Appendix 1: Patient management pathway

Protocol for detection of Hypertension (HTN) and Atrial Fibrillation (AF) by community pharmacy

Step 1: Identify patients to offer HTN/AF check

  1. Inclusion criteria:
  2. Adults over 40 years old and
  3. Registered with a General Practice (GP) within the Bedford, Luton or Milton Keynes STP region and
  4. Without known cardiovascular disease including : High blood pressure (or are on treatment for high blood pressure), Atrial Fibrillation, Diabetes, Chronic Kidney Disease, Angina, Stroke, Transient ischaemic attack, Heart failure and Myocardial infarction.

Step 2: HTN/AF check in pharmacy (using WatchBP Home A device- Microlife)

  1. Measure blood pressure (BP) in both arms.
  2. If the difference in readings between arms is more than 20 mmHg, repeat the measurements.
  3. If the difference in readings between arms remains more than 20 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading.
  4. If the difference in readings between arms is more than 20 mmHg systolic or 10mmHg diastolic, refer to GP.
  1. If blood pressure measured in the clinic is 140/90 mmHg or higher:
  2. Take a second measurement during the consultation.
  3. If the second measurement is substantially different from the first, take a third measurement.
  4. Record the lower of the last two measurements as the clinic blood pressure.
  1. If asymptomatic AF is detected
  2. Do not offer home monitoring BP monitor as they can be inaccurate in the presence of AF. Refer to GP.

Step 3: Standard home blood pressure monitoring (HBPM) (using Omron M2 Basic)

  1. Give home monitoring device if in pharmacy blood pressure is ≥140/90mmHg and <180/110mmHg
  2. Patients to fill in patient monitoring journal. When using HBPM to confirm a diagnosis of hypertension, ensure that:
  3. For each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated and
  4. Blood pressure is recorded twice daily, ideally in the morning and evening and
  5. Blood pressure recording continues for at least 4 days, ideally for 7 days.
  6. Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension.

Step 4: Referral criteria and pathway

Scenario / Description / Referral Guide
1.Suspected Atrial Fibrillation / In pharmacy it will be picked up on the WatchBP Home A device (Microlife) / Refer to GP for an appointment within a week.
2.Significant difference in blood pressure reading between arms / In pharmacy a difference in readings between arms is more than 20 mmHg systolic or 10mmHg diastolic / Refer to GP for an appointment within a week.
3.Hypotensive and symptomatic / In pharmacy blood pressure <90/60mmHg and patient is having symptoms like feeling lightheaded or dizzy when standing / Refer to GP for an appointment within a week.
4.Stage one hypertension / In pharmacy blood pressure ≥140/90 mmHg, and subsequent HBPM average ≥135/85 mmHg. / Refer to GP for an appointment within 4 weeks.
5.Stage two hypertension / In pharmacy blood pressure ≥160/100 mmHg, and subsequent HBPM average is ≥150/95 mmHg. / Refer to GP for an appointment within 2 weeks.
6.Severe hypertension / In pharmacy systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥110 mmHg. / Refer same day to GP over the phone /111.
7.No referral (clinically not indicted) / Normotensive and AF not suspected / Lifestyle advice: British Heart Foundation 10 minutes to change your life leaflets/ NHS choices – live well.
Repeat BP in 5 years or earlier if close to 140/90 (if not hypertensive)
8.No referral (patient reasons) / Patient declined / Ensure patient is aware of reasons why a referral is advised and document reasons for refusal.
  1. Complete the pharmacy monitoring form within the pharmacy patient pack (this is kept in pharmacy). A summary of the outcome is also recorded in the patient monitoring journal for the patient to take home or with them to their GP appointment if referred.
  2. If referring, pharmacy will fax to the GP the template letter to GP and pharmacy monitoring journal (pages 4-6 of pharmacy patient pack).
  3. Patients will be advised to actively contact their GP to arrange an appointment for a review within the recommended timeframe.
  4. In addition, if accelerated hypertension is detected pharmacist will call the GP or 111 to arrange a same day review.

Patient management pathway

Bibliography

[1] / National Institute for Health and Care Excellence (NICE), "Hypertension in adults: diagnosis and management. Clinical guideline [CG127]," NICE, 09 2011. [Online]. Available: [Accessed 02 01 2018].
[2] / National Institute for Health and Care Excellence (NICE), "Atrial fibrillation: management. Clinical guideline [CG180]," NICE, 06 2014. [Online]. Available: [Accessed 02 01 2018].
[3] / National Institute for Health and Care Excellence (NICE) , "WatchBP Home A for opportunistically detecting atrial fibrillation during diagnosis and monitoring of hypertension. Medical technologies guidance [MTG13].," NICE, 01 2013. [Online]. Available: [Accessed 02 01 2018].
[4] / Halton CCG, "Service guide. Screening for hypertension and atrial fribrillation in community pharmacy," PSNC, [Online]. Available: [Accessed 02 01 2018].

1