Understanding Blood Pressure Measurement
Accurate blood pressure measurement is the cornerstone of hypertension diagnosis. Healthcare professionals must be well-trained and regularly assessed to ensure consistent and reliable readings.
For precise measurements, especially when using automated devices, it’s crucial to check for pulse irregularities like atrial fibrillation by palpating the radial or brachial pulse. If irregularities are detected, manual blood pressure measurement using a stethoscope over the brachial artery is recommended.
Healthcare facilities should utilize validated blood pressure monitoring devices, ensuring they are properly maintained and recalibrated according to manufacturer guidelines. Resources like the British and Irish Hypertension Society website provide lists of validated devices.
Whether in a clinic or at home, create a standardized, comfortable environment for blood pressure readings. The room should be quiet and at a comfortable temperature. The individual should be seated and relaxed, with their arm supported at heart level. Using the correct cuff size is also essential for accurate results.
Addressing Postural Hypotension
For individuals experiencing symptoms of postural hypotension, such as dizziness or falls when standing, a specific measurement protocol is necessary.
Initially, measure blood pressure while the person is lying down (or seated if lying down is difficult). Then, repeat the measurement after they have stood for at least one minute.
A significant drop in blood pressure – a systolic decrease of 20 mmHg or more, or a diastolic decrease of 10 mmHg or more – after standing indicates postural hypotension. In such cases, investigate potential causes, including medication review, and manage accordingly. Subsequent blood pressure measurements should be taken in a standing position. If symptoms persist despite addressing likely causes, specialist referral should be considered.
If the blood pressure drop is less pronounced but symptoms suggest postural hypotension, and the initial measurement was seated, repeat the measurements starting with the person lying down to ensure accuracy.
Referral for specialist assessment is recommended if postural hypotension is suspected but not confirmed through blood pressure measurements.
Diagnosing Hypertension: A Step-by-Step Guide
When hypertension is suspected, blood pressure should be measured in both arms initially.
If a difference of more than 15 mmHg is observed between arms, repeat the measurements. If the difference persists after the second measurement, use the arm with the higher reading for all subsequent measurements.
If a clinic blood pressure reading is 140/90 mmHg or higher, take a second measurement during the same consultation. If there is a notable difference between the first and second readings, a third measurement is advised. The lower of the last two readings should be recorded as the clinic blood pressure.
For clinic blood pressure readings between 140/90 mmHg and 180/120 mmHg, Ambulatory Blood Pressure Monitoring (ABPM) is recommended to confirm a hypertension diagnosis. For readings of 180/120 mmHg or higher, refer to the section on specialist referral.
If ABPM is unsuitable or not tolerated by the individual, Home Blood Pressure Monitoring (HBPM) should be offered as an alternative for confirming hypertension.
While awaiting hypertension diagnosis confirmation, routine assessments for cardiovascular risk factors and potential target organ damage should be conducted.
When using ABPM for diagnosis, ensure at least two readings per hour are taken during waking hours (e.g., 8:00 AM to 10:00 PM). A diagnosis of hypertension is confirmed if the average of at least 14 measurements taken during waking hours is 135/85 mmHg or higher.
For HBPM diagnosis confirmation:
- Take two consecutive measurements at least one minute apart for each recording, with the person seated.
- Record blood pressure twice daily, ideally in the morning and evening.
- Continue recording for at least 4 days, ideally 7 days.
- Discard the first day’s measurements and use the average of all remaining measurements to confirm hypertension.
Hypertension diagnosis is confirmed if clinic blood pressure is 140/90 mmHg or higher AND ABPM daytime average or HBPM average is 135/85 mmHg or higher.
If hypertension is not diagnosed but target organ damage is evident, investigate alternative causes for the damage, referring to NICE guidelines on chronic kidney disease and chronic heart failure for investigation guidance.
If hypertension is ruled out, clinic blood pressure should be checked at least every 5 years. More frequent checks should be considered if clinic blood pressure is close to 140/90 mmHg.
Annual Blood Pressure Checks for Type 2 Diabetes
For adults with type 2 diabetes without a prior hypertension or renal disease diagnosis, annual blood pressure measurement is recommended. Lifestyle advice should be offered and reinforced during these checks.
