The introduction is also posted on Spotify as a podcast by “Gerry at The Health Equation”
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Gerry Gajadharsingh writes:
“The idea of finding a balance, or “golden mean,” is a recurring theme in ancient Greek philosophy. Some sources suggest this concept can be traced back to Aristotle, who emphasized the importance of moderation in all things.
Many cultures have proverbs that express the same sentiment, emphasizing the dangers of extremes. For example, the Chinese proverb “Too much spoils; too little doesn’t satisfy”.
The idea is still relevant today, with people often using phrases like “too much of a good thing” or “everything in moderation” to express the importance of balance in various aspects of life.
Blood sugar is a good example, too much of it, although we’re often unaware if we have high blood glucose, causes damage to tissues and organs. Two little blood sugar and we are very much aware of the symptoms, headache, fatigue, confusion and even in extreme cases fainting and collapse.
Blood pressure is similar, many patients with high blood pressure (hypertension), often do not have symptoms, apart from a headache if blood pressure is very high. Whereas with low blood pressure, we are often aware of and contributes towards, dizziness, fainting, falling and fatigue.
It’s one of the reasons why in healthcare, we try to help patients achieve a balance, not too much and not too little.
Hypertension is a known cardiovascular risk factor as well as causing damage to other organs if allowed to go on long-term.
Primary hypertension (or essential hypertension) accounts for about 90% of all hypertension cases. It presents as persistently elevated blood pressure without an identifiable cause—unlike secondary hypertension, which is linked to conditions such as kidney disease, endocrine disorders, or pregnancy-related complications.
My blog provides a concise comparison of international guidelines relevant to primary care clinicians, drawing from respected authorities including NICE (UK), ESC/ESH (Europe), ACC/AHA (US), WHO, and ISH. All recommendations were compiled by the Medscape Guidelines Team and reviewed by Dr. Shouvik Haldar.
Adult screening suggests at least every three years for those under 40 years of age and at least annually for those over 40 years of age.
Normal blood pressure is considered to be 120/80 mmHg. So, it’s a pressure measurement the first reading is called systolic blood pressure, the pressure in the arteries when the heart is contracting, the second reading is called diastolic blood pressure the pressure in the arteries when the heart is relaxed.
The threshold is 140/90 and needs to be monitored and treated with lifestyle advice initially, and in my opinion tools such as achieving better balance within the autonomic nervous system, such as relaxed breathing patterns and techniques such as meditation and some forms of exercise, weight management and dietary change.
The diagnosis is often confirmed with ABPM or HBPM, especially if clinic BP is in the 140/90–180/120 mmHg range. The main difference between Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) lies in how they assess blood pressure. ABPM involves a device that automatically records blood pressure at regular intervals (e.g., every 15-30 minutes) over a 24-hour period, capturing daytime and nighttime readings during normal daily activities. HBPM, on the other hand, involves patients manually measuring their blood pressure at home, typically twice a day (morning and evening), over a period of several days, while seated and resting.
Majority of patients are treated in primary care and if they are unsuccessful with lifestyle intervention with medication, with numerous medications available to achieve optimal blood pressure control.
Immediate same-day specialist referral is required for Clinic BP ≥180/120 mmHg
with:
Retinal haemorrhages or papilloedema
New confusion, chest pain, heart failure, or acute kidney injury
Suspected phaeochromocytoma (usually a benign tumour on the adrenal glands)
Symptoms such as episodic hypertension, headache, sweating, palpitations, or abdominal pain
If severe BP elevation occurs without signs of acute damage, Investigate for target organ damage (TOD). If TOD is found, initiate antihypertensive treatment (medication) immediately.
Target Organ Damage (TOD) Assessment can be assessed by the history and physical examination
Look for chest pain, visual changes, dyspnoea, or neurological symptoms
Assess comorbidities (e.g., diabetes, kidney disease)
Investigations can include
Urine tests: Proteinuria, haematuria
Blood tests: Renal function, HbA1c, lipids
ECG & Echocardiogram: LVH, cardiac function
Fundoscopy: Retinal changes
Imaging: Brain CT/MRI if neurological involvement suspected
Global hypertension guidelines agree on the importance of opportunistic screening, accurate measurement techniques, and prompt referral in high-risk scenarios.”
Medscape Guidelines Team and reviewed by Dr. Shouvik Haldar.
Screening Recommendations
Opportunistic Screening: Recommended for all adults, with regular intervals:
<40 years: at least every 3 years
≥40 years: at least annually
Primary Aldosteronism (Conn’s syndrome): Consider screening all adults with BP ≥140/90 mmHg using renin and aldosterone levels.
Secondary Hypertension: Screen when clinical suspicion arises based on symptoms or medical history.
Measuring & Diagnosing Hypertension
NICE (UK) advises:
Measure BP in both arms at initial assessment. If >15 mmHg difference, continue using the arm with the higher reading.
If clinic BP is ≥140/90 mmHg, repeat the measurement. If readings vary, take a third and use the lower of the last two.
Confirm diagnosis with ABPM or HBPM, especially if clinic BP is in the 140/90–180/120 mmHg range.
Assess for postural hypotension in those with dizziness or falls by measuring lying and standing BPs. Refer if persistent despite intervention.
The main difference between Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) lies in how they assess blood pressure. ABPM involves a device that automatically records blood pressure at regular intervals (e.g., every 15-30 minutes) over a 24-hour period, capturing daytime and nighttime readings during normal daily activities. HBPM, on the other hand, involves patients manually measuring their blood pressure at home, typically twice a day (morning and evening), over a period of several days, while seated and resting.
When to Refer
Immediate same-day specialist referral is required for:
Clinic BP ≥180/120 mmHg with:
Retinal haemorrhages or papilloedema
New confusion, chest pain, heart failure, or acute kidney injury
Suspected phaeochromocytoma:
Symptoms such as episodic hypertension, headache, sweating, palpitations, or abdominal pain
If severe BP elevation occurs without signs of acute damage:
Investigate for target organ damage (TOD)
If TOD is found, initiate antihypertensive treatment immediately
Otherwise, confirm diagnosis via repeat measurements or ABPM/HBPM within 7 days
Target Organ Damage (TOD) Assessment
History & Physical:
- Look for chest pain, visual changes, dyspnoea, or neurological symptoms
- Assess comorbidities (e.g., diabetes, kidney disease)
Investigations:
- Urine tests: Proteinuria, haematuria
- Blood tests: Renal function, HbA1c, lipids
- ECG & Echocardiogram: LVH, cardiac function
- Fundoscopy: Retinal changes
- Imaging: Brain CT/MRI if neurological involvement suspected
Conclusion
Global hypertension guidelines agree on the importance of opportunistic screening, accurate measurement techniques, and prompt referral in high-risk scenarios. Differences emerge around thresholds, risk stratification tools, and drug initiation protocols, but a unified emphasis remains on early detection and comprehensive cardiovascular risk management.
Understanding and applying these frameworks equips primary care clinicians to tailor their approach to the needs of their population, within the context of international best practice.