This guidance is based on NICE NG136

Definitions

• Stage 1 hypertension:  Clinic BP ranging from 140/90mmHg to 159/99mmHg and subsequent ABPM or HBPM average ranging from 135/85mmHg to 149/94mmHg
• Stage 2 hypertension: Clinic BP of 160/100mmHg or higher; but less than 180/120mmHg and subsequent ABPM or HBPM average of 150/95mmHg or higher
• Stage 3 or severe hypertension: Clinic systolic BP of 180mmHg or higher or clinic diastolic BP 120mmHg or higher
• ABPM: ambulatory BP monitoring
• HBPM: home BP monitoring

Diagnosis

• Measure BP in both arms. If difference in readings between arms is greater than 15mmHg, repeat the measurements. If difference is greater than 15mmHg on second measurement, measure subsequent BPs using arm with higher reading.
• If BP 140/90mmHg or higher take second measurement during the consultation. If this is substantially different from the first, take a third measurement. Record the lower of the last two measurements as the clinic BP.

Ensure that devices are properly validated, maintained and regularly recalibrated. A list of validated devices is available on the British and Irish Hypertension Society website.

Clinic BP 140/90mmHg to 179/119mmHg

Confirm diagnosis of hypertension using 24 hour ABPM or HBPM.

Carry out investigations for target organ damage and assess cardiovascular risk using a formal cardiovascular risk assessment tool.

Clinic BP 180/120mmHg or higher

Refer for same-day specialist assessment if there are:

• Signs of retinal haemorrhage and/or papilloedema (accelerated hypertension).
• Life-threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
• Suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis)

If there are no symptoms or signs indicating same-day specialist assessment, assess for target organ damage as soon as possible:

• If target organ damage identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
• If no target organ damage, repeat clinic BP measurement within 7 days or ensure a clinic review within 7 days if monitoring using ABPM/HBPM.

Specialist referral

Refer to clinical referral guidance: South Devon / West Devon

Reviewing patients without hypertension

If hypertension is not diagnosed, measure the person's clinic BP at least every 5 years subsequently, and consider measuring it more frequently if the person's clinic BP is close to 140/90 mmHg.

Type 1 and type 2 diabetes
Measure BP at least annually in an adult with type 1 or 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice

Assessing cardiovascular risk

Offer advice on healthy lifestyle changes to reduce cardiovascular risk

Clinic BP must be used to calculate cardiovascular risk.
Use the QRISK assessment tool to assess cardiovascular disease risk for the primary prevention of cardiovascular disease up to and including age 84 years.
Do not use the risk assessment tool for patients with established cardiovascular disease.

Other drugs that reduce cardiovascular risk must also be considered; this includes  lipid-lowering therapies (see Management of Lipids) and antiplatelet therapy for secondary prevention of cardiovascular disease. 
Routine use of aspirin 75mg for primary prevention is not recommended locally.

Encourage healthy lifestyle changes whether or not people choose to start antihypertensive drug treatment.

NICE has developed a patient decision aid on options for controlling BP.

Primary hypertension 

Use clinical judgement for people with frailty or multimorbidity

Stage 1 hypertension

Clinic BP 140/90 to 159/99mmHg and subsequent ABPM or HBPM average 135/85 to 149/94mmHg

Over 80 years of age with clinic BP over 150/90mmHg, consider starting antihypertensive drug treatment. 

Under 80 years discuss starting antihypertensive drug treatment with people who have one or more of the following:

• target organ damage
• established cardiovascular disease
• renal disease
• diabetes
• a 10-year risk of cardiovascular disease of 10% or more

Under 60 years of age with 10-year risk of cardiovascular disease below 10%, consider antihypertensive drug treatment. Encourage healthy lifestyle changes.

• Evidence of benefit from treatment for people with a low cardiovascular risk is uncertain. Bear in mind that 10-year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease.

Under 40 years of age, consider seeking specialist evaluation of secondary causes of hypertension and assessment of long-term benefits and risks of antihypertensive drug treatment.

Stage 2 hypertension

Clinic BP 160/100mmHg or higher but less than 180/120mmHg and subsequent ABPM or HBPM average of 150/95mmHg or higher

Offer antihypertensive drug treatment to adults of any age. Use clinical judgement for people with frailty or multimorbidity.

Under 40 years of age, consider seeking specialist evaluation of secondary causes of hypertension and assessment of long-term benefits and risks of antihypertensive drug treatment.