Specialist Investigations for Secondary Hypertension
Consider specialist investigations for individuals exhibiting signs or symptoms suggesting secondary hypertension.
For a detailed explanation of the 2019 guideline changes and their impact on diagnosis, refer to the rationale and impact section on diagnosing hypertension in the original guideline document.
Further details on evidence and committee discussions can be found in evidence review A: diagnosis.
Cardiovascular Risk and Target Organ Damage Assessment
Refer to NICE guidelines on chronic kidney disease for guidance on early identification and management of chronic kidney disease.
Formal cardiovascular risk estimation is crucial for discussing prognosis and treatment options with hypertensive individuals, considering both blood pressure and other modifiable risk factors.
Cardiovascular risk should be estimated according to NICE guidelines on cardiovascular disease, using clinic blood pressure measurements for calculation.
For all individuals diagnosed with hypertension, offer the following assessments:
- Urine test for protein (albumin:creatinine ratio) and reagent strip test for hematuria.
- Blood sample to measure glycated hemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol, and HDL cholesterol.
- Fundoscopy to examine for hypertensive retinopathy.
- 12-lead electrocardiogram (ECG).
Hypertension Treatment and Monitoring Strategies
Lifestyle Modifications
Refer to NICE guidelines on obesity prevention and cardiovascular disease prevention for lifestyle guidance.
Lifestyle advice should be offered to all individuals with suspected or diagnosed hypertension and reinforced regularly.
Inquire about diet and exercise habits, as healthy eating and regular physical activity can effectively lower blood pressure. Provide relevant guidance and resources to support lifestyle changes.
Assess alcohol consumption and encourage reduced intake for those drinking excessively, as this can lower blood pressure and provide broader health benefits. Refer to NICE guidelines on alcohol-use disorders for practice recommendations.
Discourage excessive intake of coffee and caffeine-rich products.
Promote a low dietary sodium intake through salt reduction or substitution, which can help lower blood pressure. Note that potassium chloride-containing salt substitutes should be avoided by older adults, people with diabetes, pregnant women, individuals with kidney disease, and those taking certain antihypertensive medications. Salt reduction is still advised for these groups.
Calcium, magnesium, or potassium supplements are not recommended as a method for blood pressure reduction.
Offer smoking cessation advice and support to smokers, referring to NICE guidelines on tobacco.
Inform individuals about local support initiatives, such as healthcare team programs or patient organizations, that promote healthy lifestyle changes, particularly group-based programs for motivation.
Relaxation therapies are no longer routinely recommended due to limited evidence of effectiveness in reducing cardiovascular events or improving quality of life. The focus should be on lifestyle modifications and pharmacological treatments.
For a detailed explanation of the removal of relaxation therapy recommendations, see the rationale and impact section on relaxation therapies in the original guideline document.
Further details on evidence and committee discussions can be found in evidence review H: relaxation therapies.
Initiating Antihypertensive Drug Treatment
NICE provides a patient decision aid on hypertension treatment options to facilitate discussions between individuals and healthcare professionals, aiding in personalized treatment decisions.
Refer to NICE guidelines on medicines optimisation for advice on shared decision-making regarding medication.
To support medication adherence, consult NICE guidelines on medicines adherence.
Antihypertensive drug treatment, in addition to lifestyle advice, is recommended for adults of any age with persistent stage 2 hypertension. Clinical judgment is advised for frail or multimorbid individuals, referring to NICE guidelines on multimorbidity.
For adults under 80 with persistent stage 1 hypertension and one or more of the following, discuss initiating antihypertensive drug treatment alongside lifestyle advice:
- Target organ damage
- Established cardiovascular disease
- Renal disease
- Diabetes
- Estimated 10-year cardiovascular disease risk of 10% or more.
Clinical judgment is necessary for frail or multimorbid individuals.
Discuss individual cardiovascular disease risk and treatment preferences, including the option of no treatment, explaining risks and benefits before starting medication. Continue to offer lifestyle advice and support regardless of treatment choice.
