A woman with high BP reading recorded at her routine clinic visit...

A 71-year-old woman is reviewed in her local GP clinic. She has recently changed practices and is having a routine new patient medical. Her blood pressure is 146/94 mmHg. This is confirmed on a second reading. In line with recent NICE guidance, what is the most appropriate management?

A. Ask her to come back in 6 months for a blood pressure check
B. Arrange 3 blood pressure checks with the practice nurse over the next 2 weeks with medical review following
C. Arrange ambulatory blood pressure monitoring
D. Reassure her this is acceptable for her age
E. Start treatment with a calcium channel blocker

Answer:
C. Arrange ambulatory blood pressure monitoring

Discussion: NICE now recommend ambulatory blood pressure monitoring to aid diagnosis.
The 2011 NICE guidelines recognise that in the past there was overtreatment of 'white coat' hypertension. The use of ambulatory blood pressure monitoring (ABPM) aims to reduce this. There is also good evidence that ABPM is a better predictor of cardiovascular risk than clinic blood pressure readings.

NICE published updated guidelines for the management of hypertension in 2011. Some of the key changes include:
 classifying hypertension into stages
 recommending the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM)

It has long been recognised by doctors that there is a subgroup of patients whose blood pressure climbs 20 mmHg whenever they enter a clinical setting, so called 'white coat hypertension'. If we just rely on clinic readings then such patients may be diagnosed as having hypertension when the vast majority of time there blood pressure is normal. This has led to the use of both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. These techniques allow a more accurate assessment of a patients' overall blood pressure. Not only does this help prevent overdiagnosis of hypertension - ABPM has been shown to be a more accurate predictor of cardiovascular events than clinic readings.