Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described inNICE's information on making decisions about your care.
Making decisions using NICE guidelinesexplains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
The recommendations on measuring blood pressure and diagnosing hypertension in this guideline apply to all adults, including those with type2 diabetes. The recommendations on treatment and monitoring link to NICE's guidelines on chronic kidney disease, type1 diabetes and hypertension in pregnancy at points in the care pathway where treatment differs. The recommendations on treatment and monitoring apply to adults with type2 diabetes and replace recommendations on diagnosing and managing hypertension in NICE's guideline on type2 diabetes in adults.
1.1 Measuring blood pressure
Training, technique and device maintenance
1.1.1
Ensure that healthcare professionals taking blood pressure measurements have adequate initial training and periodic review of their performance. [2004]
1.1.2
Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. [2011]
1.1.3
Healthcare providers must ensure that devices for measuring blood pressure are properly validated, maintained and regularly recalibrated according to manufacturers' instructions. See the British and Irish Hypertension Society's website for a list of validated blood pressure monitoring devices. [2004]
1.1.4
When measuring blood pressure in the clinic or in the home, standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. Use an appropriate cuff size for the person's arm. [2011, amended 2019]
Postural hypotension
1.1.5
In people with symptoms of postural hypotension, including falls or postural dizziness:
-
measure blood pressure with the person lying on their back (or consider a seated position, if it is inconvenient to measure blood pressure with the person lying down)
-
measure blood pressure again after the person has been standing for at least 1minute. [2004, amended 2023]
1.1.6
If the person's systolic blood pressure falls by 20mmHg or more, or their diastolic blood pressure falls by 10 mmHg or more, after the person has been standing for at least 1 minute:
-
consider likely causes, including reviewing their current medication
-
manage appropriately (for example, for advice on preventing falls in older people, see NICE's guideline on falls in older people: assessing risk and prevention)
-
measure subsequent blood pressures with the person standing
-
consider referral to specialist care if symptoms of postural hypotension persist despite addressing likely causes. [2004, amended 2023]
1.1.7
If the blood pressure drop is less than the thresholds in recommendation 1.1.6 despite suggestive symptoms and the baseline measurement was previously taken from a seated position, repeat the measurements this time starting with the person lying on their back. [2023]
1.1.8
Consider referring the person for further specialist assessment if blood pressure measurements do not confirm postural hypotension despite suggestive symptoms. [2023]
1.2 Diagnosing hypertension
1.2.1
When considering a diagnosis of hypertension, measure blood pressure in both arms:
-
If the difference in readings between arms is more than 15mmHg, repeat the measurements.
-
If the difference in readings between arms remains more than 15mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading. [2019]
1.2.2
If blood pressure measured in the clinic is 140/90mmHg 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 2measurements as the clinic blood pressure. [2019]
1.2.3
If clinic blood pressure is between 140/90mmHg and 180/120mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. See the section on identifying who to refer for people with a clinic blood pressure 180/120mmHg or higher. [2019]
1.2.4
If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. [2019]
1.2.5
While waiting for confirmation of a diagnosis of hypertension, carry out:
-
investigations for target organ damage (see recommendation 1.3.3), followed by
-
formal assessment of cardiovascular risk using a cardiovascular risk assessment tool (see the section on full formal risk assessment in NICE's guideline on cardiovascular disease). [2019]
1.2.6
When using ABPM to confirm a diagnosis of hypertension, ensure that at least 2measurements 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 14measurements taken during the person's usual waking hours to confirm a diagnosis of hypertension. [2011]
1.2.7
When using HBPM to confirm a diagnosis of hypertension, ensure that:
-
for each blood pressure recording, 2consecutive measurements are taken, at least 1minute apart and with the person seated and
-
blood pressure is recorded twice daily, ideally in the morning and evening and
-
blood pressure recording continues for at least 4days, ideally for 7days.
Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. [2011]
1.2.8
Confirm diagnosis of hypertension in people with a:
-
clinic blood pressure of 140/90mmHg or higher and
-
ABPM daytime average or HBPM average of 135/85mmHg or higher. [2019]
1.2.9
If hypertension is not diagnosed but there is evidence of target organ damage, consider carrying out investigations for alternative causes of the target organ damage (for information on investigations, see NICE's guidelines on chronic kidney disease and chronic heart failure). [2011]
1.2.10
If hypertension is not diagnosed, measure the person's clinic blood pressure at least every 5years subsequently, and consider measuring it more frequently if the person's clinic blood pressure is close to 140/90mmHg. [2011]
Annual blood pressure measurement for people with type2 diabetes
1.2.11
Measure blood pressure at least annually in an adult with type2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice. [2009]
Specialist investigations for possible secondary causes of hypertension
1.2.12
Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. [2004, amended 2011]
For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on diagnosing hypertension.