Consider antihypertensive drug treatment alongside lifestyle advice for adults under 60 with stage 1 hypertension and a 10-year risk below 10%, acknowledging that 10-year risk may underestimate lifetime cardiovascular disease probability.
For individuals over 80 with stage 1 hypertension, consider drug treatment if clinic blood pressure exceeds 150/90 mmHg, using clinical judgment for frail or multimorbid individuals.
For adults under 40 with hypertension, consider specialist evaluation for secondary causes and detailed assessment of long-term treatment benefits and risks.
For a detailed explanation of the 2019 guideline changes on initiating drug treatment, refer to the rationale and impact section on starting antihypertensive drug treatment in the original guideline document.
Further details on evidence and committee discussions can be found in evidence review C: initiating treatment.
Monitoring Treatment and Blood Pressure Targets
Refer to NICE guidelines on chronic kidney disease, type 1 diabetes, and hypertension in pregnancy for specific blood pressure control recommendations in these populations.
Consult Table 1 and Table 2 in the original guideline for clinic blood pressure targets for individuals under 80 and over 80, respectively, including those with and without type 2 diabetes, chronic kidney disease, or type 1 diabetes.
Clinic blood pressure measurements should be used to monitor response to lifestyle changes or drug treatment.
Check for postural hypotension in individuals with hypertension who also have type 2 diabetes, symptoms of postural hypotension, or are aged 80 and over. For those with significant postural drop or symptoms, treatment targets should be based on standing blood pressure.
Advise hypertensive individuals who choose self-monitoring to use HBPM, with support available through programs like NHS England’s blood pressure@home scheme.
Consider ABPM or HBPM in addition to clinic measurements for individuals with suspected white-coat effect or masked hypertension, noting that ABPM and HBPM targets are 5 mmHg lower than clinic targets.
For individuals using HBPM, provide training and advice on monitor use and information on actions if targets are not met.
For adults under 80 with hypertension, aim to reduce clinic blood pressure below 140/90 mmHg and maintain it at that level or lower. Refer to Table 1 for specific targets for those with type 1 diabetes or severe chronic kidney disease.
For adults 80 and over, reduce clinic blood pressure below 150/90 mmHg and maintain it, using clinical judgment for frail or multimorbid individuals. Refer to Table 2 for specific targets for those with type 1 diabetes or severe chronic kidney disease.
When monitoring treatment response with ABPM or HBPM, use average waking hours blood pressure. Reduce and maintain blood pressure below 135/85 mmHg for those under 80 and below 145/85 mmHg for those 80 and over, using clinical judgment for frail or multimorbid individuals.
Blood pressure targets are the same for individuals with and without cardiovascular disease.
Annual care reviews are essential for adults with hypertension to monitor blood pressure, provide support, and discuss lifestyle, symptoms, and medication.
Treatment Review Upon Type 2 Diabetes Diagnosis
For adults with type 2 diabetes diagnosed while on antihypertensive medication, review blood pressure control and current medications. Make changes only if control is poor or current treatment is inappropriate due to microvascular complications or metabolic issues.
Selecting Antihypertensive Drug Treatment
These recommendations apply to individuals with hypertension, with or without type 2 diabetes, replacing previous guidelines on hypertension management in type 2 diabetes. For type 1 diabetes, refer to NICE guidelines on type 1 diabetes for antihypertensive drug treatment.
ACE inhibitors and angiotensin II receptor antagonists are contraindicated in pregnancy, breastfeeding, or for women planning pregnancy unless absolutely necessary, with careful risk-benefit discussion. Consult MHRA safety advice for detailed guidance.
For individuals with chronic kidney disease, refer to NICE guidelines on chronic kidney disease for hypertensive agent selection. Whenever possible, prescribe once-daily medications.
Prescribe non-proprietary drugs when appropriate to minimize costs.
Isolated systolic hypertension (systolic blood pressure ≥160 mmHg) should be treated the same as combined systolic and diastolic hypertension.
Antihypertensive drug treatment for women of childbearing potential with hypertension should align with these guidelines, but management during pregnancy and breastfeeding should follow NICE guidelines on hypertension in pregnancy.
