Hypertension

Emergency department referrals

All urgent cases must be discussed with the on call Registrar to obtain appropriate prioritisation and treatment. Contact through:

Caboolture Hospital (07) 5433 8888
Redcliffe Hospital (07) 3883 7777
Royal Brisbane and Women's Hospital (07) 3646 8111
The Prince Charles Hospital (07) 3139 4000

Urgent cases accepted via phone must be accompanied with a written referral and a copy faxed immediately to the Central Patient Intake Unit: 1300 364 952.

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region:

Hypertensive emergency (BP>220/120)
Severe hypertension (systolic BP >180 mmHg) with any of the following concerning features:
- headache
- confusion
- blurred vision
- retinal haemorrhage
- reduced level of consciousness
- seizures
- proteinuria
- papilloedema
- signs of heart failure
- chest pain
- acute kidney injury
If suspected gestational induced hypertension or pre-eclampsia refer patient to the emergency department or maternity assessment unit of a facility that offers obstetric services where possible (Caboolture, RBWH or Redcliffe Hospitals)
Phaeochromocytoma in crisis with uncontrolled hypertension

Does your patient wish to be referred?

Minimum referral criteria

Does your patient meet the minimum referral criteria?

Category 1

Appointment within 30 days is desirable

All hypertension referrals would be triaged to General Medicine, unless the referral contains specific clinical indicators warranting sub-specialist review. Referrals may be allocated to Kidney Medicine, Cardiology, or Endocrinology where clearly justified by comorbidities, diagnostic complexity, or suspected secondary causes of hypertension.

Severe hypertension (>180/110mmHg but <220/140mmHg) in patients without any of the following concerning features:
- headache
- confusion
- blurred vision
- retinal haemorrhage
- reduced level of consciousness
- seizures
- proteinuria
- papilloedema
- signs of heart failure
- chest pain

Subspeciality referral for the following:
- Cardiology:
  - Hypertension with symptoms suggestive of angina
  - Hypertension with symptoms suggestive of heart failure
- Kidney Medicine:
  - If associated significant albuminuria or proteinuria and/or abnormal kidney function
- Endocrinology:
  - Confirmed or suspected phaeochromocytoma
  - Confirmed or suspected Cushing’s Syndrome
  - Confirmed or suspected Primary Hyperaldosteronism with potassium <3mmol/L

Category 2

Appointment within 90 days is desirable

Refractory hypertension (>140/90mmHg but below 180/110mmHg) in patients receiving 3 or more antihypertensive agents
Subspeciality referral for the following:
- Cardiology:
  - Uncontrolled hypertension in the context of a history of symptomatic ischaemic heart disease or previous coronary revascularisation
  - Uncontrolled hypertension in the context of known cardiomyopathy (or heart failure)
- Kidney Medicine:
  - Suspected or confirmed renal artery stenosis
  - Hypertension if associated with CKD Stage 4 or 5
- Endocrinology:
  - Primary hyperaldosteronism (Conn’s syndrome) with potassium ≥3 mmol/L
  - Patients suspected of having any other secondary endocrine cause for hypertension

Category 3

Appointment within 365 days is desirable

Patients with hypertension not reaching target BP levels despite 2 antihypertensive agents
Subspeciality referral for the following:
- Cardiology:
  - Nil noted
- Kidney Medicine:
  - If associated with stable CKD
  - Hypertension without clear diagnosis, especially in young patients
- Endocrinology:

If your patient does not meet the minimum referral criteria

Consider other treatment pathways or an alternative diagnosis.

If you still need to refer your patient:

Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
Please note that your referral may not be accepted or may be redirected to another service

Other important information for referring practitioners

Not an exhaustive list

Refer to HealthPathways for assessment and management information if available
The Heart Foundation Hypertension Guidelinesprovide some additional guidance for patient management.
Nomenclature has also been redefined by KDIGOand may be worth reassessing
KHA Fact Sheet – Blood pressure and chronic kidney disease
Hypertension may impact on a patient’s medical fitness to drive. The Queensland Government’s Transport and Motoring website and Austroads – Assessing Fitness to Drive website has advice about managing driving

Referral requirements

A referral may be rejected without the following information.

Essential referral information

Medical History & Clinical Background:
- Detailed medical history emphasising any cardiac, renal, or endocrine concerns.
- History of blood pressure (BP) measurements (preferred both arms), including 24-hour or home measurements if available.
- Current medication list, including over-the-counter (OTC) medications, and detailing all treatments tried, including efficacy.
Cardiac Investigations:
- Electrocardiogram (ECG).
- Echocardiogram*
- Fasting lipid profile.
Renal Investigations:
- Renin and aldosterone levels.
- Estimated Glomerular Filtration Rate (eGFR).
- Urinalysis results.
- Urine midstream M/C/S (microscopy/culture/sensitivity) for infection, morphology, and casts.
- urine albumin:creatinine ratio
- Renal artery assessment via renal duplex report (if stenosis is suspected).
Endocrine Investigations:
- 1mg dexamethasone suppression test and/or 24-hour urinary free cortisol levels.
- Plasma free metanephrine and normetanephrine levels.
Imaging & Other Diagnostic Tests:
- Chest X-ray report.
Laboratory Investigations:
- Full Blood Count (FBC).
- Electrolytes, Liver Function Tests (LFTs).

Note: *Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

Additional referral information

History of smoking, alcohol intake and drug use (including recreational drugs)
Ethnicity, highlighting Aboriginal and Torres Strait Islander populations as especially at risk
Records and results of investigations pertinent to co-morbidities or tests excluding other secondary causes (e.g., sleep studies).

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

Clinical Modifiers (where relevant)

Impact on employment
Impact on education
Impact on home
Impact on activities of daily living
Impact on ability to care for others
Impact on personal frailty or safety
Identifies as Aboriginal and/or Torres Strait Islander

Reason for Referral (essential)

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can’t order, or the patient can’t afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

Clinical Information (essential)

Presenting symptoms (evolution and duration)
Physical findings
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
Body mass index (BMI)
Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use