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Slide Set | 2017 Guideline For the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Updated May 2018)

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Date: May 07, 2018    

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Hypertension Clinical Presentation

• Author: Mackenzie Samson, MD; Chief Editor: Eric H Yang, MD  more...
• Sections Hypertension
• Practice Essentials
• Pathophysiology
• Epidemiology
• Patient Education
• Physical Examination
• Hypertension and Cerebrovascular Disease
• Hypertensive Emergencies
• Hypertensive Heart Disease
• Hypertension in Pediatric Patients
• Hypertension in Pregnancy
• Primary Aldosteronism
• Approach Considerations
• Baseline Laboratory Evaluation
• Radiologic Studies
• Nonpharmacologic Therapy
• Pharmacologic Therapy
• Management of Diabetes and Hypertension
• Management of Hypertensive Emergencies
• Management of Hypertension in Pregnancy
• Management of Hypertension in Pediatric Patients
• Management of Hypertension in the Elderly
• Management of Hypertension in Black Patients
• Management of Ocular Hypertension
• Management of Renovascular Hypertension
• Management of Resistant Hypertension
• Management of Pseudohypertension
• Management of Pheochromocytoma
• Management of Primary Hyperaldosteronism
• Interventions for Improving Blood Pressure Control
• Medication Summary
• Diuretics, Thiazide
• Diuretic, Potassium-Sparing
• Diuretics, Loop
• Beta-Blockers, Beta-1 Selective
• Beta-Blockers, Alpha Activity
• Beta-Blockers, Intrinsic Sympathomimetic
• Vasodilators
• Calcium Channel Blockers
• Aldosterone Antagonists, Selective
• Alpha2-agonists, Central-acting
• Renin Inhibitors/Combos
• Alpha-Blockers, Antihypertensives
• Antihypertensives, Other
• Antihypertensive Combinations
• Endothelin Antagonists
• Questions & Answers
• Media Gallery

Following the documentation of hypertension, which is confirmed after an elevated blood pressure (BP) on at least three separate occasions (based on the average of two or more readings taken at each of two or more follow-up visits after initial screening), a detailed history should extract the following information:

Extent of end-organ damage (eg, heart, brain, kidneys, eyes)

Assessment of patients’ cardiovascular risk status

Exclusion of secondary causes of hypertension

Patients may have undiagnosed hypertension for years without having had their BP checked. Therefore, a careful history of end-organ damage should be obtained. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) identifies the following as targets of end-organ damage [ 7 ] :

Heart: left ventricular hypertrophy, angina/previous myocardial infarction, previous coronary revascularization, and heart failure

Brain: stroke or transient ischemic attack, dementia

Chronic kidney disease

Peripheral arterial disease

Retinopathy

The JNC 7 identifies the following as major cardiovascular risk factors [ 7 ] :

Hypertension: Component of metabolic syndrome

Tobacco use, particularly cigarettes, including chewing tobacco

Elevated low-density lipoprotein (LDL) cholesterol (or total cholesterol ≥240 mg/dL) or low high-density lipoprotein (HDL) cholesterol: component of metabolic syndrome

Diabetes mellitus: component of metabolic syndrome

Obesity (body mass index [BMI] ≥30 kg/m 2 ): component of metabolic syndrome

Age greater than 55 years for men or greater than 65 years for women: Increased risk begins at the respective ages; the Adult Treatment Panel III used earlier age cut points to suggest the need for earlier action

Estimated glomerular filtration rate less than 60 mL/min

Microalbuminuria

Family history of premature cardiovascular disease (men < 55 years; women < 65 years)

Lack of exercise

Obtain a history of the patient’s use of over-the-counter (OTC) medications; herbal medicines such as herbal tea containing licorice (the issue is products containing licorice root; a large amount of licorice in the US is licorice candy, but black licorice and OTC licorice root supplements are increasingly available); ephedrine/ephedra ; current and previous unsuccessful antihypertensive medication trials; oral contraceptives; tizanidine; ethanol; and illicit drugs such as cocaine. Include the patient’s lifestyle factors, such as changes in weight, dietary intake of sodium and cholesterol, exercise level, and psychosocial stressors. [ 9 ]

The historical and physical findings that suggest the possibility of secondary hypertension are a history of known renal disease, bruits, abdominal masses, anemia, and urochrome pigmentation. A history of sweating, labile hypertension, and palpitations suggests the diagnosis of pheochromocytoma. A history of cold or heat tolerance, sweating, lack of energy, and bradycardia or tachycardia may indicate hypothyroidism or hyperthyroidism. Abdominal bruits may indicate renovascular hypertension. Kidney stones raise the possibility of hyperparathyroidism. A history of weakness suggests hyperaldosteronism. A history of obstructive sleep apnea may be noted.

