Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Medicine for High Blood Pressure article more useful, or one of our other health articles.
Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
See the separate Hypertension and Hypertension in Pregnancy articles. This article is based primarily on current guidelines in the UK from the National Institute for Health and Care Excellence (NICE), namely the Clinical Guideline, the Hypertension Pathway and the Quality Standard for hypertension in adults.[1, 2, 3]
Hypertension in the context of multimorbidity
Multimorbidity is increasingly the norm. One UK-based study found that two thirds of people with hypertension have a comorbidity. Those with multimorbidity tend to be excluded from trials, making it difficult to determine optimum management. Management needs to be tailored to the individual, and NICE has developed guidelines to aid in the assessment and management of those with multimorbidity.
- Type 1 diabetes: lifestyle review is particularly important in people with type 1 diabetes. An ACE inhibitor or ARB is the recommended first-line option. Selective beta‑adrenergic blockers may be considered. Low-dose thiazides may be combined with beta‑blockers. If calcium-channel blockers (CCBs) are considered, long-acting preparations are recommended.
- Atrial fibrillation: if rate control is needed, add a beta-blocker (but not sotalol) or a rate-limiting CCB such as diltiazem. If on amlodipine, change to a rate-limiting CCB such as diltiazem.
- Chronic kidney disease: treatment depends on whether there is diabetes or not and on the albumin:creatinine ratio (ACR).
Benefits of hypertension treatment
Research continues to demonstrate the significant benefits of lowering high blood pressure. A 2018 systematic review and meta-analysis showed primary preventative BP lowering is associated with reduced risk for death and cardiovascular disease if baseline systolic BP is 140 mm Hg or higher. At lower BP levels, treatment is not associated with any benefit in primary prevention but might offer additional protection in patients with coronary heart disease.
Self-monitoring may result in better BP control.
Identifying who to refer for same-day specialist review
- If a person has severe hypertension (clinic blood pressure of 180/120 mm Hg or higher), but no symptoms or signs indicating same-day referral, carry out investigations for target organ damage 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 seven days.
- Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mm Hg 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 - eg, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis (excessive, abnormal sweating).
- Discuss lifestyle measures in patients undergoing assessment for, or treatment of, hypertension. Inform about any local initiatives, and supplement advice with leaflets or audiovisual information. Continue to offer lifestyle advice periodically.
- Ask about diet and exercise patterns (a healthy diet and regular exercise can reduce blood pressure). Offer advice to promote lifestyle changes.
- Ask about alcohol consumption and encourage a reduced intake if they drink excessively (this can reduce blood pressure and has broader health benefits).
- Discourage excessive consumption of coffee and other caffeine-rich products.
- Encourage people to keep dietary sodium intake low as this can reduce blood pressure. 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.
- 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 also the separate articles on Healthy Diet Advice and Enjoyable Eating, Smoking Cessation, Alcoholism and Alcohol Misuse - Recognition and Assessment, Obesity in Adults and Physical Training.
- Stage 1 hypertension - clinic BP 140/90 mm Hg to 159/99 mm Hg and subsequent ABPM daytime average or HBPM average blood pressure 135/85 mm Hg to 149/94 mm Hg..
- Stage 2 hypertension - clinic BP 160/100 mm Hg or higher but less than 180/120 mm Hg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mm Hg or higher.
- Stage 3 or severe hypertension - clinic systolic BP of 180 mm Hg or higher or clinic diastolic BP of 120 mm Hg or higher..
- Accelerated (or malignant) hypertension - severe increase in BP to 180/120 mm Hg or higher (and often over 220/120 mm Hg) with signs of retinal haemorrhage and/or papilloedema. It is usually associated with new or progressive target organ damage.
Use clinical judgement for people of any age with frailty or multimorbidity.
- Offer antihypertensive drug treatment in addition to lifestyle advice for persistent stage 2 hypertension.
- Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, if aged under 80 with persistent stage 1 hypertension who have one or more of the following:
- Target organ damage.
- Established cardiovascular disease.
