PassFinals
Cardiovascular

Hypertension

Hypertension is persistently raised arterial blood pressure, usually without symptoms, diagnosed by correctly measured clinic pressure plus ambulatory or home confirmation unless severe pressure and acute target-organ injury require immediate specialist assessment.

In a nutshell

Hypertension is usually an asymptomatic measurement diagnosis. Confirm a clinic BP from 140/90 to below 180/120 mmHg with ABPM or structured HBPM, assess target-organ damage and CVD risk, then treat by current NICE thresholds and the NICE stepwise ladder. Severe pressure with retinal or life-threatening organ injury is a same-day problem.

Classic presentation

An asymptomatic adult has repeated clinic BP at or above 140/90 mmHg and a raised waking ABPM or structured HBPM average, often with additional cardiovascular risk factors but no acute complaint.

Key points

  • Confirm routine hypertension with clinic BP at least 140/90 mmHg plus waking ABPM or HBPM average at least 135/85 mmHg.
  • Stage 1 is clinic 140/90 to 159/99 with ABPM or HBPM 135/85 to 149/94; stage 2 is clinic 160/100 to below 180/120 with ABPM or HBPM at least 150/95 mmHg.
  • Severe hypertension means clinic systolic BP at least 180 or diastolic BP at least 120 mmHg, but same-day referral depends on retinal signs, life-threatening symptoms or suspected phaeochromocytoma.
  • Every confirmed case needs urine ACR and haematuria testing, HbA1c, renal function and electrolytes, lipids, fundoscopy and ECG. Use QRISK3 only when formal calculation is appropriate; established CVD, type 1 diabetes, familial hypercholesterolaemia and CKD with eGFR below 60 and/or albuminuria are already high-risk pathways.
  • Step 1 is ACE inhibitor or ARB for type 2 diabetes or age under 55 without Black African or African-Caribbean family origin; otherwise use a CCB when there is no type 2 diabetes.
  • Use current NICE NG136 risk- and age-based treatment thresholds and general age-based targets for the normative UK pathway.
  • Suspected ACE-inhibitor angioedema requires immediate permanent discontinuation of the ACE inhibitor and urgent airway assessment; onset can be delayed for years and bradykinin-mediated attacks may not respond to standard anaphylaxis treatment.
  • True resistant hypertension requires uncontrolled BP on optimal ACE inhibitor or ARB, CCB and thiazide-like diuretic therapy, confirmed out of office with adherence and postural review.
  • General clinic targets are below 140/90 under age 80 and below 150/90 from age 80, but use standing BP with postural hypotension and apply CKD or type 1 diabetes targets first.

First-line investigation

Repeat a correctly performed clinic measurement, then use ABPM for confirmation, or structured HBPM if ABPM is unsuitable; meanwhile complete the target-organ screen and assess cardiovascular risk, using QRISK3 only when the person is not already in a NICE high-risk group.

Management

Separate emergency from severe asymptomatic pressure

  • BP 180/120 mmHg or higher with retinal haemorrhage or papilloedema requires same-day specialist assessment; confusion, chest pain, acute heart failure or acute kidney injury also requires immediate treatment through the relevant organ-emergency pathway.1,7
  • Suspected phaeochromocytoma is also a same-day referral. Without same-day features, investigate target-organ damage urgently and arrange treatment or confirmation plus clinical review within 7 days.1,7
  • Pregnancy with severe hypertension or pre-eclampsia symptoms needs urgent maternity assessment; do not use the routine adult prescribing ladder.4

Confirm, stage and decide whether to treat

  • Use bilateral, repeated clinic measurement followed by ABPM or structured HBPM. When symptoms, type 2 diabetes or age 80 and over make postural hypotension relevant, measure from supine where practicable and repeat after at least 1 minute standing; if seated testing is negative despite symptoms, repeat from supine.1
  • Offer treatment for persistent stage 2. In stage 1 under age 80, discuss it with target-organ damage, CVD, renal disease, diabetes or 10-year CVD risk at least 10%; consider it below that risk when under 60.1,3
  • Consider treatment for stage 1 over age 80 when clinic BP exceeds 150/90 mmHg, using clinical judgement for frailty or multimorbidity; consider specialist secondary-cause assessment below age 40.1,6,7