An accurate measurement of blood pressure (BP) is the key to diagnosis. Several determinations should be made over a period of several weeks. At any given visit, 2-3 BP readings taken 1-2 minutes apart using a validated device is preferable. [ 1 , 9 ] On the first visit, BP should be checked in both arms and in one leg to avoid missing the diagnosis of coarctation of the aorta or subclavian artery stenosis.

The patient should rest quietly for at least 5 minutes before the measurement. BP should be measured in both the supine and sitting positions, auscultating with the bell of the stethoscope. As improper cuff size may influence BP measurement, a wider cuff is preferable, particularly if the patient’s arm circumference exceeds 30 cm.

Ambulatory or home BP monitoring provides a more accurate prediction of cardiovascular risk than do office BP readings. [ 66 ] "Nondipping" is the loss of the usual physiologic nocturnal drop in BP and is associated with an increased cardiovascular risk.

A study by Wong and Mitchell indicated that independent of other risk factors, the presence of certain signs of hypertensive retinopathy (eg, retinal hemorrhages, microaneurysms, cotton-wool spots) is associated with an increased cardiovascular risk (eg, stroke, stroke mortality). [ 67 ] Consequently, a funduscopic eye evaluation can help identify any signs of early or late, chronic or acute hypertensive retinopathy, such as arteriovenous nicking or vessel wall changes (eg, copper/silver wiring, hard exudates, flame-shaped hemorrhages, papilledema). Acute or chronic ocular changes can be the initial finding in asymptomatic patients that requires a primary care referral. Alternatively, a symptomatic patient may be referred to the ophthalmologist for visual alterations due to hypertensive changes.

Palpation of all peripheral pulses should be performed. Absent, weak, or delayed femoral pulses suggest coarctation of the aorta or severe peripheral vascular disease. In addition, the neck should be examined for carotid bruits, distended veins, or an enlarged thyroid gland. [ 7 , 9 ] Auscultation should be performed over the upper abdomen for renal artery bruits. The presence of a bruit with both a systolic and diastolic component suggests renal artery stenosis.

Perform a careful cardiac examination to evaluate signs of left ventricular hypertrophy. These include displacement of the apex, a sustained and enlarged apical impulse, and the presence of an S 4 . Occasionally, a tambour S 2 is heard with aortic root dilatation.

Blood pressure is a powerful determinant of risk for ischemic stroke and intracranial hemorrhage; in fact, long-standing hypertension may manifest as hemorrhagic and atheroembolic stroke or encephalopathy. Both the high systolic and diastolic pressures are harmful; a diastolic pressure of more than 100 mm Hg and a systolic pressure of more than 160 mm Hg are associated with a significant incidence of strokes. The American Heart Association notes that individuals whose blood pressure level is lower than 120/80 mm Hg have about 50% the lifetime stroke risk of that of hypertensive individuals.

Other cerebrovascular manifestations of complicated hypertension include hypertensive hemorrhage, hypertensive encephalopathy, lacunar-type infarctions, and dementia.

Hypertensive encephalopathy is one of the clinical manifestations of cerebral edema and microhemorrhages seen with dysfunction of cerebral autoregulation, and it is characterized by hypertension, altered mentation, and papilledema.

The history and physical examination determine the nature, severity, and management of the hypertensive event. The history should focus on the presence of end-organ dysfunction, the circumstances surrounding the hypertension, and any identifiable etiology. The physical examination should assess whether end-organ dysfunction is present (eg, neurologic, cardiovascular). BP should be measured in both the supine position and the standing position (assess volume depletion). BP should also be measured in both arms (a significant difference may suggest aortic dissection).

The most common clinical presentations of hypertensive emergencies are cerebral infarction (24.5%), pulmonary edema (22.5%), hypertensive encephalopathy (16.3%), and congestive heart failure (12%). Other clinical presentations associated with hypertensive emergencies include intracranial hemorrhage, aortic dissection , and eclampsia , [ 68 ] as well as acute myocardial infarction. Hypertension is also one of several conditions that have been increasingly recognized as having an association with posterior reversible encephalopathy syndrome (PRES), a condition characterized by headache, altered mental status, visual disturbances, and seizures. [ 69 ]

Uncontrolled and prolonged blood pressure (BP) elevation can lead to a variety of changes in the myocardial structure, coronary vasculature, and cardiac conduction system. These changes in turn can lead to the development of left ventricular hypertrophy (LVH), coronary artery disease, various conduction system diseases, and systolic and diastolic dysfunction of the myocardium, which manifests clinically as angina or myocardial infarction , cardiac arrhythmias (especially atrial fibrillation), and congestive heart failure (CHF) . Thus, hypertensive heart disease is a term applied generally to heart diseases—such as LVH, coronary artery disease , cardiac arrhythmias, and CHF—that are caused by direct or indirect effects of elevated BP. Hypertension is thought to be one of the leading causes of heart failure with preserved ejection fraction (HFpEF), with an associated prevalence of 60-89% in patients with HFpEF. [ 1 ]

Although these diseases generally develop in response to chronically elevated BP, keep in mind that marked and acute elevation of BP can also lead to accentuation of an underlying predisposition to any of the symptoms traditionally associated with chronic hypertension.

