How To Manage Hypertension?

Dr Zaid Ismail

13 Mar 2025

Hypertension affects over a quarter of UK adults and is a major modifiable risk factor for stroke, MI, CKD, and heart failure. Most patients are asymptomatic. Management focuses on accurate diagnosis, cardiovascular risk assessment, and appropriate lifestyle and pharmacological interventions.

Diagnosis

Clinic BP ≥140/90 mmHg should prompt consideration of hypertension.
Ambulatory BP Monitoring (ABPM) or Home BP Monitoring (HBPM) is recommended to confirm diagnosis:
- Stage 1 Hypertension: ABPM/HBPM average ≥135/85 mmHg
- Stage 2 Hypertension: ABPM/HBPM average ≥150/95 mmHg
- Severe Hypertension: Clinic BP ≥180/120 mmHg

Lifestyle Advice

Recommend lifestyle interventions for all patients:

Reduce salt intake
Maintain healthy weight
Regular aerobic exercise
Limit alcohol consumption
Smoking cessation
Balanced diet rich in fruit and vegetables

Initiating Drug Treatment

Initiate antihypertensive medication based on patient’s stage and cardiovascular risk:

Stage 1 Hypertension:
- Treat if under 80 years with target organ damage, cardiovascular risk ≥10%, diabetes, renal disease, or established cardiovascular disease.
Stage 2 Hypertension:
- Treat all patients irrespective of age.
Severe Hypertension:
- Immediate assessment and prompt initiation of treatment.

NICE Treatment Algorithm

Step 1:

Under 55 years: ACE inhibitor or ARB
Over 55 years or African/Caribbean origin: Calcium channel blocker (CCB)

Step 2:

ACE inhibitor/ARB + CCB or thiazide-like diuretic

Step 3:

ACE inhibitor/ARB + CCB + thiazide-like diuretic

Step 4 (Resistant Hypertension):

Consider adding low-dose spironolactone if blood potassium ≤4.5 mmol/L.
Alpha-blocker or beta-blocker as alternatives.
Specialist referral if BP remains uncontrolled.

BP Targets

Under 80 years: Clinic BP <140/90 mmHg; ABPM/HBPM <135/85 mmHg
Over 80 years: Clinic BP <150/90 mmHg; ABPM/HBPM <145/85 mmHg

Monitoring and Follow-up

Annual BP checks for controlled hypertension.
Regular medication review for adherence and side effects.

Summary

Confirm hypertension diagnosis with ABPM/HBPM.
Lifestyle interventions for all.
Follow NICE stepped approach to medication.
Aim for NICE recommended BP targets.