HYPERTENSION COMMUNITY CLINIC REFERRAL FORM EMAIL YOUR REFERRAL TO………………

• Resistant hypertension: defined as BP not controlled despite 3 drugs at max dose or max tolerated dose.

• Pseudo hypertension in the elderly:

• Overestimation of BP by sphygmomanometer measurement due to arteriosclerosis and/or calcification in arteries.

• When to suspect:

• Absence of end-organ effects in long-standing "hypertension"

• Treatment-resistant hypertension

• Development of hypotensive symptoms on medications

• Calcification of brachial artery on radiological examination

• Palpable radial artery pulse despite an upper arm inflated cuff occluding the brachial artery

Referral criteria – definitions:

1. Community Hypertension Service:

• Resistant hypertension (defined as BP not controlled despite 3 drugs at maximum dose or maximum tolerated dose)

• Multiple adverse reactions to antihypertensive therapies

• Patients in whom prescribing decisions are complex due to co-morbidities

• Persistent non-adherence to drug therapies despite best efforts of the GP practice

To note, the community clinic will also undertake follow up of specific patients reviewed in secondary care specialist hypertension services and discharged with a management plan suitable for primary care.

2. Secondary care specialist services

• Emergency referral (A&E)

• Accelerated or malignant hypertension (BP>180/110mmHg), especially if evidence of grade III-IV retinopathy (papilloedema / retinal haemorrhages)

• Suspected TIA

• Suspected Aortic dissection

• Hypertension clinic:

• Suspected secondary hypertension: Phaeochromocytoma, Coon's syndrome, Cushing syndrome, Diagnosed obstructive sleep apnoea syndrome,

• Rapidly worsening hypertension,

• Hypertension in young individuals (<40 years) especially with no FH of hypertension & where a secondary cause is suspected.

• Labile hypertension

• Pseudo-hypertension in the elderly

• Other relevant services:

• Renal: renal disease, renal artery stenosis

• Obs & Gynae: hypertension in pregnancy

• Fall clinic: postural hypotension after exclusion of common causes

Hypertension: who to refer and where?

Suspect a secondary cause if resistant to treatment, BP increasing for no reason after being well controlled, and/or severe onset.

• Renal artery stenosis:

• In young resistant to treatment hypertension

• Deteriorating renal function with ACE/ARBs inhibitors, especially in patient with PVD

• Abdominal bruit

• Phaeochromocytoma: anxiety, postural hypotension, headaches, palpitations, pallor, excessive sweating.

• Conn's syndrome: hypokalaemia with increased or normal plasma sodium.

• Cushing: truncal obesity, moon face, purple striae, muscle weakness, easy bruising, hirsutism, hyperglycaemia, hyperlipidaemia.

• Gynaecomastia: can be seen in patients with hyperthyroidism, chronic renal failure, and adrenal hyperplasia tumors. But do exclude drug-induced gynaecomastia (amphetamines, calcium antagonists, anabolic steroids, cyclosporine methyldopa, angiotensin-converting-enzyme (ACE) inhibitors, and alpha-1 blockers).

When to suspect secondary hypertension?