In a study by Tymchak et al, patients presenting with acute heart failure as a manifestation of hypertensive emergency were more likely to be Black and to have a history of heart failure; they were also more likely to have higher levels of B-type natriuretic peptide (BNP) and creatinine as well as lower left ventricular ejection fraction. Note that BNP is inversely proportional to the degree of a patient’s obesity. [ 70 ]

Systemic hypertension is less common in children than in adults, but the incidence of hypertension in children is approximately 1-5% and seems to be increasing in Western societies. The presence of hypertension in younger children is usually indicative of an underlying disease process (secondary hypertension), including childhood obesity. In children, approximately 5-25% of cases of secondary hypertension are attributed to renovascular disease.

Advances in the ability to identify, evaluate, and care for infants with hypertension, coupled with advances in the practice of neonatology in general, have led to an increased awareness of hypertension in modern neonatal intensive care units (NICUs) since its first description in the 1970s.

Hypertension is the most common medical problem encountered during pregnancy, complicating 2-3% of pregnancies. [ 71 ]

A large, population-based study that compared 26,651 pregnant women with hypertensive disorders to 213,397 pregnant women without hypertensive disorders to determine the risk of end-stage renal disease found that the incidence of chronic kidney disease was almost 11-fold higher in the hypertensive group. [ 72 ] This group also exhibited a 14-fold increased risk for end-stage renal disease. The risk was much greater for women with preeclampsia or eclampsia.

The American College of Obstetricians and Gynecologists (ACOG) recommends that women with prior preeclampsia who have delivered preterm (< 37.5 weeks) or who have a history of recurrent preeclampsia undergo yearly assessment of blood pressure, lipid profile, plasma glucose, and body weight. [ 73 ]

Mineralocorticoid excess secondary to primary hyperaldosteronism (PA) is characterized by excessive production of aldosterone. Previously considered a rare cause of hypertension, PA is now recognized to be the most common cause of secondary hypertension. Renal sodium retention, kaliuresis, hypokalemia, and hypochloremic metabolic alkalosis are common manifestations. Consider PA in patients who have an exaggerated hypokalemic response to a thiazide diuretic or who have hypokalemia unprovoked by a diuretic. These patients develop increased intravascular volume, resulting in hypertension. Hypokalemia, however, is present in less than half of patients with PA, and thus the ratio of plasma aldosterone to renin activity should be used to screen suspected cases. Blood pressure (BP) increase may vary from mild hypertension to marked elevation. Patients may have underlying adenoma or hyperplasia of the adrenal gland and, rarely, have an extra-adrenal source for aldosterone.

Although the incidence of primary hyperaldosteronism in one study was estimated to be 1.5%, [ 21 ] newer estimates based on 24-hour urinary aldosterone levels have indicated that up to 30% of patients with resistant hypertension have hyperaldosteronism. Obesity is increasingly associated with PA, and treatment with aldosterone receptor antagonists have proven effective in this population.

To screen for primary hyperaldosteronism, the most precise and accurate test is the aldosterone:renin activity ratio. [ 1 ] A ratio of 30 is the most commonly used cutoff value, with a plasma aldosterone level of at least 10 ng/dL. [ 1 ] A confirmatory test, such as an intravenous saline suppression test or oral salt-loading test with measurement of 24-hour urine aldosterone and sodium, is needed to make the diagnosis. Once the diagnosis is confirmed, adrenal venous sampling should be performed to determine if excess aldosterone is unilateral or bilateral. If unilateral production is confirmed, a laparoscopic adrenalectomy can be curative. If the patient is not fit for surgery or bilateral excessive aldosterone production is present, a mineralocorticoid receptor antagonist (spironolactone or eplerenone) can be used for treatment. [ 1 ]

