referral criteria from primary care - hypertension

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Suggested indications for referral include:

if there is urgent treatment indicated

severe hypertension (e.g. 220/120 mmHg) (1)
impending complications e.g. TIA (1)
NICE (2) state:
- specialist investigations and referral for hypertension is indicated in the following circumstances:
  - identifying who to refer for same-day specialist review
    - if a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral, carry out investigations for target organ damage as soon as possible:
      - if target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
      - If no target organ damage is identified, repeat clinic blood pressure measurement within 7 days
    - refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:
    - refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis)
  - consider the need for the specialist investigations in people with signs and symptoms suggesting secondary cause of hypertension
  - for adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks
  - for people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice
  - if blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4 drugs, seek specialist advice

hypertension with a possible underlying cause (1)

patients with hypokalaemia/increased plasma sodium (e.g. Conn's syndrome)
haematuria or proteinuria
raised serum creatinine
young age (any hypertension under 20 years: needing treatment < 30 years)
sudden-onset or worsening hypertension
hypertension that is resistant to multi-drug regimen, that is, >= 3 drugs

for the evaluation of therapeutic failures or problems (1)

special circumstances e.g. pregnancy, possible white coat hypertension, unusually variable blood pressure (1)

Notes:

accelerated hypertension
- a severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension
resistant hypertension
- when more than 3 drugs are needed to treat hypertension
Stage 1 hypertension
- clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg
Stage 2 hypertension
- clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher
Stage 3 or severe hypertension
- clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher

Reference:

Last edited 09/2019

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referral criteria from primary care - hypertension