Hypertension in adults: diagnosis and management

Measuring blood pressure

• Ensure that healthcare professionals taking blood pressure measurements have adequate initial training and periodic review of their performance
  
• Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery
• Healthcare providers must ensure that devices for measuring blood pressure are properly validated^[A], maintained and regularly recalibrated according to manufacturers’ instructions
• When measuring blood pressure in the clinic or in the home, standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. Use an appropriate cuff size for the person’s arm
• In people with symptoms of postural hypotension (falls or postural dizziness):
  • measure blood pressure with the person either supine or seated
  • measure blood pressure again with the person standing for at least 1 minute before measurement
• If the systolic blood pressure falls by 20 mmHg or more when the person is standing:
  • review medication
  • measure subsequent blood pressures with the person standing
  • consider referral to specialist care if symptoms of postural hypotension persist.
    

Diagnosing hypertension

• When considering a diagnosis of hypertension, measure blood pressure in both arms:
  • If the difference in readings between arms is more than 15 mmHg, repeat the measurements.
  • If the difference in readings between arms remains more than 15 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading
    
• If blood pressure measured in the clinic is 140/90 mmHg or higher:
  • Take a second measurement during the consultation.
  • If the second measurement is substantially different from the first, take a third measurement
    
    Record the lower of the last 2 measurements as the clinic blood pressure.
    
• If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. See section 1.5 of the full guideline for people with a clinic blood pressure 180/120 mmHg or higher
• If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension
• While waiting for confirmation of a diagnosis of hypertension, carry out:
  • investigations for target organ damage (see recommendation 1.3.3), followed by
  • formal assessment of cardiovascular risk using a cardiovascular risk assessment tool (see the section on full formal risk assessment in NICE’s guideline on cardiovascular disease)
    
• When using ABPM to confirm a diagnosis of hypertension, ensure that at least 2 measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension
  
• When using HBPM to confirm a diagnosis of hypertension, ensure that:
  • for each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute apart and with the person seated and
  • blood pressure is recorded twice daily, ideally in the morning and evening and
  • blood pressure recording continues for at least 4 days, ideally for 7 days
    
    Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension.
    
• Confirm diagnosis of hypertension in people with a:
  • clinic blood pressure of 140/90 mmHg or higher and
  • ABPM daytime average or HBPM average of 135/85 mmHg or higher
    
• If hypertension is not diagnosed but there is evidence of target organ damage, consider carrying out investigations for alternative causes of the target organ damage (for information on investigations, see NICE’s guidelines on chronic kidney disease in adults and chronic heart failure)
• If hypertension is not diagnosed, measure the person’s clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person’s clinic blood pressure is close to 140/90 mmHg
• Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice
  
• Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension.
  

Assessing cardiovascular risk and target organ damage

For guidance on the early identification and management of chronic kidney disease, see NICE’s guideline on chronic kidney disease in adults.

• Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension, both for raised blood pressure and other modifiable risk factors
  
• Estimate cardiovascular risk in line with the recommendations on identifying and assessing cardiovascular disease risk in NICE’s guideline on cardiovascular disease. Use clinic blood pressure measurements to calculate cardiovascular risk
• For all people with hypertension offer to:
  • test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip
  • take a blood sample to measure glycated haemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol
  • examine the fundi for the presence of hypertensive retinopathy
  • arrange for a 12-lead electrocardiograph to be performed.
    

Treating and monitoring hypertension

Lifestyle interventions

For guidance on the prevention of obesity and cardiovascular disease, see NICE’s guidelines on obesity prevention and cardiovascular disease prevention.

• Offer lifestyle advice to people with suspected or diagnosed hypertension, and continue to offer it periodically
• Ask about people’s diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes
• Ask about people’s alcohol consumption and encourage a reduced intake if they drink excessively, because this can reduce blood pressure and has broader health benefits. See the recommendations for practice in NICE’s guideline on alcohol-use disorders
  
• Discourage excessive consumption of coffee and other caffeine-rich products
  
• Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure^[B]
  
• Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure
• Offer advice and help to smokers to stop smoking. See NICE’s guideline on stop smoking interventions and services
  
• Inform people about local initiatives by, for example, healthcare teams or patient organisations that provide support and promote healthy lifestyle change, especially those that include group work for motivating lifestyle change.
  