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• Hypertension. Anteroposterior x-ray from a 28-year old woman who presented with congestive heart failure secondary to her chronic hypertension, or high blood pressure. The enlarged cardiac silhouette on this image is due to congestive heart failure due to the effects of chronic high blood pressure on the left ventricle. The heart then becomes enlarged, and fluid accumulates in the lungs, known as pulmonary congestion.
• Hypertension. Electrocardiogram (ECG) from a 47-year-old man with a long-standing history of uncontrolled hypertension. This image shows left atrial enlargement and left ventricular hypertrophy.
• Hypertension. Electrocardiogram (ECG) from a 46-year-old man with long-standing hypertension. This ECG shows left atrial abnormality and left ventricular hypertrophy with strain.
• Hypertension. Hypertrophied cardiac myocytes with enlarged "box car" nuclei.
• Hypertension. Prevalence of hypertension among adults aged 18 and older, by sex and age: United States, 2017-2018. Courtesy of the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS).
• Hypertension. Age-adjusted trends in hypertension among adults aged 18 and older: United States, 1999–2018. Courtesy of the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS).
• Table 2. NHIS/NCHS Age-Adjusted Prevalence Estimates in Individuals Aged 18 Years and Older in 2015.
• Table 2. Identifiable Hypertension and Screening Tests
• Table 3. Hypertensive Disorders in Pregnancy
• Table 4. Guidelines for Blood Pressure Screening in Adults
• Table 5. Target Blood Pressure Recommendations
• Table 6. American Society of Hypertension/International Society of Hypertension Treatment Recommendations
• Table 7. JNC 7 Classification of Hypertensive Disorders in Pregnancy

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Hypertension in adults: diagnosis and management

NICE Guideline, No. 136

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This guideline replaces CG127.

This guideline partially replaces NG28.

This guideline is the basis of QS181, QS28 and QS209.

This guideline covers identifying and treating primary hypertension (high blood pressure) in people aged 18 and over, including people with type 2 diabetes. It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively.

NICE has also produced a guideline on hypertension in pregnancy .

Who is it for?

• Healthcare professionals
• Commissioners and providers
• People who have or may have high blood pressure, their families and carers
• Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE’s information on making decisions about your care .

Making decisions using NICE guidelines explains 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 type 2 diabetes. The recommendations on treatment and monitoring link to NICE’s guidelines on chronic kidney disease , type 1 diabetes and hypertension in pregnancy at points in the care pathway where treatment differs. The recommendations on treatment and monitoring apply to adults with type 2 diabetes and replace recommendations on diagnosing and managing hypertension in NICE’s guideline on type 2 diabetes in adults.

1.1. Measuring blood pressure

Training, technique and device maintenance.

Ensure that healthcare professionals taking blood pressure measurements have adequate initial training and periodic review of their performance. [2004]

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]

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]

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

• 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 1 minute. [2004, amended 2023]
• 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]

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]

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

• If the difference in readings between arms is more than 15 mmHg, repeat the measurements.
• If the difference in readings between arms remains more than 15 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading. [2019]
• 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 2 measurements as the clinic blood pressure. [2019]

If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, 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 180/120 mmHg or higher. [2019]

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]

• 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]

When using ABPM to confirm a diagnosis of hypertension, ensure that at least 2 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 a diagnosis of hypertension. [2011]

• for each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute 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 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 a diagnosis of hypertension. [2011]
• clinic blood pressure of 140/90 mmHg or higher and
• ABPM daytime average or HBPM average of 135/85 mmHg or higher. [2019]

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]

If hypertension is not diagnosed, measure the person’s clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person’s clinic blood pressure is close to 140/90 mmHg. [2011]

Annual blood pressure measurement for people with type 2 diabetes

Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice. [2009]

Specialist investigations for possible secondary causes of hypertension

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 .

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]

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]

• 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 .

Offer lifestyle advice to people with suspected or diagnosed hypertension, and continue to offer it periodically. [2004]

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]

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]

Discourage excessive consumption of coffee and other caffeine-rich products. [2004]

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 angiotensin II receptor blockers. Encourage salt reduction in these groups. [2004, amended 2019]

Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. [2004]

Offer advice and help to smokers to stop smoking. See NICE’s guideline on tobacco . [2004]

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 .

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension . Use clinical judgement for people of any age with frailty or multimorbidity (see also NICE’s guideline on multimorbidity ). [2019]

• target organ damage
• established cardiovascular disease
• renal disease
• 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]

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]

Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 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]

Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with stage 1 hypertension if their clinic blood pressure is over 150/90 mmHg. Use clinical judgement for people with frailty or multimorbidity (see also NICE’s guideline on multimorbidity ). [2019]

For adults aged under 40 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.

Clinic blood pressure targets for people aged under 80.

Clinic blood pressure targets for people aged 80 and over.

Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension. [2019]

• type 2 diabetes or
• symptoms of postural hypotension (see also recommendation 1.1.7 ) or
• aged 80 and 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]

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]

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 5 mmHg lower than for clinic measurements (see recommendation 1.2.8 for diagnostic thresholds ). [2019]

• 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 5 mmHg lower than for clinic measurements (see recommendation 1.2.8 for diagnostic thresholds ). [2019]

For adults with hypertension aged under 80, reduce clinic blood pressure to below 140/90 mmHg 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]

For adults with hypertension aged 80 and over, reduce clinic blood pressure to below 150/90 mmHg 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]

• below 135/85 mmHg for adults aged under 80
• below 145/85 mmHg for adults aged 80 and 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 .

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 .

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 type 2 diabetes is diagnosed

For an adult with type 2 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 type 2 diabetes)

The recommendations in this section apply to people with hypertension with or without type 2 diabetes. They replace the recommendations on diagnosing and managing hypertension in NICE’s guideline on type 2 diabetes in adults . For guidance on choosing antihypertensive drug treatment in people with type 1 diabetes, see also the section on control of cardiovascular risk in NICE’s guideline on type 1 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 .

For guidance on choice of hypertensive agent 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]

Prescribe non-proprietary drugs if these are appropriate and minimise cost. [2004]

Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure. [2004]

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]

When choosing antihypertensive drug treatment for adults of Black African or African–Caribbean family origin, consider an angiotensin II 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 .

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 type 1 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

• have type 2 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
• are aged under 55 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 .

If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB to treat hypertension. [2019]

Do not combine an ACE inhibitor with an ARB to treat hypertension. [2019]

• are aged 55 or over and do not have type 2 diabetes or
• are of Black African or African–Caribbean family origin and do not have type 2 diabetes (of any age). [2019]

If a CCB is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension. [2019]

If there is evidence of heart failure, offer a thiazide-like diuretic and follow NICE’s guideline on chronic heart failure . [2019]

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]

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 step 1 treatment .

Full details of the evidence and the committee’s discussion are in evidence review E: step 1 treatment .

Step 2 treatment

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]

• a thiazide-like diuretic. [2019]
• an ACE inhibitor or

If hypertension is not controlled in adults of Black African or African–Caribbean family origin who do not have type 2 diabetes taking step 1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step 1 treatment. [2019]

Step 3 treatment

• review the person’s medications to ensure they are being taken at the optimal tolerated doses and
• discuss adherence (see recommendation 1.4.40 ). [2019]
• an ACE inhibitor or ARB (see also recommendation 1.4.30 for people of Black African or African–Caribbean family origin) and

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 step 2 and 3 treatment .

Full details of the evidence and the committee’s discussion are in evidence review F: step 2 and step 3 treatment .

Step 4 treatment

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]

• 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]

For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice. [2019]

Consider further diuretic therapy with low-dose spironolactone for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of 4.5 mmol/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 .

When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium and potassium and renal function within 1 month of starting treatment and repeat as needed thereafter. [2019]

Consider an alpha-blocker or beta-blocker for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4.5 mmol/l. [2019]

If blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4 drugs, 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 step 4 treatment .

Full details of the evidence and the committee’s discussion are in evidence review G: step 4 treatment .

1.5. Identifying who to refer for same-day specialist review

• If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

repeating clinic blood pressure measurement within 7 days, 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]

• 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]

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 .

A severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) 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.

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.

Clinic blood pressure measurements are normal (less than 140/90 mmHg), 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.

High blood pressure at repeated clinical encounters.

Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg.

Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.

Clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.

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.

A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.

• Recommendations for research

The 2019 and 2022 guideline committees have made the following recommendations for research.

1. Automated blood pressure monitoring in people with atrial fibrillation

Which automated blood pressure monitors are suitable for people with hypertension and atrial fibrillation? [2019]

For a short explanation of why the committee made the recommendation for research, see the rationale on monitoring treatment and blood pressure targets for people without cardiovascular disease .

2. Thresholds for interventions in adults aged under 40

In adults aged under 40 with hypertension (with or without type 2 diabetes), what are the appropriate risk and blood pressure thresholds for starting treatment? [2019]

For a short explanation of why the committee made the recommendation for research, see the rationale on starting antihypertensive drug treatment .

3. Blood pressure targets for people aged over 80

What is the optimum blood pressure target for people aged over 80 with treated primary hypertension (with or without cardiovascular disease)? [2022]

For a short explanation of why the committee made the recommendation for research, see the rationale on blood pressure targets for people with cardiovascular disease .

Full details of the evidence and the committee’s discussion are in evidence review D: targets .

4. Step 1 treatment

Are there subgroups of people with hypertension who should start on dual therapy? [2019]

For a short explanation of why the committee made the recommendation for research, see the rationale on step 1 treatment .

5. Relaxation therapies

What is the clinical and cost effectiveness of relaxation therapies for managing primary hypertension in adults in terms of reducing cardiovascular events and improving quality of life? [2019]

For a short explanation of why the committee made the recommendation for research, see the rationale on relaxation therapies .

