Hypertension: clinical management of primary hypertension in adults continued

Diagnosing hypertension

Measuring the clinic blood pressure

• Measure blood pressure in both arms:
  • if the difference in readings between arms is more than 20 mmHg, repeat the measurements
  • if the difference in readings between arms remains more than 20 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading
• If blood pressure measured in the clinic is 140/90 mmHg or higher:
  • take a second measurement during the consultation
  • if the second measurement is substantially different from the first, take a third measurement
• Record the lower of the last two measurements as the clinic blood pressure

Confirming the diagnosis

• If the clinic blood pressure is 140/90 mmHg or higher, offer ABPM to confirm the diagnosis of hypertension
• If a person is unable to tolerate ABPM, HBPM is a suitable alternative to confirm the diagnosis of hypertension
• While waiting to confirm the diagnosis, carry out investigations for target organ damage and a formal assessment of cardiovascular risk

Severe hypertension

• Consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM, for people with severe hypertension

Specialist investigations

• Refer people to specialist care the same day if they have:
  • accelerated hypertension (blood pressure usually higher than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage) or
  • suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor, and diaphoresis)
• Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension

Using ambulatory or home blood pressure monitoring

• Ambulatory blood pressure monitoring
  • ensure that at least two measurements per hour are taken during the person's usual waking hours (for example, between 08.00 and 22.00)
  • use the average value of at least 14 measurements taken during the person's usual waking hours to confirm the diagnosis
• Home blood pressure monitoring
  • ensure that:
    • for each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated
    • blood pressure is recorded twice daily, ideally in the morning and evening
    • blood pressure recording continues for at least 4 days, ideally for 7 days
  • discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm the diagnosis

If hypertension is not diagnosed

• Offer to measure the person's blood pressure at least every 5 years
• Consider measuring it more often than every 5 years if the person's clinic blood pressure is close to
  140/90 mmHg
• If there is evidence of target organ damage such as left ventricular hypertrophy, albuminuria or proteinuria, consider carrying out investigations for alternative causes of the target organ damage

Hypertension: clinical management of primary hypertension in adults continued

Care pathway for hypertension

• See main text for more details

Hypertension: clinical management of primary hypertension in adults continued

Assessing cardiovascular risk and target organ damage

• 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 Identification and assessment of CVD risk in 'Lipid modification'
• Assess target organ damage:
  • 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 plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate (eGFR), serum total cholesterol and HDL cholesterol
  • examine the fundi for the presence of hypertensive retinopathy
  • arrange for a 12-lead electrocardiograph to be performed
• For people aged under 40 with stage 1 hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people

Lifestyle interventions

• Lifestyle advice should be offered initially and then periodically to people undergoing assessment or treatment for hypertension
• Ask people about their diet and exercise patterns, and offer guidance and written or audiovisual materials to promote lifestyle changes
• Ask people about their alcohol consumption and encourage them to cut down if they drink excessively
• Discourage excessive consumption of coffee and other caffeine-rich products
• Encourage people to keep their salt intake low or substitute sodium salt
• Offer people who smoke advice and help to stop smoking
• Tell people about local initiatives (for example, run by healthcare teams or patient organisations) that provide support and promote lifestyle change
• Do not offer calcium, magnesium or potassium supplements as a method of reducing blood pressure
• Relaxation therapies can reduce blood pressure and people may wish to try them. However, it is not recommended that primary care teams provide them routinely

Antihypertensive drug treatment

General principles

• If possible, offer 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 higher) the same treatment as people with both raised systolic and diastolic blood pressure
• Offer people aged over 80 years the same antihypertensive drug treatment as people aged 55–80 years, taking into account any comorbidities
• Do not combine an angiotensin-converting enzyme (ACE) inhibitor with an angiotensin II receptor blocker (ARB)
• Offer antihypertensive drug treatment to women of child-bearing potential in line with the recommendations on Management of pregnancy with chronic hypertension and Breastfeeding in 'Hypertension in pregnancy'

