Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Management of Hypertension in Adults
- Referral: Urgent referral for same-day specialist assessment is required if clinic blood pressure ≥180/120 mmHg with signs of accelerated hypertension or life-threatening symptoms such as confusion or chest pain NICE CKS.
- Investigations: For those not requiring urgent referral, carry out investigations to detect target organ damage and assess cardiovascular risk, including urine testing for protein, blood tests, ECG, and fundoscopy NICE CKS,NICE NG136.
- Lifestyle Advice: Offer and continue to offer lifestyle advice periodically, including promoting a healthy diet, regular exercise, weight loss for overweight individuals, reducing excessive caffeine and alcohol intake, lowering dietary sodium (with caution regarding potassium salt substitutes in specific groups), and smoking cessation support NICE CKS,NICE NG136.
- Blood Pressure Targets: Aim for clinic blood pressure <140/90 mmHg in adults <80 years, and <150/90 mmHg in those ≥80 years, using clinical judgment in frail or multimorbid patients NICE CKS,NICE NG136. When using ambulatory or home blood pressure monitoring, targets are 5 mmHg lower: <135/85 mmHg (<80 years) and <145/85 mmHg (≥80 years) NICE CKS,NICE NG136.
- Antihypertensive Treatment: Initiate antihypertensive drugs alongside lifestyle advice in adults with persistent stage 2 hypertension (clinic BP ≥160/100 mmHg but <180/120 mmHg) regardless of age NICE CKS,NICE NG136.
- Stage 1 Hypertension (clinic 140/90 to 159/99 mmHg): Discuss drug treatment with adults <80 years who have target organ damage, established cardiovascular disease, renal disease, diabetes, or ≥10% 10-year CVD risk NICE CKS,NICE NG136. Consider drug treatment in adults <60 years with stage 1 hypertension and <10% 10-year CVD risk and in adults >80 years with clinic BP >150/90 mmHg, applying clinical judgment especially if frail or multimorbid NICE CKS,NICE NG136.
- Monitoring: Use clinic blood pressure measurements to monitor treatment response; in patients with type 2 diabetes, symptoms of postural hypotension, or age ≥80 years, also measure standing BP and treat to standing BP targets if significant postural hypotension is present NICE CKS,NICE NG136.
- Self-Monitoring: Encourage home blood pressure monitoring (HBPM) with appropriate training and guidance on targets and actions if targets are not met NICE CKS,NICE NG136.
- Treatment Review and Referral: In resistant hypertension on four optimised drugs, or if blood potassium >4.5 mmol/L, consider alpha- or beta-blockers and specialist referral NICE CKS.
- Shared Decision Making: Discuss individual cardiovascular risk, treatment benefits and risks, and patient preferences before starting antihypertensives, continuing lifestyle advice regardless of treatment choice NICE CKS,NICE NG136.