6. Same-day hospital specialist assessment

Which people with extreme hypertension (220/120 mmHg or higher) or emergency symptoms should be referred for same-day hospital specialist assessment? [2019]

For a short explanation of why the committee made the recommendation for research, see the see rationale on identifying who to refer for same-day specialist review .

7. Blood pressure targets for people with aortic aneurysm

What are the optimal blood pressure targets in adults with hypertension and aortic aneurysm, and does this vary by age? [2022]

For a short explanation of why the committee made the recommendation for research, see the rationale and impact section on blood pressure targets for people with cardiovascular disease .

8. Blood pressure targets for people with prior ischaemic or haemorrhagic stroke

What are the optimal blood pressure targets in adults with prior ischaemic or haemorrhagic stroke, and does this vary by age? [2022]

• Rationale and impact

These sections briefly explain why the committee made the recommendations and how they might affect practice. They link to details of the evidence and a full description of the committee’s discussion.

Diagnosing hypertension

Recommendations 1.2.1 to 1.2.5 and 1.2.8

Why the committee made the recommendations

Overall, there was limited new evidence on the accuracy of different methods of measuring blood pressure. Most of the studies identified were small, and the populations and protocols for measurement varied making interpretation difficult. However, the committee agreed that it was important to focus on the evidence from these more recent studies (post-2000) because the evidence should reflect the current use of electronic sphygmomanometers, which have replaced mercury-based sphygmomanometers.

The evidence did not show that changing the current blood pressure thresholds for clinic measurement or home blood pressure monitoring (HBPM) would improve diagnostic accuracy compared with ambulatory blood pressure monitoring (ABPM), so the committee agreed the 2011 thresholds for diagnosis should be retained. The committee noted that these are in line with most international guidance.

Limited evidence suggested that clinic blood pressure measurement is less accurate than HBPM or ABPM when used to diagnose hypertension. The committee members acknowledged that these findings were in line with their clinical experience and agreed that clinic blood pressure measurement alone would not be an adequate method to diagnose hypertension.

The committee discussed repeat clinic blood pressure measurements when there is a difference in blood pressure between arms and noted that clinical practice varied. Based on their experience and knowledge, the committee members agreed that a cut-off of 15 mmHg would be more suitable than 20 mmHg, which was specified in the 2011 recommendations. This is in line with recent evidence that suggests a small difference in arm blood pressure is associated with an increased risk of cardiovascular events, possibly due to vascular damage.

ABPM correlates well with invasive blood pressure measurement and can identify both white-coat and masked hypertension. Based on the evidence in the 2011 guideline and the committee’s experience and knowledge, it was agreed that ABPM remains the gold standard for the accurate measurement of blood pressure in primary care. ABPM has therefore been retained as the preferred method for the diagnosis of hypertension. In addition, economic evidence obtained by updating the health economic model for the 2011 guideline confirmed that ABPM is still likely to be the most cost-effective method for diagnosis, even with the inclusion of new data for improved accuracy of home and clinic measurement.

The evidence showed that validated HBPM is an accurate method of diagnosing hypertension for people in sinus rhythm. The committee’s experience in clinical practice supported this, and the committee agreed that it is a suitable alternative when ABPM is unsuitable or not tolerated. The committee noted that the British and Irish Hypertension Society maintains a list of validated blood pressure devices for home use. The British and Irish Hypertension Society is an independent reviewer of published work and this does not imply any endorsement of specific devices by NICE.

The evidence did not suggest that there were any benefits of adding telemonitoring to HBPM. Therefore, the committee agreed that it could not make a recommendation on telemonitoring for the diagnosis of hypertension.

How the recommendations might affect practice

The recommendations reinforce current good practice. However, the committee noted that implementation of the 2011 recommendations on ABPM has been challenging and that there is still variation in practice. A change in practice and additional resources and training will be needed in areas where there is currently no access to ABPM devices. However, ABPM was found to be the most cost-effective method of diagnosis, and it is anticipated that the long-term benefits of accurate diagnosis and treatment (such as avoiding over diagnosis and unnecessary treatment) will outweigh any initial costs.

Return to recommendations

Relaxation therapies

Why the committee deleted the recommendation on relaxation therapies.

The evidence on relaxation therapies was limited to a single small study. The study suggested some benefit in reducing angina and myocardial infarction, but it also suggested an increase in stroke. The committee agreed that the study was not adequate to assess the effectiveness of these therapies or to make a recommendation.

