Hypertension Treatment

Authored by , Reviewed by Dr Hayley Willacy | Last edited | Meets Patient’s editorial guidelines

This article is for Medical Professionals

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].

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.

Healthy diet

Advice from NICE includes:

  • Weight reduction should be suggested if necessary, to maintain an ideal body mass index (BMI) of 18.5-24.9 kg/m2[5]. Offer a diet sheet and/or dietetic appointment. Dietary self-help (eg, dieting clubs, for which there may be local referral options) may be appropriate. Encourage physical activity alongside dietary changes. NICE guidelines for obesity make further recommendations about pharmaceutical and surgical options where appropriate.
  • Use of wholegrain varieties of starchy food (eg, rice, pasta, bread) where possible.
  • Reduction of saturated fats, and increasing mono-unsaturated fats, using olive or rapeseed oils and spreads.
  • Reduction in sugar intake and that of foods containing refined sugars.
  • Eating at least five portions of fruit and vegetables per day.
  • Eating at least two portions of fish per week, including a portion of oily fish.
  • Eating at least 4-5 portions of unsalted nuts, seeds and legumes per week.
  • Reducing any excessive caffeine consumption.
  • Low dietary salt (see section below).
  • Keeping alcohol within current national recommended levels. (Currently no more than 14 units per week for men and women, spread through the week, with at least two days alcohol-free[6].)
  • Calcium, magnesium or potassium supplements are not recommended.

Stopping smoking

Patients should stop smoking (offer help ± nicotine replacement therapy). See the separate Smoking Cessation article.

Encouraging exercise

  • Make physical activities part of everyday life (eg, walk or cycle to work, use the stairs instead of the lift, walk at lunchtime) and build in enjoyable activities to leisure time every week (eg, walking, cycling, gardening, swimming, aerobics, etc).
  • Minimise sedentary activities (eg, limit television watching or sitting at a computer or playing video games).
  • Once more, look for local activities, join a sporting group, take advantage of taster sessions and get used to exercising regularly, ideally several times a week.

Salt[1, 7, 8]

  • Salt reduction to 4.4 g per day results in a reduction of ~4/2 mm Hg in blood pressure (BP).
  • Guidelines recommend that we should have no more than 5-6 grams of salt per day.
  • Patients should be advised not to add salt to food and to avoid processed foods.
  • Food labelling is making it easier to determine the salt content of food.
Diagnosing hypertension (see also the separate Hypertension article):
  • Stage 1 hypertension - BP in surgery/clinic is ≥140/90 mm Hg and ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) ranges from 135/85 mm Hg to 149/94 mm Hg.
  • Stage 2 hypertension - BP in surgery/clinic is ≥160/100 mm Hg but less than 180/120 mm Hg and ABPM or HBPM is ≥150/95 mm Hg.
  • Stage 3 or severe hypertension - systolic BP in surgery/clinic is 180 mm Hg or higher or diastolic BP is 120 mm Hg or higher.
  • Use clinic BP to monitor lifestyle changes or medication.
  • Measure standing as well as sitting BP in people with hypertension and:
    • Type 2 diabetes.
    • Symptoms of postural hypotension.
    • Who are aged 80 years or over.
  • Treatment targets should be based on standing blood pressure in people with significant postural drop or symptoms of postural hypotension.
  • People who choose to monitor their own blood pressure should be advised to use HBPM.
  • Consider ABPM or HBPM, as well as clinic blood pressure measurements, for people with hypertension who have a white-coat effect or masked hypertension (in which clinic and non-clinic blood pressure results are conflicting). Note that the 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.
    • Advice on what to do if they are not achieving their target blood pressure.
  • For people with hypertension aged under 80, reduce clinic BP to below 140/90 mm Hg and maintain that level.
  • Offer antihypertensive treatment along with lifestyle advice to people of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age who are frail or have multi-morbidity.
  • Discuss starting antihypertensive drug treatment, as well as lifestyle advice, with adults aged under 80 years with persistent stage 1 hypertension who have one 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.
  • Discuss with the person their individual cardiovascular risk and the risks and benefits of antihypertensive treatment. Those who decide not to take medication should be nevertheless encouraged to pursue appropriate lifestyle changes.
  • Offer antihypertensive treatment combined with lifestyle advice to people under 60 years with persistent stage 1 hypertension and a 10-year cardiovascular risk below 10%.
  • For people over 80 years with a clinic BP above 150/90 mm Hg, offer antihypertensive medication in addition to lifestyle advice, using clinical judgement to assess whether this is appropriate in cases of frailty or multi-morbidity.
  • Consider specialist referral in people under 40 years with hypertension, to rule out secondary causes and advise on the risks and benefits of long-term antihypertensive medication. 
Initial antihypertensive choices 
If the patient is young (≤55 years) and non-black, start with:
  • (A) angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB).
  • An ARB may be appropriate if ian ACE inhibitor is not tolerated (eg, due to cough).
  • Do not combine an ACE inhibitor with an ARB.
If the patient is aged >55 years 
  • (C) calcium-channel blocker (CCB).
  • (D) thiazide-like diuretic if CCB not suitable - eg, indapamide ((1.5 mg modified-release once daily or 2.5 mg once daily).

