Hypertension in Adults: Diagnosis and Management in Secondary Care

This specialist secondary care summary covers identifying and treating primary hypertension (high blood pressure) in people aged 18 and over, including people with type 2 diabetes. It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively.

Please refer to the full guideline for information on measuring blood pressure and identifying who to refer for same-day specialist review.

Diagnosing Hypertension

Figure 1: Hypertension in adults: diagnosis and treatment

For guidance on measuring blood pressure, please refer to the full guideline.

Assessing Cardiovascular Risk and Target Organ Damage

For guidance on the early identification and management of chronic kidney disease, see NICE's guideline on chronic kidney disease.

• Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension, both for raised blood pressure and other modifiable risk factors. 
• Estimate cardiovascular risk in line with the recommendations on identifying and assessing cardiovascular disease risk in NICE's guideline on cardiovascular disease. Use clinic blood pressure measurements to calculate cardiovascular risk. 
• For all people with hypertension offer to:
  • test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip
  • take a blood sample to measure glycated haemoglobin (HbA_1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and high-density lipoprotein (HDL) cholesterol
  • examine the fundi for the presence of hypertensive retinopathy
  • arrange for a 12‑lead electrocardiograph to be performed. 

Treating and Monitoring Hypertension

Lifestyle Interventions

For guidance on the prevention of obesity and cardiovascular disease, see NICE's guidelines on obesity prevention and cardiovascular disease prevention.

• Offer lifestyle advice to people with suspected or diagnosed hypertension, and continue to offer it periodically. 
• Ask about people's diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes. 
• Ask about people's alcohol consumption and encourage a reduced intake if they drink excessively, because this can reduce blood pressure and has broader health benefits. See the recommendations for practice in NICE's guideline on alcohol-use disorders. 
• Discourage excessive consumption of coffee and other caffeine-rich products. 
• Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. Note that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). Encourage salt reduction in these groups. 
• Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. 
• Offer advice and help to smokers to stop smoking. See NICE's guideline on tobacco. 
• Inform people about local initiatives by, for example, healthcare teams or patient organisations that provide support and promote healthy lifestyle change, especially those that include group work for motivating lifestyle change. 

Starting Antihypertensive Drug Treatment

Figure 2: Choice of antihypertensive drug, monitoring treatment and BP targets

NICE has produced a patient decision aid on treatment options for hypertension to help people and their healthcare professionals discuss the different types of treatment and make a decision that is right for each person.

For advice on shared decision making for medicines, see the information on patient decision aids in NICE's guideline on medicines optimisation.

To support adherence and ensure that people with hypertension make the most effective use of their medicines, see NICE's guideline on medicines adherence.

• Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity (see also NICE's guideline on multimorbidity). 
• Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 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.
    Use clinical judgement for people with frailty or multimorbidity (see also NICE's guideline on multimorbidity). 
• Discuss with the person their individual cardiovascular disease risk and their preferences for treatment, including no treatment, and explain the risks and benefits before starting antihypertensive drug treatment. Continue to offer lifestyle advice and support them to make lifestyle changes (see the section on Lifestyle interventions), whether or not they choose to start antihypertensive drug treatment. 
• Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10‑year risk below 10%. Bear in mind that 10‑year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease. 
• Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with stage 1 hypertension if their clinic blood pressure is over 150/90 mmHg. Use clinical judgement for people with frailty or multimorbidity (see also NICE's guideline on multimorbidity). 
• For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks. 

Monitoring Treatment and Blood Pressure Targets

For specific recommendations on blood pressure control in people with other conditions or who are pregnant, see also the NICE guidelines on chronic kidney disease, type 1 diabetes and hypertension in pregnancy.

• Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension. 
• Measure standing as well as seated blood pressure in people with hypertension and:
  • with type 2 diabetes or
  • with symptoms of postural hypotension or
  • aged 80 and over.
    In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure. 
• Advise people with hypertension who choose to self-monitor their blood pressure to use HBPM (NHS England is supporting the use of HBPM through the blood pressure@home scheme).
• Consider ABPM or HBPM, in addition to clinic blood pressure measurements, for people with hypertension identified as having a white-coat effect or masked hypertension (in which clinic and non-clinic blood pressure results are conflicting). Be aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurements (see the section on Diagnosing hypertension for diagnostic thresholds in the full guideline for more information). 
• For people who choose to use HBPM, provide:
  • training and advice on using home blood pressure monitors
  • information about what to do if they are not achieving their target blood pressure
    Be aware that the corresponding measurements for HBPM are 5 mmHg lower than for clinic measurements (see the section on Diagnosing hypertension for diagnostic thresholds in the full guideline for more information). 
• For adults with hypertension aged under 80, reduce clinic blood pressure to below 140/90 mmHg and ensure that it is maintained below that level. 
• For adults with hypertension aged 80 and over, reduce clinic blood pressure to below 150/90 mmHg and ensure that it is maintained below that level. Use clinical judgement for people with frailty or multimorbidity (see also NICE's guideline on multimorbidity). 
• When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person's usual waking hours (see the section on Diagnosing hypertension in the full guideline for more information). Reduce blood pressure and ensure that it is maintained:
  • below 135/85 mmHg for adults aged under 80
  • below 145/85 mmHg for adults aged 80 and over.
    Use clinical judgement for people with frailty or multimorbidity (see also NICE's guideline on multimorbidity).
• Use the same blood pressure targets for people with and without cardiovascular disease. 
• Provide an annual review of care for adults with hypertension to monitor blood pressure, provide people with support, and discuss their lifestyle, symptoms and medication. 

