Recommendation ID

Which people with extreme hypertension (220/120 mmHg or higher) or emergency symptoms should be referred for same-day hospital specialist assessment?

Any explanatory notes
(if applicable)

Why the committee made the recommendations
There was no evidence identified to inform recommendations on this topic. The committee reviewed the 2011 recommendations and agreed that they should be updated by consensus based on their clinical expertise. In particular they agreed it would be helpful to clarify which features warranted same-day referral, which would need further investigation and when repeat blood pressure measurement should be taken.

The committee noted that it can be difficult to differentiate between accelerated hypertension and severe hypertension. They discussed the advantages and disadvantages of broader criteria for same-day referral, which would increase referrals to hospital but reduce the risk of missing people who need urgent treatment. The committee decided it would be beneficial to add some emergency symptoms to the existing recommendation, which will help healthcare professionals to decide when to refer.

Based on their experience, the committee members agreed that some people with severe hypertension could be receiving unnecessary treatment because the 2011 guideline recommended treatment based on severe hypertension alone. The committee agreed that this could be prevented if investigations for target organ damage were carried out quickly before offering treatment in people with severely raised blood pressure and no other symptoms of concern. The committee also agreed that checking blood pressure again within 7 days in people with no target organ damage would ensure that people with severe hypertension are followed up and offered suitable treatment.

The committee agreed that further research is needed in this area, particularly for people with extreme hypertension (220/120 mmHg or higher) or emergency symptoms. The committee members developed a research recommendation to help inform future recommendations on same-day specialist assessment.

How the recommendations might affect practice
The emergency symptoms listed in the recommendation may lead to more referrals to hospital. However, people with emergency symptoms will benefit from urgent treatment because accelerated hypertension can be fatal if untreated.

There may be some additional resource use from doing target organ damage tests more quickly and re-measuring blood pressure within 7 days. However, the number of people started on treatment immediately may be reduced because of undertaking investigations first.

The population with severe hypertension is very small, and the proportion with severe hypertension and additional symptoms that suggest accelerated hypertension is even smaller; therefore, resource impact is unlikely to be substantial.

Full details of the evidence and the committee's discussion are in evidence review I: same-day specialist review.

Source guidance details

Comes from guidance
Hypertension in adults: diagnosis and management
Date issued
August 2019

Other details

Is this a recommendation for the use of a technology only in the context of research? No  
Is it a recommendation that suggests collection of data or the establishment of a register?   No  
Last Reviewed 31/08/2019