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Hypertension in adults

Hypertension in adults-diagnosis and management. A summary of 2019 NICE guidance.

Measuring –Automated machines cannot measure accurately if a pulse irregularity exists e.g AF- use a manual method
 Postural hypotension is suspected

♦ measure BP supine or seated

♦ check again- interval atleast 1 minute with person standing

♦ a drop of 20 or more , when standing reflects a postural drop
- in such cases 

- review medication 
- measure subsequent bp with the person standing
- refer specialist care if the symptoms of postural hypotension
( e.g falls or postural

Equipment -validated , maintained and calibrated Both at home and clinic settings – standardise the environment and provide a relaxed , temperate setting person should be quiet , seated , arms outstretched and supported use the correct cuff size

Diagnosis-Hypertension diagnosis suspected-measure BP in both arms if the difference is > 15 mm hg- repeat difference persists > 15 on 2nd measurement , measure subsequent BP in the arm with the higher BP. BP equal to or > 140/90 -take a 2nd reading during the consultation 2nd reading -substantially different from 1st- take a 3rd reading

record the lower of the last 2 measurements as the clinic bp. offer ABPM if ABPM not suitable offer HBPM If BP > 180/120 or higher. Investigate while awaiting confirmation of a diagnosis.-for target organ damage CV risk assessment using a tool for e.g QRisk2

ABPM-ensure atleast 2 measurements / hr-during usual waking hours e.g between -800 and 2200 use average value of atleast 14 measurements to confirm a diagnosis

HBPM-for each BP recording , 2 consecutive measurements are taken , atleast 1 min apart and with the person seated and twice daily recording continues for atleast 4 days ideally 7

Discard 1st day readings- use the average value of the remaining to confirm a diagnosis

Diagnose hypertension-clinic bp of 140/90 or higher ABPM daytime average or HBPM average of 135 /85 or higher

Stage 1 is 
♦ clinic BP 140/90 to 159/99 mmHg
♦ subsequent HBPM from 135/85 to 149/94
 Stage 2
♦ clinic BP of 160/100 or higher but < 180/120 and subsequent
♦ ABPM daytime average or HBPM average BP of 150 /95 or higher
 Stage 3 or severe hypertension
♦ clinic systolic BP of 180 or higher or
♦ clinic diastolic BP of 120 or higher

target organ damage without hypertension-If hypertension is not diagnosed but tests indicated target organ damage – look for alternative causes and carry out further investigations ( NICE recommends visiting guidance on CKD and chronic heart failure )

Hypertension not diagnosed-measure BP atleast every 5 yrs more frequently if bp nearer to 140/90 annually in people with type 2 diabetes with no pre-existing hypertension or renal disease reinforce lifestyle measures advice

Referral-Refer specialist if secondary causes suspected- remember most patients have primary hypertension but 5-10 % may have an underlying potentially reversible cause

BP > 180/120-
Severe hypertension
 but no symptoms or signs indicating same-day referral check for end organ damage ASAP if target organ damage found- consider starting treatment without waiting for ABPM or HBPM result
 If no target organ damage- repeat clinic BP within 7 days. ♦ signs of retinal haemorrhage or 
papilloedema or
♦ life-threatening symptoms as new onset 
confusion , chest pain , signs of heart failure or 
acute kidney injury
 suspected phaeocromocytoma

- refer same day

Cardiovascular risk assessment-Formal CV risk estimation using
♦ clinic BP
♦ estimate CV risk in line with recommendations on identifying and assessing CV disease risk in NICE guideline on CV disease
 Discuss prognosis and healthcare options – both for raised BP and modifiable risk factors. protein in urine -ACR ratio and test for haematuria using a reagent strip HbA1C Us and Es with eGFR Total cholesterol and HDL cholesterol Examine fundi 12 lead ECG

Treatment-Offer to all people with suspected or diagnosed and continue to offer periodically Diet , exercise patterns Alcohol Coffee and caffeine rich products- discourage excessive consumption Low dietary sodium intake – reduce or substitute sodium salt Do not offer calcium , magnesium or potassium supplements for reducing BP Smoking Local initiatives.

Offer treatment to adults of any age with persistent stage 2 hypertension 
 Adults aged under 80 with persistent stage 1 hypertension + any 1 or more of the following

♦ target organ damage
♦ established CV disease
♦ renal disease
♦ diabetes
♦ estimated 10 yr CV disease risk of 10 % or more

Discuss individual CV risk preferences , risks, benefits & lifestyle incl no treatment
 People > 80 with a clinic BP of > 150/90
♦ consider treatment + lifestyle
 Adults < 60 with stage 1 hypertension and an estimated 10 yr risk below 10 %
♦ consider treatment
♦ take into account that 10 yr CV risk may underestimate the lifetime probability of developing CV disease
 Adults < 40 with hypertension
♦ consider referral
♦ may need further investigations for secondary causes and to
♦ discuss benefits and risks of long-term treatment

Target-Age < 80
♦ clinic BP < 140/90
♦ ABPM / HBPM < 135/85 Age > = 80 yrs
♦ clinic BP < 150/90
♦ ABPM / HBPM < 145/85 Frailty or multimorbidity- use clinical judgement

This is for people with or without type 2 diabetes CKD- see separate NICE guidance People with isolated systolic hypertension should be treated in same way as people with both raised systolic and diastolic BP An ARB is preferred over ACEi in adults of black African or African- Caribbean family origin

Confirm resistant hypertension – confirm elevated BP with ABPM or HBPM , check for postural hypotension and discuss adherence
 Consider seeking specialist advice or adding a : low dose spironolactone if K + level is < = 4.5 mmol/l alpha blocker or beta blocker if blood K + level is > 4.5 mmol/l

Seek expert advice if BP is uncontrolled on optimal 
tolerated doses of 4 drugs.


American Heart Association flowchart and guidance for healthcare professionals – 2017 Hypertension Clinical Practice Guideline 

AHA Hypertension Guideline Toolkit – a very useful plain language document from AHA. A must-read for all primary care clinicians

ASCVD Risk Estimator Plus!/calculate/estimate/

QRisk Calculator

British Heart Foundation– information for patients on hypertension

Home BP diary- choose and become familiar with one

British Hypertension Society

NHS Lothian

Hypertension Canada

NICE Guideline: Hypertension in adults: diagnosis and management August 2019

European Society of Cardiology Clinical Practice Hypertension Guidelines 2019



  1. Secondary Hypertension: Discovering the Underlying Cause Am Fam Physician. 2017 Oct 1; 96 (7) : 453-461
  2. NICE proposes a lower threshold for treating high blood pressure Hypertension in adults: diagnosis and management NICE Guideline 136 August 2019
  3. NICE updates hypertension guidelines by Felix David Trends in Urology and Men’s Health
  4. NICE Pathways- hypertension
  5. NICE guideline on hypertension
  6. Williams, B., Sudano, I., Beuschlein, F., & Lüscher, T. (2018-12). Secondary causes of hypertension. In ESC CardioMed. Oxford, UK: Oxford University Press. Retrieved 21 Apr. 2021, from


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