Full details of the evidence and the committee's discussion are in evidence review A: diagnosis.
1.3 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.
1.3.1
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. [2004]
1.3.2
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. [2008]
1.3.3
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 (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol
-
examine the fundi for the presence of hypertensive retinopathy
-
arrange for a 12‑lead electrocardiograph to be performed. [2011, amended 2019]
1.4 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.
1.4.1
Offer lifestyle advice to people with suspected or diagnosed hypertension, and continue to offer it periodically. [2004]
1.4.2
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. [2004]
1.4.3
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. [2004, amended 2019]
1.4.4
Discourage excessive consumption of coffee and other caffeine-rich products. [2004]
1.4.5
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 ACE inhibitors and angiotensinII receptor blockers. Encourage salt reduction in these groups. [2004, amended 2019]
1.4.6
Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. [2004]
1.4.7
Offer advice and help to smokers to stop smoking. See NICE's guideline on tobacco. [2004]
1.4.8
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. [2004]
For a short explanation of why the committee deleted the recommendation on relaxation therapies and how this might affect practice, see the rationale and impact section on relaxation therapies.
Full details of the evidence and the committee's discussion are in evidence review H: relaxation therapies.
Starting antihypertensive drug treatment
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.
1.4.9
Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity (see also NICE's guideline on multimorbidity). [2019]
1.4.10
Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under80 with persistent stage1 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). [2019]
1.4.11
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. [2019]
1.4.12
Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under60 with stage1 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. [2019]
1.4.13
Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over80 with stage1 hypertension if their clinic blood pressure is over 150/90mmHg. Use clinical judgement for people with frailty or multimorbidity (see also NICE's guideline on multimorbidity). [2019]
1.4.14
For adults aged under40 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. [2019]
For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on starting antihypertensive drug treatment.
Full details of the evidence and the committee's discussion are in evidence review C: initiating treatment.
Monitoring treatment and blood pressure targets
For specific recommendations on blood pressure control in people with other conditions or who are pregnant, see NICE's guidelines on chronic kidney disease, type 1 diabetes and hypertension in pregnancy.
See also table 1 for clinic blood pressure targets for people aged under 80 and table 2 for clinic blood pressure targets for people aged 80 and over. The tables cover people with hypertension (with or without type 2 diabetes) as well as people with chronic kidney disease or type 1 diabetes.
Person under 80 with: | Clinic blood pressure target | Source |
---|---|---|
| Below 140/90 | Recommendation 1.4.20 NICE's guideline on type 1 diabetes in adults (recommendation 1.13.8) NICE's guideline on chronic kidney disease (recommendation 1.6.1) |
| Below 130/80 | NICE's guideline on type 1 diabetes in adults (recommendation 1.13.8) NICE's guideline on chronic kidney disease (recommendation 1.6.2) |
Person aged 80 and over with: | Clinic blood pressure target | Source |
---|---|---|
| Below 150/90 | Recommendation 1.4.21 NICE's guideline on type 1 diabetes in adults (recommendation 1.13.8) |
| Below 140/90 | NICE's guideline on chronic kidney disease (recommendation 1.6.1) |
| Below 130/80 | NICE's guideline on chronic kidney disease (recommendation 1.6.2) |
1.4.15
Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension. [2019]
1.4.16
Check for postural hypotension (see recommendation 1.1.5) in people with hypertension and:
-
type2 diabetes or
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symptoms of postural hypotension (see also recommendation 1.1.7) or
-
aged 80and over.
In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure. [2019, amended 2023]
1.4.17
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.) [2019]
1.4.18
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 5mmHg lower than for clinic measurements (see recommendation1.2.8 for diagnostic thresholds). [2019]
1.4.19
For people who choose to use HBPM, provide:
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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 5mmHg lower than for clinic measurements (see recommendation1.2.8 for diagnostic thresholds). [2019]
1.4.20
For adults with hypertension aged under80, reduce clinic blood pressure to below 140/90mmHg and ensure that it is maintained below that level. See also table 1 for guidance on clinic blood pressure targets for people aged under 80 with type 1 diabetes or severe chronic kidney disease. [2019, amended 2022]
1.4.21
For adults with hypertension aged 80and over, reduce clinic blood pressure to below 150/90mmHg and ensure that it is maintained below that level. Use clinical judgement for people with frailty or multimorbidity (see NICE's guideline on multimorbidity). See also table 2 for guidance on clinic blood pressure targets for people aged 80 and over with type 1 diabetes or severe chronic kidney disease. [2019, amended 2022]
1.4.22
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 recommendations1.2.6 and 1.2.7). Reduce blood pressure and ensure that it is maintained:
-
below 135/85mmHg for adults aged under80
-
below 145/85mmHg for adults aged 80and over.
