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Hypertension in adults: diagnosis and management (NICE guideline NG136) Published 28 Aug 2019 • Last updated 26 Feb 2026

Introduction – what has changed (NG136, last updated 26 Feb 2026)

  • New in 2026: if someone has raised BP but doesn’t meet diagnostic criteria, still give brief healthy-living advice (don’t just “recheck later” with no intervention).

  • Diagnosis remains “confirm outside clinic”: clinic ≥140/90 usually needs ABPM (or HBPM) before you label hypertension.

  • Severe readings pathway stays clear: clinic ≥180/120 triggers rapid assessment for target-organ damage and same-day referral if specific red flags are present (e.g., retinal signs, life-threatening symptoms).

  • Stage 1 treatment = risk-based, shared decision: for under-80s with persistent stage 1, meds are mainly driven by risk/organ damage comorbidity, with explicit room for patient preference (including deferring meds).

  • Postural hypotension got extra attention (2023): more structured guidance on how to measure and what to do when there’s a postural drop—especially relevant in older/frail patients.

  • Targets were tightened/clarified (2022 updates): clinic targets remain <140/90 (<80) and <150/90 (≥80), with lower ABPM/HBPM equivalents; extra tables were added to align targets with CKD/type 1 diabetes guidance.


  • 🗣️ What is NICE emphasising here?

    • Don’t miss the “quiet majority” with raised BP: even before a formal diagnosis, start behaviour change early.

    • Keep hypertension work safe and reproducible: confirm properly, spot the true emergencies, and treat long-term risk with targets that are easy to apply in routine reviews.


Area What’s different / clearer now Practical GP implication
New (2026) Even if you don’t diagnose hypertension, people with ↑BP should still get healthy-living advice (not just “come back later”). Use every “borderline BP” contact to start prevention: weight, salt, alcohol, activity, smoking, sleep.
Diagnosis Clinic BP ≥140/90 generally needs ABPM (or HBPM) before labelling HTN. Don’t diagnose on one clinic reading (except severe/complicated cases).
Severe BP pathway ≥180/120 → assess quickly for target-organ damage; same-day specialist assessment if specific red flags. Treat as a safety issue first; don’t wait weeks for routine confirmation.
Stage 1 treatment More explicit “discuss and decide” approach using risk/organ damage + patient preference (incl. option of no meds). Stage 1 ≠ automatic tablets, but risk/organ damage should trigger a proper meds discussion.
Younger adults Under-60s with stage 1 and ↓10-yr risk: consider treatment (lifetime risk may be underestimated). Under-40s: consider secondary causes/specialist evaluation. Be more proactive in younger people with persistent stage 1 (especially strong FHx).
Resistant HTN Clearer step-4 approach: confirm true resistance + check postural BP + address adherence; spironolactone if K ≤4.5, otherwise alpha/beta-blocker options. Don’t escalate blindly—confirm with ABPM/HBPM and sort contributors (NSAIDs, alcohol, missed doses).