For individuals of Black African or African-Caribbean descent, consider angiotensin II receptor blockers (ARBs) over ACE inhibitors as initial therapy.
For individuals with cardiovascular disease:
- Prioritize disease-specific guidelines from NICE for conditions like acute coronary syndromes, acute heart failure, chronic heart failure, stable angina, and type 1 diabetes when choosing drug therapy.
- If blood pressure remains uncontrolled, follow the antihypertensive drug treatment recommendations outlined below.
For a detailed explanation of the 2022 guideline changes on drug treatment for cardiovascular disease, refer to the rationale and impact section on choosing antihypertensive drug treatment for people with cardiovascular disease in the original guideline document.
Further details on evidence and committee discussions can be found in evidence review K: pharmacological treatment in cardiovascular disease.
Step 1 Treatment
Offer ACE inhibitors or ARBs as first-line treatment for hypertension to adults under 55 years and adults of any age with type 2 diabetes.
If ACE inhibitors are not tolerated (e.g., due to cough), offer ARBs.
Do not combine ACE inhibitors and ARBs for hypertension treatment.
Offer calcium-channel blockers (CCBs) as step 1 treatment for adults aged 55 and over without type 2 diabetes, or for adults of Black African or African-Caribbean descent without type 2 diabetes, regardless of age.
If CCBs are not tolerated (e.g., due to edema), offer thiazide-like diuretics.
In cases of heart failure, offer thiazide-like diuretics, following NICE guidelines on chronic heart failure.
When initiating or changing diuretic treatment, thiazide-like diuretics such as indapamide are preferred over conventional thiazide diuretics like bendroflumethiazide or hydrochlorothiazide.
For individuals already stable on bendroflumethiazide or hydrochlorothiazide, continue their current treatment if blood pressure is well-controlled.
For a detailed explanation of the 2019 guideline changes on step 1 treatment, refer to the rationale and impact section on step 1 treatment in the original guideline document.
Further details on evidence and committee discussions can be found in evidence review E: step 1 treatment.
Step 2 Treatment
Before advancing to step 2 treatment, discuss medication adherence with the individual and provide support as per NICE guidelines on medicines adherence.
If hypertension remains uncontrolled on step 1 treatment with an ACE inhibitor or ARB, offer a choice of adding either a CCB or a thiazide-like diuretic.
If hypertension remains uncontrolled on step 1 treatment with a CCB, offer a choice of adding an ACE inhibitor, an ARB, or a thiazide-like diuretic.
For individuals of Black African or African-Caribbean descent without type 2 diabetes, if hypertension is uncontrolled on step 1 treatment, consider adding an ARB over an ACE inhibitor.
Step 3 Treatment
Before considering step 3 treatment:
- Review medication doses to ensure they are optimized and tolerated.
- Discuss medication adherence.
If hypertension remains uncontrolled on step 2 treatment, offer a combination of:
- An ACE inhibitor or ARB (consider ARB preference for individuals of Black African or African-Caribbean descent).
- A CCB.
- A thiazide-like diuretic.
For a detailed explanation of the 2019 guideline changes on step 2 and 3 treatment, refer to the rationale and impact section on step 2 and 3 treatment in the original guideline document.
Further details on evidence and committee discussions can be found in evidence review F: step 2 and step 3 treatment.
Step 4 Treatment
Individuals with hypertension uncontrolled on optimal doses of an ACE inhibitor or ARB, a CCB, and a thiazide-like diuretic are considered to have resistant hypertension.
Before proceeding with further treatment for resistant hypertension:
- Confirm elevated clinic blood pressure using ABPM or HBPM.
- Assess for postural hypotension.
- Discuss medication adherence.
For confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice.
Consider adding low-dose spironolactone as a fourth drug for step 4 treatment in resistant hypertension if blood potassium is ≤4.5 mmol/l, with caution in individuals with reduced eGFR due to hyperkalemia risk.
When using further diuretic therapy for step 4 treatment, monitor blood sodium, potassium, and renal function within one month and regularly thereafter.
Consider alpha-blockers or beta-blockers as fourth-line agents for resistant hypertension if blood potassium is >4.5 mmol/l.