Use clinical judgement for people with frailty or multimorbidity (see also NICE's guideline on multimorbidity). [2019, amended 2022]
For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on monitoring treatment and blood pressure targets for people without cardiovascular disease.
Full details of the evidence and the committee's discussion are in evidence review B: monitoring the response to treatment.
1.4.23
Use the same blood pressure targets for people with and without cardiovascular disease. [2022]
For a short explanation of why the committee made the recommendation on blood pressure targets for people with cardiovascular disease and how this might affect practice, see the rationale and impact section on monitoring treatment and blood pressure targets for people with cardiovascular disease.
Full details of the evidence and the committee's discussion are in the evidence review J: blood pressure targets.
1.4.24
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. [2004]
Treatment review when type2 diabetes is diagnosed
1.4.25
For an adult with type2 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. [2009]
Choosing antihypertensive drug treatment (for people with or without type2 diabetes)
The recommendations in this section apply to people with hypertension with or without type2 diabetes. They replace the recommendations on diagnosing and managing hypertension in NICE's guideline on type2 diabetes in adults. For guidance on choosing antihypertensive drug treatment in people with type1 diabetes, see also the section on control of cardiovascular risk in NICE's guideline on type1 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.
1.4.26
For guidance on choice of antihypertensive medicine 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. [2004]
1.4.27
Prescribe non-proprietary drugs if these are appropriate and minimise cost. [2004]
1.4.28
Offer people with isolated systolic hypertension (systolic blood pressure 160mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure. [2004]
1.4.29
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. [2010, amended 2019]
1.4.30
When choosing antihypertensive drug treatment for adults of Black African or African–Caribbean family origin, consider an angiotensinII receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor. [2019]
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.
1.4.31
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:
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drug therapy for secondary prevention in NICE's guideline on acute coronary syndromes
-
treatment after stabilisation in NICE's guideline on acute heart failure
-
treating heart failure with reduced ejection fraction in NICE's guideline on chronic heart failure
-
drugs for secondary prevention of cardiovascular disease in NICE's guideline on stable angina
-
blood pressure management in NICE's guideline on type1 diabetes in adults.
-
-
If their blood pressure remains uncontrolled, offer antihypertensive drug treatment in line with the recommendations in this section. [2022]
For a short explanation of why the committee made the recommendation on choosing antihypertensive drug treatment for people with cardiovascular disease and how this might affect practice, see the rationale and impact section on choosing antihypertensive drug treatment for people with cardiovascular disease.
Full details of the evidence and the committee's discussion are in the evidence review K: pharmacological treatment in cardiovascular disease.
Step 1 treatment
1.4.32
Offer an ACE inhibitor or an ARB to adults starting step1 antihypertensive treatment who:
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have type2 diabetes and are of any age or family origin (see also recommendation 1.4.30 for adults of Black African or African–Caribbean family origin) or
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are aged under55 but not of Black African or African–Caribbean family origin. [2019]
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.
1.4.33
If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB to treat hypertension. [2019]
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.
1.4.34
Do not combine an ACE inhibitor with an ARB to treat hypertension. [2019]
1.4.35
Offer a calcium-channel blocker (CCB) to adults starting step1 antihypertensive treatment who:
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are aged 55or over and do not have type2 diabetes or
-
are of Black African or African–Caribbean family origin and do not have type2 diabetes (of any age). [2019]
1.4.36
If a CCB is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension. [2019]
1.4.37
If there is evidence of heart failure, offer a thiazide-like diuretic and follow NICE's guideline on chronic heart failure. [2019]
1.4.38
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. [2019]
1.4.39
For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment. [2019]
For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on step1 treatment.
Full details of the evidence and the committee's discussion are in evidence review E: step1 treatment.