Treatment Review When Type 2 Diabetes is Diagnosed

• For an adult with type 2 diabetes on antihypertensive drug treatment when diabetes is diagnosed, review blood pressure control and medications used. Make changes only if there is poor control or if current drug treatment is not appropriate because of microvascular complications or metabolic problems. 

Choosing Antihypertensive Drug Treatment (for People With or Without Type 2 Diabetes)

The recommendations in this section apply to people with hypertension with or without type 2 diabetes. They replace the recommendations on diagnosing and managing hypertension in NICE's guideline on type 2 diabetes in adults. For guidance on choosing antihypertensive drug treatment in people with type 1 diabetes, see also the section on control of cardiovascular risk in NICE's guideline on type 1 diabetes.

Note that ACE inhibitors and angiotensin II receptor antagonists should not be used in pregnant or breastfeeding women or women planning pregnancy unless absolutely necessary, in which case the potential risks and benefits should be discussed. Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, recommendations on how to use for breastfeeding and the related clarification on breastfeeding.

• For guidance on choice of hypertensive agent in people with chronic kidney disease, see NICE's guideline on chronic kidney disease. If possible, offer treatment with drugs taken only once a day. 
• Prescribe non-proprietary drugs if these are appropriate and minimise cost. 
• Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure. 
• Offer antihypertensive drug treatment to women of childbearing potential with diagnosed hypertension in line with the recommendations in this guideline. For women considering pregnancy or who are pregnant or breastfeeding, manage hypertension in line with the recommendations on management of pregnancy with chronic hypertension, and on antihypertensive treatment while breastfeeding in NICE's guideline on hypertension in pregnancy. 
• When choosing antihypertensive drug treatment for adults of Black African or African–Caribbean family origin, consider an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor. 

  Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, how to use for breastfeeding and clarification on breastfeeding.
• For people with cardiovascular disease:
  • follow the recommendations for disease-specific indications in the NICE guideline on their condition (for example, when prescribing an ACE inhibitor or an ARB for secondary prevention of myocardial infarction). Relevant recommendations include:
    • drug therapy for secondary prevention in the NICE guideline on acute coronary syndromes
    • treatment after stabilisation in the NICE guideline on acute heart failure
    • treating heart failure with reduced ejection fraction in the NICE guideline on chronic heart failure
    • drugs for secondary prevention of cardiovascular disease in the NICE guideline on stable angina
    • blood pressure management in the NICE guideline on type 1 diabetes in adults.
  • If their blood pressure remains uncontrolled, offer antihypertensive drug treatment in line with the recommendations in this section. 

Step 1 Treatment

• Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:
  • have type 2 diabetes and are of any age or family origin (see also previous section for recommendation for adults of Black African or African–Caribbean family origin) or
  • are aged under 55 but not of Black African or African–Caribbean family origin. 
    Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, how to use for breastfeeding and clarification on breastfeeding.
• If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB to treat hypertension. 
  Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, how to use for breastfeeding and clarification on breastfeeding.
• Do not combine an ACE inhibitor with an ARB to treat hypertension. 
• Offer a calcium-channel blocker (CCB) to adults starting step 1 antihypertensive treatment who:
  • are aged 55 or over and do not have type 2 diabetes or
  • are of Black African or African–Caribbean family origin and do not have type 2 diabetes (of any age). 
• If a CCB is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension. 
• If there is evidence of heart failure, offer a thiazide-like diuretic and follow NICE's guideline on chronic heart failure. 
• If starting or changing diuretic treatment for hypertension, offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. 
• For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment. 

Step 2 Treatment

• Before considering next step treatment for hypertension discuss with the person if they are taking their medicine as prescribed and support adherence in line with NICE's guideline on medicines adherence. 
• If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step 1 treatment:
  • a CCB or
  • a thiazide-like diuretic. 
• If hypertension is not controlled in adults taking step 1 treatment of a CCB, offer the choice of 1 of the following drugs in addition to step 1 treatment:
  • an ACE inhibitor or
  • an ARB or
  • a thiazide-like diuretic. 
• If hypertension is not controlled in adults of Black African or African–Caribbean family origin who do not have type 2 diabetes taking step 1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step 1 treatment. 

Step 3 Treatment

• Before considering next step treatment for hypertension:
  • review the person's medications to ensure they are being taken at the optimal tolerated doses and
  • discuss adherence. 
• If hypertension is not controlled in adults taking step 2 treatment, offer a combination of:
  • an ACE inhibitor or ARB (see also recommendation Choosing antihypertensive drug treatment for people with or without type 2 diabetes for people of Black African or African–Caribbean family origin and
  • a CCB and
  • a thiazide-like diuretic (see the first recommendation under Step 2 treatment, above). 

Step 4 Treatment

• If hypertension is not controlled in adults taking the optimal tolerated doses of an ACE inhibitor or an ARB plus a CCB and a thiazide-like diuretic, regard them 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 (see the first recommendation under Step 2 treatment, above).
• For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice. 
  Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, how to use for breastfeeding and clarification on breastfeeding.
• Consider further diuretic therapy with low-dose spironolactone for adults with resistant hypertension starting step 4 treatment 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 because they have an increased risk of hyperkalaemia. 
  In March 2019, this was an off-label use of some preparations of spironolactone. See NICE's information on prescribing medicines.
• When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium and potassium and renal function within 1 month of starting treatment and repeat as needed thereafter. 
• 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 with resistant hypertension taking the optimal tolerated doses of 4 drugs, seek specialist advice.