Referral criteria from primary care - malignant hypertension

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:
        • signs of retinal haemorrhage or papilloedema (accelerated hypertension) or
        • life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury
        • 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:

1. Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004;BHS IV. J Hum Hypertens 2004;18: 139-85
2. NICE (August 2019). Hypertension - management of hypertension in adults in primary care.