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- If BP ≥140/90mmHg, take a second reading; if considerably different, take a third. Record the lower of the last two measurements as clinic BP.
- Take a supine or seated reading in patients with symptoms of postural hypotension, followed by a reading after ≥1 min standing.
- If clinic BP is ≥140/90mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm diagnosis.
- If patient is unable to tolerate ABPM, offer home blood pressure monitoring (HBPM).
- If severe hypertension, consider starting treatment immediately without waiting for results of ABPM or HBPM.
- Measure BP on both of patient’s arms, if difference is >20mmHg repeat the measurement and if it remains >20mmHg use the arm with the higher reading for future measurements.
- While waiting for ABPM or HBPM results, test for proteinuria. Measure plasma glucose, electrolytes, creatinine, eGFR, serum total cholesterol and HDL-cholesterol. Arrange a 12-lead ECG. Assess for hypertensive retinopathy.
- Estimate 10-year cardiovascular disease (CVD) risk in accordance with the Joint British Societies assessment scheme.
- If hypertension is not diagnosed, assess in 5 years or consider more frequently if clinic BP is close to 140/90mmHg.
ABPM
- Take ≥2 measurements per hour during patient’s usual waking hours.
- Use average value of ≥14 measurements to confirm diagnosis.
HBPM
- For each BP recording, take two measurements ≥1 min apart whilst patient is seated.
- Record BP twice daily, ideally in the morning and evening.
- Record BP for ≥4 days, ideally 7 days.
- Discard measurements on day 1 and use the average value of remaining measurements to confirm diagnosis.
Aims
- To reduce clinic BP to <140/90mmHg or average ABPM/HBPM to <135/85mmHg in patients <80 years.
- To reduce clinic BP to <150/90mmHg or average ABPM/HBPM to <145/85mmHg in patients ≥80 years.
Note: See Hypertension in Pregnancy (NICE CG 107) for advice on the management of hypertension in women of childbearing potential.
| Clinic BP (mmHg) | Average ABPM or HBPM (mmHg) | Recommended Action | |
|---|---|---|---|
| Stage 1 hypertension | ≥140/90 and ≥135/85 | Offer treatment to patients <80 years with ≥1 of the following: target organ damage, established CVD, renal disease, diabetes or a 10 year CVD risk ≥20%. | |
| Stage 2 hypertension | ≥160/100 and ≥150/95 | Offer treatment to patients of any age. | |
| Severe hypertension | systolic ≥180 or diastolic ≥110 | – | Consider immediate treatment. |
Lifestyle measures
- Offer lifestyle advice to all patients undergoing assessment or treatment for hypertension.
- Assess patients' diet and exercise patterns and encourage appropriate lifestyle changes.
- Advise patients to:
– Limit weekly alcohol intake.
– Avoid excessive consumption of coffee and other caffeine-rich products.
– Limit dietary sodium intake by reducing intake or substituting sodium salt. - Offer smoking cessation help and advice.
- Encourage stress reduction.
Note: Calcium, magnesium or potassium supplements should not be offered as a method for reducing BP.
Treatment
- Offer patients ≥80 years the same treatment as younger patients taking account of any co-morbidity and patient’s existing burden of drug use.
- Offer patients with isolated systolic hypertension (systolic BP ≥160mmHg) the same treatment as patients with both raised systolic and diastolic BP.
- Provide patients with appropriate guidance and material about the benefits of drugs and the unwanted side effects that may occur in order to help patients make informed choices.
- Where possible, recommend treatment with drugs that can be taken once daily.
- Prescribe generic preparations where these are appropriate and minimise cost.
- Use clinic BP measurements to monitor response to treatment. Consider ABPM or HBPM as an adjunct in patients identified as having ‘white-coat effect’.
Refer to Treatment Algorithm at top of article
Note
- β-blockers are not a preferred initial therapy but are an alternative in patients <55 years with an intolerance or contraindication to ACE inhibitors (or angiotensin II receptor antagonists), women of childbearing potential, or if evidence of increased sympathetic drive.
- If therapy initiated with a β-blocker, add a calcium-channel blocker rather than a thiazide-like diuretic to reduce risk of diabetes.
- In patients well controlled with a regimen that includes a conventional thiazide diuretic, there is no absolute need to replace the conventional thiazide diuretic with an alternative agent.
- If calcium–channel blocker not suitable or not tolerated, offer thiazide-like diuretic.
- Angiotensin II receptor antagonist preferred to ACE inhibitor in black patients of African/Caribbean descent.
Follow-up
- Annual review – monitor BP, provide patients with support and discuss lifestyle, symptoms and medication.
Specialist referral
- Consider in patients with signs and symptoms suggesting secondary cause of hypertension. Accelerated (malignant) hypertension or suspected phaeochromocytoma require immediate referral.
- Consider in patients with symptoms of, or documented, postural hypotension (fall in systolic BP when standing of 20mmHg or more).
- Consider in patients with unusual signs or symptoms or in those whose management depends critically on the accurate measurement of their BP.
- Consider if <40 years and no evidence of target organ damage, CVD, renal disease or diabetes.