Starting antihypertensive drug treatment

NICE has produced a patient decision aid on treatment options for hypertension to help people and their healthcare professionals discuss the different types of treatment and make a decision that is right for each person.

For advice on shared decision making for medicines, see the information on patient decision aids in NICE’s guideline on medicines optimisation.

To support adherence and ensure that people with hypertension make the most effective use of their medicines, see NICE’s guideline on medicines adherence.

• Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity (see also NICE’s guideline on multimorbidity)
  
• Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:
  • target organ damage
  • established cardiovascular disease
  • renal disease
  • diabetes
  • an estimated 10-year risk of cardiovascular disease of 10% or more
    
    Use clinical judgement for people with frailty or multimorbidity (see also NICE’s guideline on multimorbidity).
    
• Discuss with the person their individual cardiovascular disease risk and their preferences for treatment, including no treatment, and explain the risks and benefits before starting antihypertensive drug treatment. Continue to offer lifestyle advice and support them to make lifestyle changes (see the section on lifestyle interventions), whether or not they choose to start antihypertensive drug treatment
  
• 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%. Bear in mind that 10-year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease
  
• Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with a clinic blood pressure of over 150/90 mmHg. Use clinical judgement for people with frailty or multimorbidity (see also NICE’s guideline on multimorbidity)
  
• 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.
  

Monitoring treatment and blood pressure targets

For guidance on blood pressure control in people with chronic kidney disease (with or without type 2 diabetes), see NICE’s guideline on chronic kidney disease in adults.

• Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension
  
• Measure standing as well as seated blood pressure in people with hypertension and:
  • with type 2 diabetes or
  • with symptoms of postural hypotension or
  • aged 80 and over
    
    In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure.
    
• Advise people with hypertension who choose to self-monitor their blood pressure to use HBPM
  
• Consider ABPM or HBPM, in addition to clinic blood pressure measurements, for people with hypertension identified as having a white-coat effect or masked hypertension (in which clinic and non-clinic blood pressure results are conflicting). Be aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurements (see recommendation 1.2.8 of the full guideline for diagnostic thresholds)
  
• For people who choose to use HBPM, provide:
  • training and advice on using home blood pressure monitors
  • information about what to do if they are not achieving their target blood pressure.
    
    Be aware that the corresponding measurements for HBPM are 5 mmHg lower than for clinic measurements.
• Reduce clinic blood pressure to below 140/90 mmHg and maintain that level in adults with hypertension aged under 80
• Reduce clinic blood pressure to below 150/90 mmHg and maintain that level in adults with hypertension aged 80 and over. Use clinical judgement for people with frailty or multimorbidity (see also NICE’s guideline on multimorbidity)
• When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person’s usual waking hours. Reduce and maintain blood pressure at the following levels:
  
  • below 135/85 mmHg for adults aged under 80
  • below 145/85 mmHg for adults aged 80 and over
    
    Use clinical judgement for people with frailty or multimorbidity (see also NICE’s guideline on multimorbidity).
• Provide an annual review of care for adults with hypertension to monitor blood pressure, provide people with support, and discuss their lifestyle, symptoms and medication
  
• For an adult with type 2 diabetes on antihypertensive drug treatment when diabetes is diagnosed, review blood pressure 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.
  

Choosing antihypertensive drug treatment (for people with or without type 2 diabetes)

The recommendations in this section apply to people with hypertension with or without type 2 diabetes. They replace the recommendations on blood pressure management in NICE’s guideline on type 2 diabetes in adults.

• For guidance on choice of hypertensive agent in people with chronic kidney disease, see NICE’s guideline on chronic kidney disease in adults. If possible, offer treatment with drugs taken only once a day
  
• Prescribe non-proprietary drugs if these are appropriate and minimise cost
  
• Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure
  
• Offer antihypertensive drug treatment to women of childbearing potential with diagnosed hypertension in line with the recommendations in this guideline. For women considering pregnancy or who are pregnant or breastfeeding, manage hypertension in line with the recommendations on management of pregnancy with chronic hypertension and breastfeeding in NICE’s guideline on hypertension in pregnancy
  
• When choosing antihypertensive drug treatment for adults of black African or African–Caribbean family origin, consider an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor^[C].
  