The 2011 guideline stated that relaxation therapies could reduce blood pressure, but it did not recommend their routine use in practice. The committee noted that this was based on evidence for reducing blood pressure only, and there was no evidence of a direct benefit to people with hypertension, such as improving quality of life or reducing cardiovascular events. The committee agreed there was insufficient evidence of benefit to recommend that people pursue this option themselves and agreed to remove this recommendation. It is not the intention of the committee to stop people from trying relaxation therapies if they wish to, but to make people aware that there is less evidence for benefit of this intervention compared with other lifestyle interventions or pharmacological treatment. The committee agreed that the clinical focus for non-pharmacological treatment of hypertension should be on encouraging people to make lifestyle changes, such as taking regular exercise and maintaining a healthy weight.

The committee agreed that further research would be useful to determine whether relaxation therapies are a clinically effective treatment for hypertension in terms of reducing cardiovascular events or improving quality of life (see the recommendation for research on relaxation therapies ). They also noted that a larger study would be needed to obtain meaningful results.

How this might affect practice

Relaxation therapies were not recommended for routine use in the 2011 guideline, and they are not used in current practice for the management of primary hypertension in adults. The 2011 recommendation advised that people may try them as part of their treatment to reduce blood pressure, but committee consensus was that uptake has been low. Therefore, current practice will not be affected by the removal of the 2011 recommendation.

Recommendations 1.4.9 to 1.4.14

The evidence suggested that antihypertensive drug treatment was effective at reducing cardiovascular events in people with a clinic blood pressure of 160/100 mmHg or more (stage 2 hypertension).

A large study also suggested there was benefit of treating people with stage 1 hypertension. However, other studies in people with a low cardiovascular risk did not identify a benefit of treatment, and the committee agreed that the benefit of treatment across different cardiovascular risk groups was uncertain. The evidence was used to develop an economic model to compare the cost effectiveness of antihypertensive treatment with no treatment in people with stage 1 hypertension at different levels of cardiovascular risk. For people aged 60, the model showed that treatment was cost effective at a 10-year cardiovascular risk level of 10%, but there was some uncertainty at around 5% risk. Further analysis showed that it was cost effective to offer antihypertensive treatment to people aged 40 and 50 with stage 1 hypertension at a 5% risk and aged 70 and 75 at a 10% or 15% risk. QRISK was specified as the risk tool because it is recommended by NICE for risk calculation and most likely to be used in practice.

Taking into account the evidence and the results of the model, the committee were confident that people under 80 with stage 1 hypertension and a cardiovascular risk above 10% should have a discussion with their healthcare professional about starting antihypertensive treatment, alongside lifestyle changes, and that this would be a clinically and cost-effective use of NHS resources. The committee also agreed that antihypertensive treatment should be considered for people under 60 with a risk below 10%, with the degree of uncertainty in treating people at low risk reflected in the strength of the recommendation.

The committee members were mindful of the additional population that would be affected by lowering the threshold and were aware that the decision to start drug treatment would depend on the person’s preferences and their individual risk of cardiovascular disease. The recommendations highlight the importance of discussing the person’s preferences for treatment and encouraging lifestyle changes.

Some studies investigated the benefits of treating hypertension in people with lower cardiovascular risk or people with blood pressure below 140/90 mmHg. However, some of these studies were not directly relevant because they included a high proportion of participants with chronic kidney disease and previous cardiovascular events. For this reason, several studies could not be used to inform the recommendations. For details of these studies see evidence review C: initiating treatment .

The committee discussed the lack of evidence to inform a threshold for starting treatment in people aged under 40. It was agreed that this is an important area for future research and the recommendation for research was carried forward from the 2011 guideline (see the recommendation for research on thresholds for interventions in adults aged under 40 ).

The committee agreed that there was no evidence to suggest that thresholds for starting treatment should be different in people with type 2 diabetes. The previous recommendations for people with type 2 diabetes (in NICE’s guideline on type 2 diabetes in adults ) suggested starting antihypertensive drug treatment if lifestyle interventions alone did not reduce blood pressure to below 140/80 mmHg or 130/80 mmHg in the presence of kidney, cerebrovascular or eye disease. However, this was based on evidence from 2 small studies in which the participants did not have hypertension. Further evidence for lower treatment thresholds in people with type 2 diabetes was limited within this review, with the committee aware of some evidence to suggest that lower blood pressure thresholds did not reduce the rate of cardiovascular events in people without additional risk factors. The committee therefore agreed that there was insufficient evidence to recommend a different threshold for starting treatment for this subgroup.

There was no evidence identified on thresholds for people aged over 80, and no prior recommendation for this age group with hypertension below stage 2; therefore, the committee agreed that the threshold for starting treatment in people aged over 80 should be consistent with the target for treatment in this population (150/90 mmHg or lower).