Isolated systolic hypertension

Offer people with isolated systolic hypertension (systolic BP 160mmHg or higher) the same treatment as people with both raised systolic and diastolic BP.

Target BP

All targets refer to clinic BP measurements

For people identified as having 'white-coat effect' hypertension, consider ABPM or HBPM in addition to clinic BP measurements. Aim for a target average BP taken during usual waking hours of:

• less 135/85mmHg for people aged under 80 years
• less 145/85mmHg for people aged 80 years and over

Use clinical judgement for people with frailty or multimorbidity.

Treat to a BP target based on standing BP for people with significant postural drop or symptoms of postural hypotension. 

Use the same BP targets for people with and without cardiovascular disease.

Table 1: Clinic blood pressure targets for people aged under 80

Use clinical judgement for adults with frailty or multimorbidity.

ACR = albumin to creatinine ratio

Table 2: Clinic blood pressure targets for people aged 80 and over 

Use clinical judgement for adults with frailty or multimorbidity.

ACR = albumin to creatinine ratio 

Target systolic BP ranges for patients with type 1 diabetes or with CKD are taken from NICE NG17 and NICE NG203 respectively.

Non-pharmacological lifestyle interventions should be offered initially and then periodically to people undergoing assessment or treatment for hypertension.

Non-pharmacological measures; weight reduction, reduced salt intake, reduced fat intake, limited alcohol consumption, aerobic exercise and increased fruit and vegetable consumption are effective in lowering blood pressure (level 1 evidence).

Weight reduction

Recommendation: Maintain BMI 20-25

Expected SBP reduction: 5-10mmHg per 10kg weight loss

DASH eating plan (link)

• Recommendation: Diet rich in fruit, vegetables, low-fat dairy produce
• Expected SBP reduction: 8-14mmHg

Dietary sodium restriction

• Recommendation: less than 6g salt per day (= 2.4g sodium or 100mmol)
• Expected SBP reduction: 2-8mmHg

Physical activity

• Recommendation: At least 30 minutes most days
• Expected SBP reduction: 4-9mmHg

Alcohol moderation

• Expected SBP reduction: Men and women 14 units per week or less
• Recommendation: 2-4mmHg

Alone or in combination these interventions can reduce the need for drug therapy and enhance the effect of antihypertensive agents. A favourable effect on cardiovascular outcome is assumed, but not proven.

To reduce overall cardiovascular risk, patients should stop smoking, reduce total fat and saturated fat intake and increase consumption of monounsaturated fats and oily fish.

Device-guided breathing (Resperate)
Results from randomised trials involving Resperate are contradictory, although it would appear there may be a small reduction in BP when the device is used over an 8 week period. The long-term effectiveness of Resperate is not known.

The British Hypertension Society (BHS) advises that there is currently insufficient evidence to recommend the use of Resperate devices.

In the absence of long-term efficacy data involving patient-centred outcomes Resperate devices should not be prescribed on NHS prescriptions. Patients wishing to use Resperate may purchase the device privately.

Annual review
Check BP, discuss lifestyle, symptoms and medication. Encourage adherence to treatment.

Women of child-bearing potential
For women considering pregnancy or who are pregnant or breastfeeding, manage hypertension in line with the guidance on the Management of hypertension in pregnancy.

Patients with cardiovascular disease
For people with hypertension and cardiovascular disease, follow treatment recommendations specific to their condition (e.g. heart failure, secondary prevention of myocardial infarction) first. If their BP remains uncontrolled, offer antihypertensive drug treatment in line with the recommendations in this section.

Type 2 diabetes
Follow recommendations below. For patients with type 2 diabetes and CKD, refer to the guidance for CKD below.

If the patient is receiving antihypertensive drug treatment when type 2 diabetes is diagnosed, review BP control and medications used. Make changes only if there is poor control or if current drug treatment is not appropriate because of microvascular complications or metabolic problems.

Pharmacological Interventions

The NICE NG136 visual summary has a flow chart of steps 1-4. First-line formulary options and cross-references to formulary drug entries and additional notes are provided below.