Hypertension: clinical management of primary hypertension in adults continued

Initiating and titrating antihypertensive drug treatment

• Also see algorithm on page 6
• Step 1 treatment
  • offer step 1 treatment to people aged under 80 with stage 1 hypertension and one or more of:
    • target organ damage
    • established cardiovascular disease
    • renal disease
    • diabetes
    • 10-year cardiovascular risk equivalent to 20% or more
  • offer step 1 treatment to people of any age with stage 2 hypertension
  • offer people aged under 55 years an ACE inhibitor or a low-cost ARB. If an ACE inhibitor is prescribed and is not tolerated (for example, because of cough), offer a low-cost ARB
  • offer people aged over 55 years and black people of African or Caribbean family origin of any age a calcium-channel blocker (CCB). If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic
  • if treatment with a diuretic is being started, or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide
  • for people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide
  • beta-blockers are not preferred in step 1. However, they may be considered for younger people if ACE inhibitors and ARBs are contraindicated or not tolerated or there is evidence of increased sympathetic drive, and for women of child-bearing potential
  • if blood pressure is not controlled by step 1 treatment, offer step 2 treatment
• Step 2 treatment
  • offer a CCB in combination with either an ACE inhibitor or an ARB
  • if a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic
  • for black people of African or Caribbean family origin, consider an ARB in preference to an ACE inhibitor, in combination with a CCB
  • if a beta-blocker was used in step 1, add a CCB rather than a thiazide-type diuretic, to reduce the person's risk of developing diabetes
  • before considering step 3 treatment, review medication to ensure step 2 treatment is at optimal or best tolerated doses
• Step 3 treatment
  • offer an ACE inhibitor or an ARB in combination with a CCB and a thiazide-like diuretic
  • regard clinic blood pressure that remains 140/90 mmHg or higher after step 3 treatment with optimal or best tolerated doses as resistant hypertension. Consider step 4 treatment or seeking expert advice
• Step 4 treatment
  • consider further diuretic therapy with low-dose (25 mg once daily) spironolactone if blood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a reduced eGFR, because they have an increased risk of hyperkalaemia
  • consider further diuretic therapy with a higher-dose thiazide-like diuretic if blood potassium level is higher than 4.5 mmol/l
  • when using further diuretic therapy, monitor blood sodium and potassium and renal function within
    1 month and repeat as required thereafter
  • if further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker
  • if blood pressure remains uncontrolled with optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained

Monitoring treatment

• Use clinic blood pressure measurement to monitor the response to treatment
• For people identified as having a 'white-coat effect', consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor the response to treatment

Blood pressure targets

• Clinic blood pressure
  • people aged under 80 years: lower than 140/90 mmHg
  • people aged over 80 years: lower than 150/90 mmHg
• Daytime average ABPM or average HBPM blood pressure during the person's usual waking hours
  • people aged under 80 years: lower than 135/85 mmHg
• • people aged over 80 years: lower than 145/85 mmHg

Hypertension: clinical management of primary hypertension in adults continued

Patient education and adherence to treatment

• Help people to make informed choices by providing guidance and materials about the benefits of drugs and the unwanted side effects sometimes experienced
• Tell people about patient organisations that have forums for sharing views and information
• Offer an annual review of care to monitor blood pressure, provide people with support and discuss their lifestyle, symptoms and medication

Interventions to support adherence to treatment

• Target the intervention to the need. Interventions might include:
  • suggesting that people record their medicine-taking
  • encouraging people to monitor their condition
  • simplifying the dosing regimen
  • using alternative packaging for the medicine
  • using a multi-compartment medicines system

• To see footnotes to the main text, please refer to the quick reference guideline

Summary of antihypertensive drug treatment

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
guidance.nice.org.uk/CG127

National Institute for Health and Care Excellence. Hypertension: clinical management of primary hypertension in adults. August 2011