- Renal disease.
- An estimated 10-year risk of cardiovascular disease of 10% or more.
- 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%. 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 stage 1 hypertension if their clinic blood pressure is over 150/90 mm Hg.
- If 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
See also the separate articles on chronic kidney disease, type 1 diabetes and hypertension in pregnancy.
- 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). Corresponding measurements for ABPM and HBPM are 5 mm;Hg lower than for clinic measurements.
- 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 mm Hg lower than for clinic measurements.
- For adults with hypertension aged under 80, reduce clinic blood pressure to below 140/90 mm Hg and ensure that it is maintained below that level.
- For adults with hypertension aged 80 and over, reduce clinic blood pressure to below 150/90 mm Hg and ensure that it is maintained below that level.
- 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 blood pressure and ensure that it is maintained:
- Below 135/85 mm Hg for adults aged under 80.
- Below 145/85 mm Hg for adults aged 80 and over. Use clinical judgement for people with frailty or multimorbidity.
- Use the same blood pressure targets for people with and without cardiovascular disease.
- 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.
Treatment review when type 2 diabetes is diagnosed
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
- ACE inhibitors and angiotensin II receptor antagonists should not be used in pregnant or breastfeeding women or women planning pregnancy unless absolutely necessary, in which case the potential risks and benefits should be discussed.
- Offer people with isolated systolic hypertension (systolic blood pressure 160 mm Hg or more) the same treatment as people with both raised systolic and diastolic blood pressure.
- 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.
Step 1 treatment
- Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:
- Have type 2 diabetes and are of any age or family origin or are aged under 55 but not of Black African or African-Caribbean family origin.
- If an ACE inhibitor is not tolerated, offer an ARB. Do not combine an ACE inhibitor with an ARB.
- 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, offer a thiazide-like diuretic to treat hypertension.
- If evidence of heart failure, offer a thiazide-like diuretic.
- 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
- If hypertension is not controlled with step 1 treatment of an ACE inhibitor or ARB, offer the choice of one of the following drugs in addition to step 1 treatment: CCB or thiazide-like diuretic.
- If hypertension is not controlled with step 1 treatment of a CCB, offer the choice of one of the following drugs in addition to step 1 treatment: 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
If hypertension is not controlled in adults taking step 2 treatment, offer a combination of:
- An ACE inhibitor or ARB; 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.
- For confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice.
- Consider further diuretic therapy with low-dose spironolactone 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 if 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 one 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 four drugs, seek specialist advice.
Further reading and references
Hypertension in pregnancy: diagnosis and management; NICE Guidance (June 2019)
Falaschetti E, Mindell J, Knott C, et al; Hypertension management in England: a serial cross-sectional study from 1994 to 2011. Lancet. 2014 May 31383(9932):1912-9. doi: 10.1016/S0140-6736(14)60688-7.
Hypertension in adults: diagnosis and management; NICE (August 2019 - last updated March 2022)
Hypertension overview; NICE Pathway, August 2011
Hypertension; NICE Quality Standards, March 2013 - last updated September 2015
Multimorbidity: clinical assessment and management; NICE Guidance (September 2016)
Brunstrom M, Carlberg B; Association of Blood Pressure Lowering With Mortality and Cardiovascular Disease Across Blood Pressure Levels: A Systematic Review and Meta-analysis. JAMA Intern Med. 2018 Jan 1178(1):28-36. doi: 10.1001/jamainternmed.2017.6015.
Zhu H, Zheng H, Liu X, et al; Clinical applications for out-of-office blood pressure monitoring. Ther Adv Chronic Dis. 2020 Jan 2011:2040622320901660. doi: 10.1177/2040622320901660. eCollection 2020.
Cardiovascular disease: risk assessment and reduction, including lipid modification; NICE Guidance (July 2014 - last updated 2016)
Williams B, Mancia G, Spiering W, et al; 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens. 2018 Oct36(10):1953-2041. doi: 10.1097/HJH.0000000000001940.