NICE patient decision aid on options for controlling BP

Step 1

Patients with type 2 diabetes of any age or family origin:

• ACE inhibitor: ramipril or lisinopril (see note 2 below) (section 2.5.5), or
• Angiotensin II receptor blocker (ARB): candesartan or losartan (section 2.5.5)

Patients without type 2 diabetes:

• Aged under 55 years and not of Black African or African-Caribbean family origin:
  • ACE inhibitor: ramipril or lisinopril, or
  • ARB: candesartan or losartan 

Aged 55 years or over, or are of Black African or African-Caribbean family origin of any age:

• Calcium channel blocker: amlodipine (see notes 4 and 5 below) (section 2.6.2) 

Notes

1. If an ACE inhibitor is not tolerated, offer an ARB.
2. For people of black African or African Caribbean family origin, ACE inhibitors are associated with an increased risk of developing angioedema which can be life threatening. Although the incidence of this adverse effect is low, consider an ARB in preference to an ACE inhibitor
3. Do not combine an ACE inhibitor with an ARB to treat hypertension.
4. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure, offer a thiazide-like diuretic (indapamide) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. If there is evidence of heart failure, follow guidance for chronic heart failure (NICE NG106).
5. Those who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose BP is stable and well controlled, should continue with their current treatment.

Step 2

If blood pressure is not controlled on Step 1 treatment, discuss adherence, add a second drug:

Step 1 treatment ACE inhibitor or ARB, add:

• calcium channel blocker (amlodipine) (section 2.6.2) or
• thiazide-like diuretic (indapamide) (section 2.2.1)

Step 1 treatment calcium channel blocker, add:

• ACE inhibitor (ramipril or lisinopril) (see note 1 below) or
• ARB (candesartan or losartan) or
• thiazide-like diuretic (indapamide)

Notes

1. For people of black African or African Caribbean family origin, ACE inhibitors are associated with an increased risk of developing angioedema which can be life threatening. Although the incidence of this adverse effect is low, consider an ARB in preference to an ACE inhibitor.
2. Do not combine an ACE inhibitor with an ARB to treat hypertension.

Step 3

Review medication to ensure step 2 treatment is at optimal or best tolerated doses and discuss adherence

If treatment with 3 drugs is required offer a combination of:

• ACE inhibitor (ramipril or lisinopril) or ARB (candesartan or losartan) (see note 1 below)
  plus
• Calcium channel blocker: amlodipine
  plus
• Thiazide-like diuretic: indapamide

Notes

1. For people of black African or African Caribbean family origin, ACE inhibitors are associated with an increased risk of developing angioedema which can be life threatening. Although the incidence of this adverse effect is low, consider an ARB in preference to an ACE inhibitor.
2. Do not combine an ACE inhibitor with an ARB to treat hypertension.

Step 4 (Resistant hypertension)

Clinic BP greater than 140/90mmHg despite optimal tolerated doses of drugs described in Step 3. Confirm elevated BP reading using ambulatory or home BP recordings, assess for postural hypotension and discuss adherence.

Seek specialist advice if the patient is receiving 3 drugs and there are complications. If there are no complications, add 4th drug:

• If serum potassium 4.5mmol/L or less, consider adding low-dose spironolactone (section 2.2.3), or
• If serum potassium above 4.5mmol/L, consider adding an alpha-blocker (doxazosin, section 2.5.4) or a beta-blocker (bisoprolol; section 2.4)

Notes

1. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia.
2. Monitor blood sodium and potassium, and renal function within 1 month of starting spironolactone and repeat as needed.
3. If BP remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek specialist advice if it has not yet been obtained.

Type 1 diabetes

Provide information to adults with type 1 diabetes on the potential for lifestyle changes to improve BP control and associated outcomes, and offer assistance in achieving their aims in this area.

• Offer an ACE inhibitor or ARB
• Add other antihypertensive drugs if necessary

If there is kidney damage (including microalbuminuria)

• Offer an ACE inhibitor or ARB
• Second-line treatment (or first-line in those who cannot tolerate ACE inhibitor or ARB) is a calcium channel blocker
• Renal specialist advice should be sought for further treatment if necessary.

Do not offer a combination of renin-angiotensin system antagonists to people with CKD.

When prescribing calcium channel blockers, only use long-acting preparations.

CKD and hypertension (see above for patients with type 1 diabetes)

ACR of 30mg/mmol or less (ACR categories A1 and A2):

• Follow treatment guidance for primary hypertension above
  • Take into account the need to prevent or ameliorate progression of CKD.

ACR over 30mg/mmol (ACR category A3 or above)

• Offer an ACE inhibitor or ARB
• Second-line treatment (or first-line in those who cannot tolerate ACE inhibitor or ARB) is a calcium channel blocker.
• Specialist advice should be sought for further treatment if necessary.

Do not offer a combination of renin-angiotensin system antagonists to people with CKD.