Prise en charge de l’hypertension artérielle de l’adulte

Objectives

Provide a practical, structured tool for optimising adult hypertension management in France, aimed at earlier detection, sustained blood-pressure control and prevention of cardiovascular, cerebrovascular, cognitive and renal complications. It addresses gaps in treatment and control, including the reported finding that around half of treated patients do not reach blood-pressure targets.[1]

• Improve detection through regular blood-pressure measurement in general practice and contributions from specialists, occupational-health doctors, nurses and community pharmacists.[2]
• Confirm hypertension outside the consultation before initiating treatment, normally through home or ambulatory blood-pressure monitoring, and distinguish sustained hypertension from white-coat or masked hypertension.[2][3][4]
• Assess cardiovascular risk, target-organ damage, secondary causes and aggravating factors through clinical history, examination, laboratory testing and electrocardiography, while identifying patients who need specialist assessment.[5]
• Achieve blood-pressure control within six months through shared treatment planning, lifestyle measures, pharmacological therapy and adherence support. For most patients, the intended clinic target is systolic blood pressure of 130 to 139 mmHg and diastolic blood pressure below 90 mmHg, confirmed through home measurements.[6][7]
• Individualise care for older people and patients with renal, cardiac or cognitive conditions, balancing blood-pressure reduction against orthostatic hypotension, adverse effects, medicine interactions and acute kidney injury.[8][9][7]
• Manage resistant hypertension by confirming uncontrolled blood pressure outside the clinic, reviewing adherence and lifestyle factors, excluding secondary causes, evaluating target-organ damage and escalating treatment or specialist care where appropriate.[4][10]
• Support healthy behaviours including physical activity, weight reduction where appropriate, lower alcohol and salt intake, smoking cessation, and a diet rich in fruit and vegetables and low in saturated fat.[6][11]

The scope covers adults managed for hypertension by general practitioners and other relevant professionals. It excludes people under 18, hypertensive emergencies, hypertension in pregnancy, and initially excludes secondary or resistant hypertension from the routine pathway, although later sections set out assessment and referral arrangements for these conditions.[1][10]

Implementation

Deliver care primarily through general practice, supported by home monitoring, pharmacies, nursing, specialist referral and patient participation. The approach combines standardised measurement, staged assessment, shared decision-making, lifestyle support, stepwise medicines and regular safety monitoring; it does not specify a wider programme governance structure, budget, formal reporting system or institutional accountability mechanism.[2][6][4][11][12]

• Measure blood pressure with a validated electronic upper-arm device and correctly sized cuff, after three to five minutes of rest, using at least two readings; measure both arms at first assessment, record heart rate and assess standing blood pressure for orthostatic hypotension.[2]
• Train patients or relatives to undertake home monitoring, using three morning readings before breakfast and medicines and three evening readings over three consecutive days, with written recording of blood-pressure and pulse results.[3]
• Undertake initial assessment through history-taking, examination, plasma sodium, potassium and creatinine with estimated glomerular filtration rate, fasting glucose and lipid testing, proteinuria assessment and a resting electrocardiogram.[5]
• Provide a dedicated information and consultation session to explain hypertension risks, expected treatment benefits and objectives, agree a care plan and initiate lifestyle interventions.[6]
• Review patients monthly during the first six months until blood pressure is controlled, assessing effectiveness, tolerance, adherence, education needs and recent home readings.[6][13]
• Initiate urgent pharmacological treatment without delay for confirmed severe hypertension, defined as systolic pressure above 180 mmHg and/or diastolic pressure above 110 mmHg.[14]
• Start most pharmacological treatment with once-daily single-agent therapy using a thiazide diuretic, calcium-channel blocker, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, while selecting medicines according to comorbidities and tolerance.[13][11]
• Escalate to dual therapy if control is not achieved after one month rather than merely changing or increasing single-agent treatment; use combinations drawn from renin-angiotensin system blockers, calcium-channel blockers and thiazide diuretics, progressing to triple therapy where needed.[13]
• Review adherence to medicines and lifestyle measures, potentially using fixed-dose combinations and information from pharmacists, nurses, relatives and other care professionals.[13][4][10]
• Refer suspected secondary hypertension for specialist investigation, particularly where hypertension is severe at presentation, arises before age 30, is associated with hypokalaemia or has other suggestive features; investigations may include hormonal, vascular, renal, genetic or sleep assessments.[5][10]
• Manage persistent resistant hypertension after exclusion of secondary causes by considering a fourth medicine for patients under 80, usually spironolactone where renal function and dehydration risk permit, with electrolyte and creatinine monitoring.[10][11]
• Arrange ongoing general-practice review every three to six months after the initial six-month period, with pharmacist or nurse involvement in therapeutic education where appropriate. Monitor blood pressure, symptoms, adherence, lifestyle, treatment tolerance and orthostatic hypotension.[14][7]
• Monitor sodium, potassium and creatinine one to four weeks after starting or changing an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker, and conduct more frequent renal and electrolyte assessment during illness, dehydration or increased clinical risk.[9][4]
• Restrict renal denervation, carotid baroreceptor stimulation and comparable emerging techniques to specialised centres after thorough assessment of resistant hypertension.[11]