Start the NICE stepwise pathway

  • Offer ACE inhibitor or ARB at step 1 for type 2 diabetes or age under 55 without Black African or African-Caribbean family origin; otherwise offer a CCB when there is no type 2 diabetes (see BNF).1,2
  • Prefer an ARB to an ACE inhibitor when renin-angiotensin blockade is chosen for Black African or African-Caribbean family origin, use an ARB after ACE-inhibitor cough, and never combine ACE inhibitor with ARB (see BNF).1,2
  • If ACE-inhibitor angioedema is suspected, stop the ACE inhibitor immediately and do not restart it. Arrange urgent airway assessment; delayed bradykinin-mediated attacks may not respond to standard anaphylaxis treatment.9
  • At step 2 add a CCB, ACE inhibitor or ARB, or thiazide-like diuretic according to the starting class; at step 3 combine ACE inhibitor or ARB plus CCB plus thiazide-like diuretic (see BNF).1,2

Treat resistant hypertension safely

  • Before step 4, confirm pressure with ABPM or HBPM, assess standing BP and adherence, ensure optimal tolerated triple therapy and revisit secondary causes.1
  • Consider low-dose spironolactone when potassium is 4.5 mmol/L or less, or an alpha-blocker or beta-blocker above 4.5 mmol/L (see BNF); monitor sodium, potassium and renal function within 1 month after further diuretic therapy.1,2
  • Seek specialist advice if optimal tolerated treatment with 4 medicines does not control BP.1

Use the comorbidity pathway when it changes the answer

  • CKD targets are age-independent: below 140/90 when ACR is below 70 mg/mmol and below 130/80 from ACR 70 mg/mmol. Offer ACE inhibitor or ARB for CKD with hypertension and ACR above 30 mg/mmol, or for CKD with diabetes from ACR 3 mg/mmol (see BNF).5,2
  • In type 1 diabetes under age 80, target below 140/90 when ACR is below 70 mg/mmol and below 130/80 from ACR 70 mg/mmol; from age 80 target below 150/90 regardless of ACR.11
  • For established CVD, give disease-specific secondary-prevention or heart-failure treatment first, then add the hypertension ladder if BP remains uncontrolled.1
  • In planned pregnancy, obtain specialist advice and discuss alternatives to ACE inhibitors, ARBs and thiazide(-like) diuretics. If pregnancy occurs on an ACE inhibitor or ARB, stop preferably within 2 working days and offer an alternative; in pregnancy treat sustained BP at least 140/90 to a 135/85 target using the NG133 labetalol, nifedipine, then methyldopa sequence as suitability requires (see BNF).4,13,2
  • Postnatally after chronic or gestational hypertension, check BP daily for 2 days and once on days 3 to 5. Pre-eclampsia needs at least 4 checks daily while inpatient and, when treated after community transfer, every 1 to 2 days for up to 2 weeks until off treatment and normotensive. Treat severe hypertension immediately, start treatment at 150/100 or higher after untreated gestational hypertension or pre-eclampsia, stop methyldopa within 2 days, and arrange 2-week treatment review plus 6-to-8-week medical review through NG133 (see BNF).4,2

Maintain control and detect harm

  • For the general NG136 pathway, use clinic targets below 140/90 under age 80 and below 150/90 from age 80, with ABPM or HBPM targets 5 mmHg lower; use clinical judgement in frailty or multimorbidity. Do not derive a 5-mmHg-lower out-of-office target for CKD or type 1 diabetes; use their stated clinic targets. Base any applicable target on standing BP when postural hypotension is present.1,11,5
  • Before an ACE inhibitor or ARB, check BP, renal function, sodium and potassium. Repeat renal function, sodium and potassium within 1 to 2 weeks after starting or changing dose, or within 7 days at higher risk; review BP within 1 month and monitor renal function and electrolytes at least annually once stable (see BNF).1,2,12
  • Teach people who self-monitor how to use a validated device, average readings and act when they remain above target.1
  • DVLA defines malignant hypertension for driving as BP at least 180 systolic or 110 diastolic with progressive organ damage, which differs from NICE accelerated hypertension. In Great Britain, uncomplicated hypertension usually does not restrict Group 1 driving, but malignant hypertension does until controlled. Group 2 drivers must stop and notify DVLA for persistent resting BP at least 180 systolic or 100 diastolic, or malignant hypertension; use DVA in Northern Ireland.14,15