Stepwise GP management table


Step Trigger / thresholds What to do (GP actions) Next decision / outcome
1. Case finding + clinic BP Clinic <140/90 • No HTN diagnosis
• Recheck at least q5 years (earlier if “high-normal”)
• 2026: if ↑BP but not diagnostic → still give healthy-living advice 		Routine follow-up + prevention focus
Clinic 140/90–179/119 • Repeat within consultation (record lower of last readings)
• Arrange ABPM (preferred) or HBPM
• Start target-organ damage screen + calculate CVD risk 		Move to Steps 2–4 in parallel
Clinic ≥180/120 • Urgent check for target-organ damage
• 🚩 Same-day specialist assessment if: retinal haemorrhage/papilloedema or life-threatening symptoms or suspected phaeochromocytoma 		If no red flags: fast work-up + review within 7 days (consider early treatment depending on findings)
2. Confirm diagnosis (ABPM/HBPM) Clinic 140/90–179/119 (or severe without red flags as part of rapid review) • ABPM: daytime average from adequate readings
• HBPM: 2 readings AM + 2 PM for 4–7 days, discard day 1, average the rest 		Diagnosis confirmed if clinic ≥140/90 and ABPM/HBPM ≥135/85
3. Stage the hypertension Based on clinic + out-of-clinic average • Stage 1: clinic 140/90–159/99 + ABPM/HBPM 135/85–149/94
• Stage 2: clinic ≥160/100 (but <180/120) + ABPM/HBPM ≥150/95
• Severe: clinic ≥180 systolic or ≥120 diastolic 		Use stage to guide intensity + urgency
4. Decide who to treat Stage 2 (persistent) • Lifestyle advice + start meds (unless strong reason not to)
• Use judgement in frailty/multimorbidity 		Start Step-1 drug choice + monitoring plan
Stage 1 (persistent), age <80 • Lifestyle advice for all
• Discuss meds if any: target-organ damage, established CVD, renal disease, diabetes, or 10-yr CVD risk ≥10% 		Shared decision (benefits/harms + preference)
Stage 1, age <60 and ↓10-yr risk (<10%) • Consider meds (lifetime risk may be underestimated) Individualise (age, FHx, BP trend, preference)
Stage 1, age ≥80 • Consider meds if clinic BP persistently >150/90 Individualise targets + tolerability
Any HTN, age <40 • Consider specialist evaluation for secondary causes + lifetime risk discussion Don’t delay control if clearly high, but ask “why so young?”
5. Baseline assessment Anyone with suspected/confirmed HTN (esp. before meds) • Target-organ damage: urine ACR + dip, HbA1c, U&Es/eGFR, lipids, fundoscopy if indicated, ECG
• Formal CVD risk calculation
• Review contributors (e.g., NSAIDs, alcohol) 		Risk-stratify + tailor intensity; document shared decision
6. Start drugs (Step 1 therapy) When meds indicated • ACEi/ARB if: type 2 diabetes (any age/ethnicity) or age <55 and not Black African/Caribbean family origin
• CCB if: age ≥55 (no T2DM) or Black African/Caribbean family origin (no T2DM)
• ACEi cough → switch to ARB 		Move to Step 2 if above target on optimal tolerated dose
7. Step up (Steps 2–4) Above target despite treatment • Step 2: add 1 agent (ACEi/ARB + CCB or thiazide-like; or CCB + ACEi/ARB/thiazide-like)
• Step 3: triple therapy (ACEi/ARB + CCB + thiazide-like)
• Resistant (Step 4): confirm with ABPM/HBPM + check postural BP + address adherence 		Step 4 add-on:
• If K ≤4.5 → low-dose spironolactone + monitor U&Es
• If K >4.5 → alpha- or beta-blocker
• If still uncontrolled on 4 drugs → specialist advice
8. Monitor + targets + follow-up Ongoing care • Routine clinic monitoring; offer HBPM for self-monitoring
• Postural BP in ≥80s, T2DM, or postural symptoms; if drop, base target on standing BP 		Targets:
• Age <80: clinic <140/90, ABPM/HBPM <135/85
• Age ≥80: clinic <150/90, ABPM/HBPM <145/85
• Review at least annually: BP, adherence, side-effects, lifestyle, CVD risk


  • This is a quick, clinic-facing overview of NICE NG136 for day-to-day primary care. It focuses on the decisions that most often matter in consultations: confirming the diagnosis, spotting severe hypertension, who to treat, how to start/step-up meds, and what targets to aim for.

    Key clinician “anchor points” (remember these)


      • Confirm before you label: clinic 140/90–179/119 → confirm with ABPM (preferred) or HBPM before diagnosing hypertension.

      • Severe BP is a safety pathway: clinic ≥180/120 → assess for target-organ damage; urgent/same-day referral if damage is present or strongly suspected (don’t wait for ABPM/HBPM).

      • Stage 1 meds = risk-led (but don’t ignore younger patients): if <80 with stage 1 plus target-organ damage / CVD / CKD / diabetes / 10-yr CVD risk ≥10% → offer treatment; if ↓risk <10%, still consider meds, especially if younger and persistent.

      • Step-1 drug rule (A/C): <55 and not Black African/African-Caribbean → ACEi/ARB; ≥55 or Black African/African-Caribbean → CCB, then step up by adding ACEi/ARB or thiazide-like diuretic stepwise.

      • Targets + resistant HTN mantra: aim clinic <140/90 (<80) or <150/90 (≥80) (with lower ABPM/HBPM targets); individualise in frailty and use standing BP if postural drop. If “resistant” on ACEi/ARB + CCB + thiazide-like → confirm with ABPM/HBPM + check adherence, then add spironolactone if K ≤4.5 (or α/β-blocker if not suitable), and seek specialist advice if still uncontrolled.

      Read-with-care notes (details omitted for brevity in this quick guide)

      • ABPM validity: ensure ≥14 daytime (waking) readings to count as a valid diagnostic ABPM set.

      • Baseline testing: include dipstick haematuria as well as urine ACR.

      • Eyes: offer fundoscopy to all patients with confirmed hypertension (not only when you feel it’s “clinically indicated”).

      • First visit technique: measure both arms initially; if a persistent >15 mmHg difference exists, use the higher arm for ongoing readings.

      • Postural hypotension definition: a significant postural drop is ↓SBP ≥20 mmHg or ↓DBP ≥10 mmHg after standing for ≥1 minute (the diastolic threshold is easy to miss but clinically important).

      • Full severe hypertension referral criteria and detailed drug titration steps are covered in the accompanying detailed print charts.

      Conclusion

      Use NG136 as a reliable “workflow”: confirm out-of-office, treat severe readings as urgent, start meds when risk/organ damage justifies it, apply the A/C step-1 rule, and be systematic when BP looks resistant (confirm + adherence + contributors before escalating). This keeps decisions safe, consistent, and quick in real GP clinics.




Reference

https://www.nice.org.uk/guidance/ng136