For white-coat hypertension, generally avoid antihypertensive medicines while implementing lifestyle and dietary measures and monitoring annually because of the risk of progression to sustained hypertension.[3]Formal population-level indicators, surveillance arrangements, financing sources, costings and resource-mobilisation plans are not specified.[1][12]

Monitoring & Evaluation

Monitoring centres on repeated clinic and out-of-clinic blood-pressure measurement, treatment safety, assessment of adherence and complications, and scheduled clinical review; however, the extracts do not establish a programme-level reporting, surveillance or accountability framework.[2][8][13][4]

• Measure blood pressure regularly in general practice and enable specialists, occupational-health doctors, pharmacists and nurses to contribute to screening and follow-up. Refer people with readings of at least 140/90 mmHg to their treating doctor.[2]
• Use validated upper-arm electronic devices, an appropriate cuff, at least two readings, initial measurement in both arms, and heart-rate recording after three to five minutes of rest.[2]
• Confirm hypertension before medicine initiation through home blood-pressure monitoring or ambulatory blood-pressure monitoring, except in hypertensive emergencies.[2]Home monitoring is particularly suited to primary care and patient participation, while ambulatory monitoring can investigate marked variability, absent nocturnal dipping or dysautonomia.[2]
• Classify average daytime ambulatory or home readings as hypertensive at systolic pressure of at least 135 mmHg or diastolic pressure of at least 85 mmHg.[3][5]
• Assess orthostatic hypotension at initial assessment and follow-up after at least one and three minutes standing, particularly in older people and people with diabetes or Parkinson’s disease.[2][14]Persistent orthostatic hypotension is associated with cognitive decline, cardiovascular morbidity and mortality, and falls.[14]
• Review blood-pressure control monthly during the first six months of treatment, alongside effectiveness, tolerance and patient education.[6]Target a clinic systolic pressure of 130–139 mmHg and diastolic pressure below 90 mmHg within six months, confirmed by home measurements.[6]
• Adapt monitoring for people aged 80 or over by seeking systolic pressure below 150 mmHg without orthostatic hypotension and by limiting treatment-related harm.[9]
• Follow people with white-coat hypertension annually because of their described high risk of progression to sustained hypertension.[3]
• Assess adherence to lifestyle measures and medicines regularly, using recent home measurements before treatment changes where possible.[13]For suspected resistant hypertension, review adherence through questionnaires and information from pharmacists, nurses, relatives and other care providers.[4][10]
• Investigate apparent uncontrolled hypertension outside the clinic at six months using home or ambulatory monitoring, including assessment for masked hypertension.[4]Masked hypertension is associated with increased cardiovascular risk and may warrant specialist advice when target-organ damage is present.[4]
• Monitor plasma sodium, potassium and creatinine one to four weeks after starting or changing an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker, and following intercurrent events.[9]Monitor sodium, potassium and creatinine when spironolactone is used, and discontinue spironolactone where dehydration risk arises.[11]
• Conduct sodium, potassium, creatinine and proteinuria testing every one to two years, or more often for people with increased risk, including diabetes, renal impairment, proteinuria, poorly controlled hypertension, cardiac decompensation, intercurrent illness or older age.[14][7]Assess fasting glucose and lipid abnormalities every three years in people without diabetes or dyslipidaemia.[7]
• Repeat raised creatinine or proteinuria testing after one month and seek nephrology advice if abnormalities persist.[8]Perform electrocardiography every three to five years, or more frequently for cardiac symptoms or known heart disease.[7]
• Assess cognitive concerns in people aged 75 or over with the consensual Mini-Mental State Examination where appropriate.[8]
• Recognise treatment and control gaps as contextual performance concerns: approximately 20% of treated patients are reported as untreated and 50% do not attain blood-pressure targets in France.[1]The extracts do not specify formal indicators beyond clinical thresholds and follow-up measures, reporting schedules, surveillance arrangements, named accountable institutions or enforcement mechanisms.[1][2][13][4]

Costing & Financing

No costing or financing framework is provided in the supplied extracts. They do not specify programme or treatment budgets, funding sources, allocations, resource-mobilisation mechanisms, funding gaps, economic assumptions, or cost-effectiveness analyses.[1][8][13][4][11]

• Identify resource-relevant clinical inputs, including validated blood-pressure devices, home or ambulatory monitoring, laboratory testing, electrocardiography, specialist assessment, pharmacist and nursing involvement, and specialised-centre assessment of selected emerging procedures; no costs or financing responsibilities are assigned to these inputs.[2][5][14][10][11]
• Provide patient education and monthly consultations during the first six months until blood pressure is controlled, followed by general-practice reviews every three to six months; the extracts do not quantify the workforce, service-delivery or patient costs of this model.[6][14]