NICE guideline [NG136] Hypertension in adults: diagnosis and management. Published: 28 Aug 2019, Last updated: 21 Nov 2023 This article only covers the scope of primary / essential / idiopathic hypertension in adults (≥18 y/o)
NICE defines hypertension as:
Primary hypertension (essential hypertension): persistently raised BP without an identifiable underlying cause.
Secondary hypertension: persistently raised BP in the presence of an identifiable underlying cause.
Accelerated / malignant hypertension: BP ≥180/120 mmHg + signs of retinal haemorrhage and/or papilloedema.The staging of hypertension is important in guiding management and stratifying severity.
Hypertension stage | Clinical reading cut-off | Ambulatory blood pressure monitoring / Home blood pressure monitoring cut-off |
---|---|---|
Stage 1 | ≥140/90 mmHg | ≥135/85 mmHg |
Stage 2 | ≥160/100 mmHg | ≥150/95 mmHg |
Stage 3 | ≥180/120 mmHg | N/A |
Typically asymptomatic, and diagnosed on incidental findings.
Possible clinical features in severe hypertension or even malignant hypertension:
It is important to screen for these features suggestive of severe hypertension and target organ damage. Use a head-eye-heart-kidney approach (from top to bottom) to help remember what to ask.
Always measure BP in both arms:
If clinic BP ≥140/90 mmHg:
Diagnosis of hypertension is confirmed if:
Gold standard diagnosis of primary hypertension involves using the average BP from ABPM / HBPM.
Although NICE recommends ABPM as 1st line to confirm hypertension, quite often HBPM is used as 1st line as ABPM is less practical.
Perform all the following:
Add 1 of the following to the current regimen (depends what the patient is already taking):
Combination of:
Before adding a 4th drug:
For confirmed resistant hypertension → seek specialist advice / add a 4th drug (choice depends on blood potassium level)
Always seek specialist advice if BP not controlled with 4 drugs.
Abbreviation | Full form | Drug Examples |
---|---|---|
ACE-I | Angiotensin-converting enzyme inhibitor | Ramipril Enalapril Perindopril |
ARB | Angiotensin receptor (II) blocker | Losartan Valsartan |
CCB | Calcium channel blocker (dihydropyridine) | Amlodipine Nifedipine |
Thiazide-like diuretic | N/A | Indapamide |
Hypertension patients without T1DM / CKD:
Age | Clinic BP target (mmHg) | ABPM / HBPM target (mmHg) |
---|---|---|
<80 y/o | <140/90 | <135/85 |
≥80 y/o | <150/90 | <145/85 |
T1DM and CKD patients:
In <80 y/o, essentially BP target is the same as hypertension patients without T1DM / CKD. Unless ACR ≥70 mg/mmol, then target is <130/80 mmHg as there are renal impairment.
The reason why BP targets are higher (or more relaxed) in older individuals is primarily due to the risk of postural hypotension and the risk of falls. The risk of fakk outweighs the benefit of optimal BP control in older patients. Importantly, take individual patient factors into account and use clinical judgment.