Exam traps

  • One high clinic reading is not routine hypertension; repeat it and confirm with ABPM or structured HBPM.
  • A clinic BP of 180/120 mmHg or higher is severe, but without retinal or life-threatening features it follows urgent target-organ assessment and a 7-day confirmation or review pathway, not automatic emergency admission.
  • ABPM diagnosis uses the waking average of at least 14 measurements; HBPM discards day 1 before averaging the remaining readings.
  • Do not treat headache alone as proof of hypertensive emergency; look for retinal, neurological, cardiac or renal injury and manage the specific emergency.
  • Type 2 diabetes overrides the age branch at step 1. For Black African or African-Caribbean family origin, NICE prefers an ARB when renin-angiotensin blockade is chosen.
  • Do not combine an ACE inhibitor with an ARB, and prefer a thiazide-like diuretic when starting or changing diuretic therapy.
  • ACE-inhibitor angioedema can begin after years of uneventful treatment. Stop the ACE inhibitor immediately and never restart it; a poor response to standard anaphylaxis treatment suggests a bradykinin-mediated mechanism and increases the need for airway-focused escalation.
  • Use standing BP for the target when postural hypotension is present, and do not apply the general age target over a different CKD or type 1 diabetes target.
  • Adults under 40 with hypertension merit consideration of specialist secondary-cause assessment even when their calculated 10-year risk is low.

Illustrations

Blood pressure determinants and drug targetsDiagram linking cardiac output and systemic vascular resistance to the complementary antihypertensive drug classes used in the NICE stepwise pathway.PassFinals · original
Hypertensive retinopathy on fundoscopyFundus photographs showing cotton-wool spots, a flame-shaped haemorrhage and optic-disc swelling. Retinal haemorrhage or papilloedema with severe hypertension requires same-day specialist assessment.Ramnani V et al., Cureus 2025, CC-BY-4.0 · CC-BY-4.0
Left ventricular hypertrophy on ECGTwelve-lead ECG showing voltage and repolarisation features of left-ventricular hypertrophy from chronic pressure load.James Heilman, MD, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. NICE, Hypertension in adults: diagnosis and management (NG136)Published 28 Aug 2019 | Updated 26 Feb 2026
  2. BNF, Hypertension treatment summary
  3. NICE, Cardiovascular disease: risk assessment and reduction, including lipid modification (NG238)Published 14 Dec 2023
  4. NICE, Hypertension in pregnancy: diagnosis and management (NG133)Published 25 Jun 2019 | Updated 17 Apr 2023
  5. NICE, Chronic kidney disease: assessment and management (NG203)Published 25 Aug 2021 | Updated 24 Nov 2021
  6. British and Irish Hypertension Society, Investigation and management of young-onset hypertension: position statement (doi:10.1038/s41371-024-00922-5)Published 28 Jun 2024
  7. British and Irish Hypertension Society, Adult hypertension referral pathway and therapeutic management: position statement (doi:10.1038/s41371-023-00882-2)Published 9 Jan 2024
  8. British and Irish Hypertension Society, Call to action: position statement on blood-pressure treatment thresholds and targets (doi:10.1038/s41371-025-01055-z)Published 23 Jul 2025 | Updated 28 Jul 2025
  9. MHRA, ACE-inhibitors: distinction between bradykinin- and histamine-mediated angioedemaPublished 16 Jun 2026
  10. British and Irish Hypertension Society, Investigation and management of resistant hypertension: position statement (doi:10.1038/s41371-024-00983-6)Published 9 Dec 2024
  11. NICE, Type 1 diabetes in adults: diagnosis and management (NG17)Published 26 Aug 2015 | Updated 17 Aug 2022
  12. NHS Specialist Pharmacy Service, ACE inhibitors and angiotensin II receptor blockers monitoringPublished 24 Jun 2021 | Updated 23 Apr 2025
  13. MHRA, ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancyPublished 11 Dec 2014
  14. DVLA, Cardiovascular disorders: assessing fitness to drivePublished 11 Mar 2016 | Updated 7 Nov 2025
  15. nidirect, When you tell DVA about a medical condition

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.