My name is Fernando Florido and I am a GP in the United Kingdom. In today’s episode I look at the NICE guidance on same day referral for hypertension. By way of disclaimer, I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.
There is a YouTube version of this and other videos that you can access here:
· The NICE GP YouTube Channel: NICE GP - YouTube
The NICE hypertension flowcharts can be found here:
· Website: https://www.nice.org.uk/guidance/ng136/resources/visual-summary-pdf-6899919517
· Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgKKs3AbARF_VLEI?e=KRIWrn
The full NICE Guideline NG136 can be found here:
· Website: https://www.nice.org.uk/guidance/NG136
· Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lgP6nFVHRypL9fdj?e=Jbtgus
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Transcript
Hello everyone and welcome. My name is Fernando Florido, a GP in the United Kingdom.
In today’s episode we will discuss hypertensive emergencies, and the NICE guidance on same day referral for hypertension. Please note, this is my interpretation and not medical advice; it’s intended for health care professionals, and you must use your clinical judgement.
Remember that there is also a YouTube version of these episodes so have a look in the episode description.
Dealing with hypertension can be challenging, but the good thing is that we often have time to decide on the right treatment. However, in some situations, we do not have the luxury of time due to hypertensive emergencies. Today, we will focus on how to identify and manage these emergencies.
Before we start, I would like to share some tips I've learned from my 25 years of experience as a GP.
Remember that we are treating the patient, not the blood pressure. The patient that we are going to be talking about today is not your typical happy antihypertensive patient. We are talking about patients who are not well; they are not happy. They will tell us and we will see it. They may have a headache, or chest pains, extreme fatigue, abdominal pain, shortness of breath, visual disturbances etc. And then, their BP is also very high. This situation is when we need to worry.
So, if someone comes into our consulting room with a spring on their step, happy and smiling and saying: hello! how are you today? we are not going to be instantly very worried, even if their BP is very high. On the other hand, we may really worry about someone who looks unwell, even if their BP is lower.
Also, when we finish the consultation, we like the patient leave happy but we should also feel happy about our management. So, following our instinct, our gut feeling is very important. We shouldn’t let a patient go if we are not entirely happy with their management.
It would be better to tell them: I am sorry, I am a little concerned about your BP today and I would like to recheck it in a few minutes. Please sit quietly in the waiting room for 15-20 minutes and then we will recheck it. And then, we can use that time to seek advice. We will normally be working alongside someone else, so maybe we could ask a colleague, or an experienced doctor in the practice. If we happen to be alone or no one is available, then, and I know that this is not going to be popular with hospital doctors, we could just pick up the phone and ask to speak to the medical duty doctor. We will explain why we are worried and we will get their advice and guidance. And in the worst-case scenario, if there is no one around and nobody picks up the phone, it’s probably best just to send the patient to A&E or the emergency department. Feeling a little silly when the patient tells us: why did you send me there? It was a waste of time! Is better than having the patient, or even worse, a relative tell us: why didn’t you? Because something horrible has happened.
But don’t worry, all of that comes with experience and our clinical judgement improves all the time. Until then, it is also a good idea to rely on clear NICE guidance, which is what we are now going to look at.
So, what do the guidelines actually say:
In summary, that we should arrange an urgent or same-day referral in hypertension when we are worried about either the patient’s:
· BP levels or
· Symptoms
Let’s start with when are concerned about BP levels, that is, when the patient’s BP is very high and there are red flags. And this situation would be when the
· BP is 180/120 mmHg or higher and they have either:
o signs of retinal haemorrhage or papilloedema or
o new onset of life-threatening symptoms
Let’s look at the retinal haemorrhage and papilloedema first. They are often a sign of accelerated or malignant hypertension which is often when the BP is >220/120
And you are probably screaming at me now saying: I can’t do fundoscopy!
And that is fine. Fundoscopy is quite a skill to master and many, if not most doctors will not be trained at a level that makes their examinations reliable. So, what would we do?
We should then be guided by the possible symptoms of retinal haemorrhage or papilloedema, which are all of these:
· Blurred or distorted vision
· Vision loss, (partial or complete)
· Seeing spots or floaters
· Reduced peripheral vision
· Difficulty seeing in the dark
· Eye pain or discomfort
· Headaches
· Nausea and vomiting
· Flashing lights and
· Double vision
But we also need to be aware that a retinal haemorrhage can have no symptoms at all!
This would be the case, for example, when the bleeding is small or occurs in the periphery of the retina
But normally that would be spotted because we would:
· Always do investigations for target organ damage on initial diagnosis and
· These investigations always include fundoscopy, so there will always be opportunities to spot this problem.
But you will probably want to shout at me again saying: I told you I can’t do fundoscopy!
And basically, what we need to do is refer the patient for fundoscopy to either:
· A doctor skilled in fundoscopy or
· An optician
If we are worried because the BP is 180/120 or higher and the patient has visual symptoms, we could play it safe and send the patient to A&E or the emergency department.
