patients without comorbidity: first choice is a low-dose thiazide (-like) diuretic. As a second option or in combination with a diuretic drug, beta-blockers, ACE inhibitors/sartans or calcium antagonists could be indicated (GRADE 1A).

·        In hypertensive patients with non-diabetic renal disease: in cases of nephropathy without proteinuria, it is advisable to start with the standard initial treatment, i.e. a diuretic. In cases of nephropathy with proteinuria, an ACE inhibitor should be started first or should be added to a diuretic (GRADE 1A).

·        In hypertensive patients with coronary artery disease (angina or myocardial infarction): initiate with a beta-blocker regardless of blood pressure values; as a second option or in case of angina, a calcium antagonist is recommended. When intolerant to beta-blockers or in case of status post myocardial infarction, an ACE inhibitor/sartan is recommended (GRADE 1B).

·        In hypertensive patients with heart failure: diuretics and ACE inhibitors/sartans. Following an acute myocardial infarction with cardiac insufficiency: an ACE inhibitor/sartan (GRADE 1A).

·        In hypertensive patients with type 2 diabetes: preference is given to an ACE inhibitor or an angiotensin-II antagonist in diabetic patients with nephropathy (GRADE 1A).

·        In hypertensive patients post stroke/TIA: standard treatment (GRADE 2B).

·        To achieve target blood pressure, a combination of two or more antihypertensive drugs can be necessary. An additive blood pressure-lowering effect is achieved by combining agents of different mechanisms of action (GRADE 1B).

Follow-up

·        In uncomplicated hypertension without comorbidity: monthly checks until blood pressure has stabilised (thereafter, every 3 to 6 months), yearly reassessment of the cardiovascular risk, detection of organ damage (creatinine), screening for associated pathologies and, depending on any comorbidity or warning signs, urine tests (protein, microalbuminuria) and ECG (GRADE 2C).

·        In hypertensive patients with non-diabetic renal disease: laboratory tests (serum creatinine, clearance, electrolytes including potassium and uric acid, fasting blood glucose, cholesterol) and urine tests (twice yearly: microalbuminuria, proteinuria and mean 24-hour clearance, proteinuria and natriuresis) (GRADE 2C).

·        In hypertensive patients with coronary artery disease: in addition to the usual checks for hypertension, yearly monitoring for other cardiovascular risk factors (GRADE 2C).

·        In hypertensive patients with type 2 diabetes: blood pressure monitoring every 3 months (strict blood pressure control ≤130/80 mm Hg); yearly: estimation of the overall cardiovascular risk, microalbuminuria determination, electrocardiogram and fundoscopy (GRADE 2B).

Referrals

Specialist advice is indicated in very high risk patients who do not respond adequately to drug treatment, patients with a hypertensive crisis, patients <40 years, suspected secondary hypertension, pregnancy, high and moderate risk patients not responding or inadequately responding to combination therapy consisting of at least three different agents, occurrence of cardiovascular complications. Urgent referral is required in patients with signs of malignant hypertension, suspected TIA, stroke (GRADE 1C).