Step 1 treatment

• Offer an ACE inhibitor or an ARB^[C] to adults starting step 1 antihypertensive treatment who:
  • have type 2 diabetes and are of any age or family origin (see also recommendation 1.4.29 for adults of black African or African–Caribbean family origin) or
  • are aged under 55 but not of black African or African–Caribbean family origin
• If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB^[C] to treat hypertension
• Do not combine an ACE inhibitor with an ARB to treat hypertension
  
• Offer a calcium-channel blocker (CCB) to adults starting step 1 antihypertensive treatment who:
  • are aged 55 or over and do not have type 2 diabetes or
  • are of black African or African–Caribbean family origin and do not have type 2 diabetes (of any age)
• If a CCB is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension
• If there is evidence of heart failure, offer a thiazide-like diuretic and follow NICE’s guideline on chronic heart failure
• If starting or changing diuretic treatment for hypertension, offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide
• For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment.
  

Step 2 treatment

• Before considering next step treatment for hypertension discuss with the person if they are taking their medicine as prescribed and support adherence in line with NICE’s guideline on medicines adherence
• If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step 1 treatment:
  • a CCB or
  • a thiazide-like diuretic
• If hypertension is not controlled in adults taking step 1 treatment of a CCB, offer the choice of 1 of the following drugs in addition to step 1 treatment:
  • an ACE inhibitor or
  • an ARB or
  • a thiazide-like diuretic
    
• If hypertension is not controlled in adults of black African or African–Caribbean family origin who do not have type 2 diabetes taking step 1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step 1 treatment.

Step 3 treatment

• Before considering next step treatment for hypertension:
  • review the person’s medications to ensure they are being taken at the optimal tolerated doses and
  • discuss adherence (see recommendation 1.4.38)
• If hypertension is not controlled in adults taking step 2 treatment, offer a combination of:
  • an ACE inhibitor or ARB (see also recommendation 1.4.30 for people of black African or African–Caribbean family origin) and
  • a CCB and
  • a thiazide-like diuretic.
    

Step 4 treatment

• If hypertension is not controlled in adults taking the optimal tolerated doses of an ACE inhibitor or an ARB plus a CCB and a thiazide-like diuretic, regard them as having resistant hypertension
  
• Before considering further treatment for a person with resistant hypertension:
  • Confirm elevated clinic blood pressure measurements using ambulatory or home blood pressure recordings.
  • Assess for postural hypotension.
  • Discuss adherence (see recommendation 1.4.38)
    
• For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice.^[C]
  
• Consider further diuretic therapy with low-dose spironolactone^[D] for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of 4.5 mmol/l or less. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia
  
• When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium and potassium and renal function within 1 month of starting treatment and repeat as needed thereafter
  
• Consider an alpha-blocker or beta-blocker for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4.5 mmol/l
  
• If blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4 drugs, seek specialist advice.
  

Identifying who to refer for same-day specialist review

• If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral (see recommendation 1.5.2), carry out investigations for target organ damage (see recommendation 1.3.3) as soon as possible:
  • If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
  • If no target organ damage is identified, repeat clinic blood pressure measurement within 7 days
    
• Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:
  • signs of retinal haemorrhage or papilloedema (accelerated hypertension) or
  • life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury
• Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis).
  

Footnotes

[A] A list of validated blood pressure monitoring devices is available on the British and Irish Hypertension Society’s website. The British and Irish Hypertension Society is an independent reviewer of published work. This does not imply any endorsement by NICE.

[B] Salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin-II receptor blockers. Encourage salt reduction in these groups.

[C] In 2007, the MHRA issued a drug safety update on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy that states ‘Use in women who are planning pregnancy should be avoided unless absolutely necessary, in which case the potential risks and benefits should be discussed’. There is also a 2009 MHRA safety update for ACE inhibitors and angiotensin II receptor antagonists: use during breastfeeding and related clarification: ACE inhibitors and angiotensin II receptor antagonists.

[D] At the time of consultation (March 2019), not all preparations of spironolactone have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.