However, if they have a BP of 180/120 or higher and they do not have any symptoms, a more sensible approach would be to arrange an
o Urgent referral to an optician or a doctor skilled in fundoscopy
o Which should ideally be the same or next day
One top tip.
Even though you say that you can’t do fundoscopy, I would advise you to love your ophthalmoscope and to use it. Look at the fundi every time that an opportunity comes along. We will probably not see anything half of the times and the other half we will not know what we are seeing. It will not change our management and we will still refer the patient for a proper assessment. However, over many years of practice and experience, we may learn to spot something. And even small victories can be satisfying and good for our professional development
Right, now, if we go to the previous slide, we see that we have dealt with the issue of a high BP and retinal concerns. The next point is to address a high BP of 180/120 or higher with new onset life threatening symptoms.
And what are these life-threatening symptoms? They would be new onset:
§ confusion
§ chest pain
§ signs of heart failure, or
§ acute kidney injury or AKI
OK, new onset confusion and chest pain are very clear but, heart failure and AKI?
You may be saying now, how can we diagnose new onset heart failure the same day?
Organising Blood tests and echocardiograms take time!
So, we do what we always do, which is to be guided by the symptoms, which we can also confirm with the physical examination:
And we need to remember that we are talking about new onset heart failure, which is basically acute heart failure. So, we are not talking about those patients who have chronic heart failure and have a little bit of shortness of breath or a bit of leg oedema, etc. We are talking about acute (or acute on chronic) heart failure which is when:
o The patient is unwell!
So, we are talking about sending to A&E or the emergency department any unwell patient with a BP of 180/120 or higher and with any of the following new symptoms:
· Shortness of breath, coughing or wheezing, especially at night or when lying down
· Tachycardia, arrhythmia
· Leg/ankle/foot oedema
· Fatigue and weakness
· Nausea and loss of appetite
· Confusion or disorientation and
· Chest pain or pressure
And now you may also be saying, how can we diagnose new onset AKI the same day?
Renal function test results take time!
So, again, we do what we always do, which is to be guided by the symptoms:
And we need to remember that we are talking about acute kidney injury, which is an acute problem. So, we are not talking about those patients who have CKD and have a few symptoms here and there. We are talking about an acute injury to the kidneys, which is when:
o The patient is unwell!
So, we are talking about sending to A&E or the emergency department any unwell patient with a BP of 180/120 or higher and with any of the following new symptoms:
· Decreased urine output or no urine output
· Leg/ankle/foot oedema
· Fatigue and weakness
· Shortness of breath
· Nausea and vomiting
· Confusion or disorientation and
· Chest pain or pressure
So, we now go back to our very first slide and we can see that we have dealt with concerns about patients’ BP levels. But there is still the question of symptoms, so…
Do you ever refer the same day if BP<180/120?
And the answer is Yes!
Because we would refer patients if they have phaeochromocytoma symptoms
Now we need to remember that a phaeochromocytoma is a rare tumour of the adrenal glands. The adrenal glands produce adrenaline and noradrenaline, which control heart rate, blood pressure and metabolism. A phaeochromocytoma can produce too much adrenaline and noradrenaline, which often results in problems such as palpitations and high blood pressure.
So what are those symptoms?
The symptoms of a phaeochromocytoma tend to be unpredictable, often occurring in sudden attacks lasting from a few minutes to an hour, sometimes longer, and the patient will therefore be intermittently unwell
So, we are talking about sending to A&E or the emergency department any patient who has hypertension (without a specific BP threshold) and who is intermittently unwell with any of the following symptoms:
· headache
· palpitations
· pallor
· abdominal pain and
· diaphoresis or excessive sweating
Right, will that be difficult to remember?
Nah!
Because in real life we will have common sense, we will follow our instinct and we will do what we would normally do for any seriously unwell patient
For example:
Regardless of their BP!
Would we refer a patient to A&E or the emergency department if they are unwell with any of these symptoms?
· Acute confusion:
· Acute chest pain:
· Acute shortness of breath:
· Acutely unwell with decreased urine output or no urine output:
· So the answer is yes, and we would do this regardless of the BP. In fact, we would probably call the ambulance first and then check the BP later!
Then, would we refer a patient to A&E or the emergency department if they had a BP of 180/120 or higher and either
· visual disturbances or
· the patient is Unwell? : And the answer is Yes! Especially if:
o Rapid or irregular heartbeat
o Leg/ankle oedema
o Fatigue and weakness
o Coughing or wheezing, especially at night or when lying down and
o Nausea and vomiting
And, after what we have learned today about pheochromocytoma, would we refer a hypertensive patient to A&E or the emergency department if they were intermittently unwell with any of these symptoms?
o Palpitations:
o Pallor
o abdominal pain or
o diaphoresis
o And the answer is Yes! we would do that because we would be worried about pheochromocytoma and we would do it regardless of their BP at the time.
But remember that this is only my interpretation of the guideline, so it is not necessarily correct.
We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye
