Executive summary
- Diagnosis: Clinic ≥140/90 mmHg requires confirmation (ABPM/HBPM ≥135/85). Severe ≥180/120 needs urgent same-day assessment if signs of retinal haemorrhage or organ damage.
- Targets: <80 years: <140/90 (clinic) / <135/85 (home). ≥80 years: <150/90 (clinic) / <145/85 (home).
- Core Steps: Follow the A/C/D logic strictly to maximise efficacy and minimise side effects.
- Step 4: Defined as resistant HTN on A+C+D; requires K+ check to decide between Spironolactone or Alpha/Beta-blocker.
Diagnosis & thresholds
- Stage 1: Clinic ≥140/90 mmHg + ABPM/HBPM ≥135/85 mmHg.
- Stage 2: Clinic ≥160/100 mmHg + ABPM/HBPM ≥150/95 mmHg.
- Severe: Clinic systolic ≥180 mmHg or diastolic ≥120 mmHg. Action: Assess urgently for target organ damage (papilloedema, chest pain, AKI). If present → same day referral. If absent → start meds immediately + check bloods/ACR + repeat BP in 7 days.
Stepwise management (The A/C/D Algorithm)
- Step 1: Initial Therapy
- Age <55 and Non-Black: ACE-inhibitor (e.g., Ramipril 1.25mg–10mg) or ARB (e.g., Losartan 50mg–100mg / Candesartan 8mg–32mg).
- Age ≥55 or Black/African-Caribbean (any age): CCB (e.g., Amlodipine 5mg–10mg). If CCB not tolerated/oedema: Thiazide-like diuretic (e.g., Indapamide 2.5mg).
- T2DM: Follow Step 1 "A" logic (ACEi/ARB) regardless of age, but usually "C" if Black African-Caribbean.
- Step 2: Combination
- A + C (ACEi + CCB) or A + D (ACEi + Diuretic).
- Preference: A+C is often preferred for tolerability; A+D if evidence of fluid overload or CCB intolerance.
- Step 3: Triple Therapy
- A + C + D (e.g., Ramipril + Amlodipine + Indapamide).
- Ensure doses are optimised (not just minimal) before declaring failure.
- Step 4: Resistant Hypertension
- Confirm adherence and elevated BP (ABPM).
- If Potassium ≤ 4.5 mmol/L: Add Spironolactone 25mg od. (Monitor U&Es at 2 weeks).
- If Potassium > 4.5 mmol/L: Add Alpha-blocker (e.g., Doxazosin) or Beta-blocker (e.g., Bisoprolol).
Frequently asked questions
When should I treat Stage 1 Hypertension?
Treat if age <80 AND one of: target organ damage, established CVD, renal disease, diabetes, or QRISK ≥10%.
How do I manage isolated systolic hypertension (ISH)?
Treat the same as standard hypertension (Step 1 usually CCB or Thiazide if >55). Target is systolic <140 (or <150 if >80y); diastolic <90 is less relevant but watch for excessive diastolic dropping (<60).
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.