Hypertension
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)
Background Information
NICE defines hypertension as:
- ≥140/90 mmHg persistent clinical reading, OR
- ≥135/85 mmHg on 24-hour blood pressure average reading
It is worth noting that the American College of Cardiology (ACC) / American Heart Association (AHA)(US) guidelines differ slightly from NICE (UK) and European Society of Cardiology (ESC) / European Society of Endocrinology (ESE) / European Stroke Organisation (ESO) (EU) which recommend a somewhat lower threshold of >130/80 mmHg.
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:
- Head:
- Headache
- Confusion
- Seizures
- Eye (hypertensive retinopathy):
- Visual disturbances
- Heart (heart failure):
- Chest pain
- Dyspnoea
- Kidney (hypertensive nephropathy)
- Proteinuria
- Nocturia
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.
Guidelines
Always measure BP in both arms:
- If difference >15 mmHg → repeat measurements
- If difference remains >15 mmHg → measure and record BP in the arm with the higher reading
If clinic BP ≥140/90 mmHg:
- Repeat the measurement → record the lower reading
The approach largely depends on the recorded clinic BP, and importantly referring patients as needed.
Immediately assess for:
Subsequent actions:
- Retinal haemorrhage or papilloedema (presence of any indicates malignant / accelerated hypertension)
- Life-threatening symptoms
- New-onset confusion
- Chest pain
- Signs of heart failure
- Signs of Acute kidney injury
Subsequent actions:
- If any of the above is present → refer for same-day specialist assessment
- If referral not indicated → urgent investigation for target organ damage
- Target organ damage present → consider starting drug treatment immediately without confirming diagnosis
- No target organ damage → repeat clinic BP within 7 days OR ABPM / HBPM
Perform the following: (see below for more details)
- Confirm hypertension diagnosis
- Assess for target organ damage
- Assess cardiovascular risk
1st line: ambulatory blood pressure monitoring (ABPM)
2nd line: home blood pressure monitoring (HBPM)
- ≥2 measurements/hour during person’s waking hours
- To confirm hypertension: use average of ≥14 measurements taken during person’s waking hours
2nd line: home blood pressure monitoring (HBPM)
- For each recording: take 2 consecutive measurements, ≥1 minute apart with the person seated
- Record BP twice daily (ideally morning and evening)
- Record BP for at least 4 days (ideally 7 days)
- To confirm hypertension: discard recording from day 1, use average of all the remaining measurements
Diagnosis of hypertension is confirmed if:
- Clinic BP ≥140/90 mmHg, AND
- ABPM / HBPM average ≥135/85 mmHg
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:
- Fundoscopy (to check for hypertensive retinopathy)
- 12-lead ECG
- Bloods: HbA1c, U&E, eGFR, total and HDL cholesterol
- Urine: Albumin:creatinine ratio and reagent strip to test for haematuria
NICE recommends QRISK3 tool to estimate 10-year risk of CVD in 25-84 y/o patients without cardiovascular diseases.
See the lipid modification therapy and CVD risk reduction article to see how to manage cardiovascular risk and how to manage patients with established cardiovascular diseases.
See the lipid modification therapy and CVD risk reduction article to see how to manage cardiovascular risk and how to manage patients with established cardiovascular diseases.
Check BP at least 5 years or more often.
All patients: lifestyle interventions
Start drug therapy in:
Additional points from NICE:
- Healthy diet
- ↓ Dietary sodium intake
- Avoid excessive consumption of caffeine
- Stop smoking
- ↓ Alcohol consumption
Start drug therapy in:
- (regardless of age)
- + <80 y/o + ANY of the following
- QRISK3 ≥10%
- Target organ damage
- Diabetes
- Renal disease
Additional points from NICE:
- Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%.
- Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with stage 1 hypertension if their clinic blood pressure is over 150/90 mmHg.
- For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks.
- If T2DM (regardless of anything) → ACE-I / ARB
- No T2DM
- >55 y/o → CCB
- Afro-Caribbean of any age → CCB
- <55 y/o and NOT Afro-Caribbean → ACE-I / ARB
Add 1 of the following to the current regimen (depends what the patient is already taking):
- ACE-I / ARB
- CCB
Combination of:
- ACE-I / ARB
- CCB
Before adding a 4th drug:
- Confirm with ABPM or HBPM
- Discuss adherence to medication
- Check for postural hypotension
For confirmed resistant hypertension → seek specialist advice / add a 4th drug (choice depends on blood potassium level)
- Potassium ≤4.5 mmol/L → spironolactone (low-dose)
- Potassium >4.5 mmol/L → alpha blocker / beta blocker
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 |
- Black African or African-Caribbean family origin: ARB preferred over ACE-I
- Patients with hypertension + CKD + ACR >30 mg/mmol → ACE-I / ARB as 1st line
- If ACR ≤30 mg/mmol → follow the above algorithm
- Pregnant patients → see separate article (ACE-I and ARB are teratogenic)
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:
- <80 y/o
- T1DM / CKD + ACR <70 mg/mmol target: <140/90 mmHg
- T1DM / CKD + ACR ≥70 mg/mmol target: <130/80 mmHg
- ≥80 y/o
- All T1DM (regardless of ACR): <150/90 mmHg
- CKD + ACR <70 mg/mmol target: <140/90 mmHg
- CKD + ACR ≥70 mg/mmol target: <130/80 mmHg
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.
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