Step 2 treatment
1.4.40
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. [2019]
1.4.41
If hypertension is not controlled in adults taking step1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step1 treatment:
-
a CCB or
-
a thiazide-like diuretic. [2019]
1.4.42
If hypertension is not controlled in adults taking step1 treatment of a CCB, offer the choice of 1 of the following drugs in addition to step1 treatment:
-
an ACE inhibitor or
-
an ARB or
-
a thiazide-like diuretic. [2019]
1.4.43
If hypertension is not controlled in adults of Black African or African–Caribbean family origin who do not have type2 diabetes taking step1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step1 treatment. [2019]
Step 3 treatment
1.4.44
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 (see recommendation1.4.40). [2019]
1.4.45
If hypertension is not controlled in adults taking step2 treatment, offer a combination of:
-
an ACE inhibitor or ARB (see also recommendation1.4.30 for people of Black African or African–Caribbean family origin) and
-
a CCB and
-
a thiazide-like diuretic. [2019]
For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on step2 and 3 treatment.
Full details of the evidence and the committee's discussion are in evidence review F: step2 and step3 treatment.
Step 4 treatment
1.4.46
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. [2019]
1.4.47
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 recommendation 1.4.40). [2019]
1.4.48
For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step4 treatment or seeking specialist advice. [2019]
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.
1.4.49
Consider further diuretic therapy with low-dose spironolactone for adults with resistant hypertension starting step4 treatment who have a blood potassium level of 4.5mmol/l or less. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia. [2019]
In March 2019, this was an off-label use of some preparations of spironolactone. See NICE's information on prescribing medicines.
1.4.50
When using further diuretic therapy for step4 treatment of resistant hypertension, monitor blood sodium and potassium and renal function within 1month of starting treatment and repeat as needed thereafter. [2019]
1.4.51
Consider an alpha-blocker or beta-blocker for adults with resistant hypertension starting step4 treatment who have a blood potassium level of more than 4.5mmol/l. [2019]
1.4.52
If blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4drugs, seek specialist advice. [2019]
For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on step4 treatment.
Full details of the evidence and the committee's discussion are in evidence review G: step4 treatment.
1.5 Identifying who to refer for same-day specialist review
1.5.1
If a person has severe hypertension (clinic blood pressure of 180/120mmHg or higher), but no symptoms or signs indicating same-day referral (see recommendation 1.5.2), carry out investigations for target organ damage (see recommendation1.3.3) as soon as possible:
-
If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
-
If no target organ damage is identified, confirm diagnosis by:
-
repeating clinic blood pressure measurement within 7days, or
-
considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), following recommendations 1.2.6 and 1.2.7, and ensuring a clinical review within 7 days. [2019]
-
1.5.2
Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120mmHg and higher with:
-
signs of retinal haemorrhage or papilloedema (accelerated hypertension) or
-
life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. [2019]
1.5.3
Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). [2019]
For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the rationale and impact section on identifying who to refer for same-day specialist review.
Full details of the evidence and the committee's discussion are in evidence review I: same-day specialist review.
Terms used in this guideline
This section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary.
Accelerated hypertension
A severe increase in blood pressure to 180/120mmHg or higher (and often over 220/120mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension.
Established cardiovascular disease
Medical history of ischaemic heart disease, cerebrovascular disease, peripheral vascular disease, aortic aneurysm or heart failure. Cardiovascular disease is a general term for conditions affecting the heart or blood vessels. It is usually associated with a build-up of fatty deposits inside the arteries (atherosclerosis) and an increased risk of blood clots. It can also be associated with damage to arteries in organs such as the brain, heart, kidneys and eyes through deposition of glassy material within the artery walls (arteriosclerosis). Cardiovascular disease is 1 of the main causes of death and disability in the UK, but it can often largely be prevented by leading a healthy lifestyle.
Masked hypertension
Clinic blood pressure measurements are normal (less than 140/90mmHg), but blood pressure measurements are higher when taken outside the clinic using average daytime ambulatory blood pressure monitoring (ABPM) or average home blood pressure monitoring (HBPM) blood pressure measurements.
Persistent hypertension
High blood pressure at repeated clinical encounters.
Stage1 hypertension
Clinic blood pressure ranging from 140/90mmHg to 159/99mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85mmHg to 149/94mmHg.
Stage2 hypertension
Clinic blood pressure of 160/100mmHg or higher but less than 180/120mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95mmHg or higher.
Stage3 or severe hypertension
Clinic systolic blood pressure of 180mmHg or higher or clinic diastolic blood pressure of 120mmHg or higher.
Target organ damage
Damage to organs such as the heart, brain, kidneys and eyes. Examples are left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy or increased urine albumin:creatinine ratio.
White-coat effect
A discrepancy of more than 20/10mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.