Hypertension in Adults (NICE Guideline)

Summary of NICE guidance on high blood pressure.

Key

A = ACE inhibitor (or angiotensin II receptor antagonist for patients of African/Caribbean descent or if ACE inhibitor not tolerated)
C = Calcium-channel blocker
D = Thiazide-like diuretic eg, indapamide

 

 

Measurement

  • 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 between 140/90mmHg and 180/120mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm diagnosis.
  • If patient is unable to tolerate ABPM or ABPM is otherwise unsuitable, offer home blood pressure monitoring (HBPM).
  • Measure BP on both of patient’s arms; if difference is >15mmHg repeat the measurement and if it remains >15mmHg use the arm with the higher reading for future measurements.
  • While waiting for ABPM or HBPM results, test for proteinuria and haematuria. Measure plasma HbA1c, electrolytes, creatinine, eGFR, serum total cholesterol and HDL-cholesterol. Arrange a 12-lead ECG. Assess for hypertensive retinopathy.
  • If patient has clinic BP ≥180/20mmHg and target organ damage identified, consider starting treatment without waiting for ABPM or HBPM results; if no target organ damage, repeat clinic BP measurement in 7 days.
  • Estimate 10-year cardiovascular disease (CVD) risk in accordance with the NICE guideline on lipid modification.
  • 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 NG133) 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 ≥10%. 

Consider treatment for patients < 60 years with an estimated 10-year CVD risk < 10%.

Consider treatment for patients > 80 years with clinic BP > 150/90mmHg.

Stage 2 hypertension ≥160/100 and ≥150/95 Offer treatment to patients of any age.
Severe hypertension systolic ≥180 or diastolic ≥120 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:
    – Avoid excessive alcohol consumption.
    – 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

  • Take into account any frailty or multimorbidity when offering treatment.
  • Offer patients with isolated systolic hypertension (systolic BP ≥160mmHg) the same treatment as patients with both raised systolic and diastolic BP.
  • Where possible, recommend treatment with drugs that can be taken once daily.
  • Use clinic BP measurements to monitor response to treatment. Consider ABPM or HBPM as an adjunct in patients identified as having ‘white-coat effect’ or masked hypertension.
  • Measure standing as well as seated BP in patients with type II diabetes, postural hypotension or ≥80 years; in patients with postural hypotension, base BP target on standing BP. Advise people who choose to self-monitor their BP to use HBPM.
  • For patients on antihypertensive treatment who are diagnosed with diabetes, change regimen only if there is poor control or current treatment is not appropriate because of microvascular complications or metabolic problems.

Refer to Treatment Algorithm at top of article

Note

  • Discuss treatment adherence with patient before moving to next step of treatment.
  • If calcium–channel blocker not tolerated or there is evidence of heart failure, offer thiazide-like diuretic.
  • See NICE guidance on chronic kidney disease (CG182) for guidance on choice of antihypertensive in people with chronic kidney disease.

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. Patients with clinic BP ≥180/20mmHg and signs of retinal haemorrhage/papilloedema, or life-threatening symptoms, and patients with 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 if < 40 years.

Adapted from: NICE Clinical Guideline 136 (August 2019) - Hypertension in adults: diagnosis and management.


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