If blood pressure remains uncontrolled on optimal doses of four drugs, seek specialist advice.
For a detailed explanation of the 2019 guideline changes on step 4 treatment, refer to the rationale and impact section on step 4 treatment in the original guideline document.
Further details on evidence and committee discussions can be found in evidence review G: step 4 treatment.
Identifying Individuals for Same-Day Specialist Review
For individuals with severe hypertension (clinic blood pressure ≥180/120 mmHg) without symptoms or signs requiring immediate referral, investigate target organ damage promptly.
- If target organ damage is identified, consider immediate antihypertensive drug treatment without awaiting ABPM or HBPM results.
- If no target organ damage is found, confirm diagnosis by repeating clinic blood pressure within 7 days or using ABPM (or HBPM if ABPM unsuitable) with clinical review within 7 days.
Refer for same-day specialist assessment if clinic blood pressure is ≥180/120 mmHg with:
- Signs of retinal hemorrhage or papilledema (accelerated hypertension).
- Life-threatening symptoms such as new confusion, chest pain, heart failure signs, or acute kidney injury.
Refer for same-day specialist assessment if pheochromocytoma is suspected (e.g., labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis).
For a detailed explanation of the 2019 guideline changes on specialist referral, refer to the rationale and impact section on identifying who to refer for same-day specialist review in the original guideline document.
Further details on evidence and committee discussions can be found in evidence review I: same-day specialist review.
Key Terms in Hypertension Guidelines
Accelerated Hypertension: A severe blood pressure elevation (≥180/120 mmHg, often >220/120 mmHg) with retinal hemorrhage and/or papilledema, usually associated with new or progressive target organ damage, also known as malignant hypertension.
Established Cardiovascular Disease: Medical history of ischemic heart disease, cerebrovascular disease, peripheral vascular disease, aortic aneurysm, or heart failure.
Masked Hypertension: Normal clinic blood pressure (<140/90 mmHg) but elevated out-of-clinic blood pressure via ABPM or HBPM.
Persistent Hypertension: High blood pressure at repeated clinical encounters.
Stage 1 Hypertension: Clinic blood pressure 140/90–159/99 mmHg and ABPM/HBPM 135/85–149/94 mmHg.
Stage 2 Hypertension: Clinic blood pressure ≥160/100 mmHg but <180/120 mmHg and ABPM/HBPM ≥150/95 mmHg.
Stage 3 or Severe Hypertension: Clinic systolic blood pressure ≥180 mmHg or diastolic blood pressure ≥120 mmHg.
Target Organ Damage: Damage to organs like heart, brain, kidneys, eyes (e.g., left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy).
White-Coat Effect: Clinic blood pressure >20/10 mmHg higher than average daytime ABPM or HBPM at diagnosis.
Recommendations for Future Research
The guideline committee has identified key areas for future research to improve hypertension management:
- Automated Blood Pressure Monitoring in Atrial Fibrillation: Identify suitable automated monitors for hypertensive individuals with atrial fibrillation.
- Intervention Thresholds for Adults Under 40: Determine appropriate risk and blood pressure thresholds for treatment initiation in younger adults with hypertension.
- Blood Pressure Targets for People Over 80: Establish optimal blood pressure targets for older adults with treated primary hypertension.
- Step 1 Treatment Strategies: Investigate subgroups of hypertensive individuals who may benefit from initial dual therapy.
- Efficacy of Relaxation Therapies: Evaluate the clinical and cost-effectiveness of relaxation therapies in reducing cardiovascular events and improving quality of life in hypertension management.
- Same-Day Specialist Assessment Criteria: Define criteria for same-day hospital referral for individuals with extreme hypertension or emergency symptoms.
- Blood Pressure Targets in Aortic Aneurysm: Determine optimal blood pressure targets for adults with hypertension and aortic aneurysm, considering age variations.
- Blood Pressure Targets Post-Stroke: Establish optimal blood pressure targets for adults with prior ischemic or hemorrhagic stroke, considering age variations.
These research recommendations aim to address current evidence gaps and refine future hypertension management strategies.