If the person is of black African or Caribbean family origin:

  • Offer a calcium channel blocker if the person does not have type 2 diabetes.
  • Consider an ARB rather than an ACE inhibitor unless the person has type 2 diabetes, in which case either can be offered.

For people with evidence of heart failure:

  • Offer a thiazide-like diuretic.
  • Use indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.
  • Continue with bendroflumethiazide or hydrochlorothiazide, for adults with hypertension who are already on such medication, and who have stable, well-controlled blood pressure.
Step 2 choices

  • Before moving on to step 2, check that the person is compliant with step 1.
  • ACE inhibitor or ARB with CCB or a thiazide-like diuretic.
  • If initially started on a CCB, add an ACE inhibitor, ARB or a thiazide-like diuretic.
  • Consider an ARB rather than an ACE inhibitor with a CCB in black people of African or Afro-Caribbean origin.
Step 3 choices

  • Before moving on to step 3, review whether the person is taking optimal tolerated doses and is compliant with treatment.
  • Use an ACE inhibitor or ARB and a CCB and a thiazide-like diuretic.
Step 4 choices
  • Consider people who have reached step 4 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.
  • Add a fourth antihypertensive drug or consider referral to a specialist.
  • Consider further diuretic therapy with low-dose spironolactone for adults 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 as they have an increased risk of hyperkalaemia. Monitor blood sodium, potassium and renal function within one month of starting treatment. Repeat as necessary.
  • 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 taking the optimal tolerated doses of four drugs, seek specialist advice.

Consider cholesterol-lowering treatment if CVD risk is ≥20%. See the separate Lipid-regulating Drugs (including Statins) article. Further ABPM/HBPM may be needed to avoid overtreatment due to 'white coat hypertension'.

Research continues to demonstrate the significant benefits of lowering high blood pressure. A 2018 systematic review and meta-analysis showed primary preventive 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[9].

Self-monitoring may result in better BP control[10].

Refer if hypertension is difficult to control in spite of optimal treatment. For other indications for specialist referral, see the separate Hypertension article.

Multimorbidity is increasingly the norm. One UK-based study found that two thirds of people with hypertension have a comorbidity[11]. 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[12].

  • 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 CCBs are considered, long-acting preparations are recommended[13].
  • 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). See Chronic Kidney Disease for more details.

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Further reading and references

  1. Hypertension in adults: diagnosis and management; NICE (August 2019)

  2. Hypertension overview; NICE Pathway, August 2011

  3. Hypertension; NICE Quality Standards, March 2013

  4. Cardiovascular disease: risk assessment and reduction, including lipid modification; NICE Guidance (July 2014 - last updated 2016)

  5. Obesity: identification assessment and management of overweight and obesity in children young people and adults; NICE Clinical Guideline (November 2014)

  6. Rosenberg G, Bauld L, Hooper L, et al; New national alcohol guidelines in the UK: public awareness, understanding and behavioural intentions. J Public Health (Oxf). 2018 Sep 140(3):549-556. doi: 10.1093/pubmed/fdx126.

  7. He FJ, Li J, Macgregor GA; Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ. 2013 Apr 3346:f1325. doi: 10.1136/bmj.f1325.

  8. Guidelines for the management of arterial hypertension; ESH/ESC Clinical Practice Guidelines, European Society of Cardiology (2013)

  9. 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.

  10. 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.

  11. Brilleman SL, Purdy S, Salisbury C, et al; Implications of comorbidity for primary care costs in the UK: a retrospective observational study. Br J Gen Pract. 2013 Apr63(609):e274-82. doi: 10.3399/bjgp13X665242.

  12. Multimorbidity: clinical assessment and management; NICE Guidance (September 2016)

  13. Type 1 diabetes in adults: diagnosis and management; NICE Guidelines (August 2015 - last updated July 2021)