The committee discussed the additional risks of starting treatment in older people, particularly those who are frail or have multiple comorbidities. Based on their expertise and experience, they agreed that the use of clinical judgement should be highlighted in decision making for people with frailty or multimorbidity, and that it should apply to people of any age. The committee agreed that a number of factors should be considered when discussing treatment options in this group and noted that healthcare professionals should refer to NICE’s guideline on multimorbidity for further advice.

The recommendations will have a significant impact on practice because more people will now be eligible for treatment. It is difficult to predict the extent of the impact because there is variability in how the 2011 recommendation with a threshold of 20% is being implemented in practice. However, it is believed, based on some recently published UK data, that potentially around 50% of people with stage 1 hypertension and risk below 20% are already being treated with antihypertensive drugs ( Association of guideline and policy changes with incidence of lifestyle advice and treatment for uncomplicated mild hypertension in primary care. Sheppard et al. 2018 ).

People with stage 1 hypertension should already be monitored every year, but reducing the threshold will increase the number of people being prescribed antihypertensive drugs and increase staff time and consultations involved in starting and monitoring their drug treatment. However, there will be a reduction in cardiovascular events resulting in savings, although it is acknowledged that the costs and savings may fall in different sectors of the NHS.

Recommendations 1.4.15 to 1.4.22

Monitoring treatment

The committee agreed that there was not enough evidence to strongly recommend home blood pressure monitoring (HBPM) for monitoring treatment in adults with hypertension. The evidence on monitoring was limited, with relatively small studies comparing different combinations of HBPM (with or without telemonitoring and with or without pharmacist input), pharmacy monitoring and clinic monitoring. It suggested that people had improved blood pressure control with HBPM with telemonitoring, with or without pharmacy input, compared with clinic monitoring, and the greatest blood pressure reduction was achieved with pharmacist input. However, the evidence was insufficient for the committee to make a recommendation.

The committee decided to retain the 2011 recommendation on using clinic blood pressure, but also agreed that the updated guideline should support home monitoring for people who wish to use it. The committee discussed the importance of patient choice and agreed that home monitoring should be an option, if it is suitable and the person is willing and motivated to use it. HBPM is already widely used in practice, especially for people with a white-coat effect. The committee agreed this would be reflected in the recommendation supported by the evidence and consensus opinion. Based on their experience, the committee agreed that training and advice would be needed for people using HBPM to ensure that people take measurements correctly and know when to contact their healthcare professional if they are not achieving their target blood pressure.

The 2011 guideline included a recommendation for further research for the best method of monitoring hypertension in people with atrial fibrillation. No evidence was identified in the updated reviews to inform recommendations for this group and therefore the committee agreed that this recommendation for research should be retained to inform future updates of the guideline (see the recommendation for research on automated blood pressure monitoring ).

The committee agreed they could not make a recommendation on telemonitoring because the evidence was not sufficient to show a clear benefit and the studies were inconsistent in the telemonitoring methods used.

The recommendations reflect current practice, so there should be no change in practice. They will encourage appropriate and suitable training to be given so that both people with hypertension and their healthcare professionals are confident that blood pressure is being measured properly using home monitoring devices.

Blood pressure targets for people without cardiovascular disease

No evidence was identified to determine whether cardiovascular risk or blood pressure targets should be used. The committee agreed that in the absence of evidence the focus should be on blood pressure targets, based on their expertise and experience of current practice.

The evidence for blood pressure targets showed that there were both benefits and harms associated with a lower clinic systolic blood pressure target of 120 mmHg compared with 140 mmHg in people with primary hypertension without type 2 diabetes. Although the evidence suggested some benefit in reducing mortality and cardiovascular events, the lower blood pressure target was associated with a greater risk of harms, such as injury from falls and acute kidney injury. The committee agreed that the long-term implications of these adverse events were unclear and that further research is needed.

This evidence came from the SPRINT trial, which was a large study undertaken in the US. The committee discussed concerns about the population included in the study and the applicability to UK practice of the methods used. The study used automated blood pressure devices with a time delay and an isolated rest period, which is not common practice in the UK. The committee considered that the use of these devices would lead to lower blood pressure readings than in routine UK clinical practice. They also had concerns that some medicines were stopped when blood pressure targets were achieved, which may have had an impact on the results. The committee also discussed concerns about applicability of the population; for example, the participants had high cardiovascular risk levels, including many with pre-existing cardiovascular disease or renal impairment, and were already receiving treatment before the study started. These concerns made the evidence difficult to interpret and use to inform the recommendations. Further details of the committee’s discussion of this study is included in evidence review D: targets .

Evidence from a smaller study also showed some benefit of lowering clinic systolic blood pressure targets to 130 mmHg. However, the committee noted that the study was based on people already receiving treatment and that it lacked information on adverse events.

The committee agreed that there was no evidence to suggest that blood pressure targets should be different in people with type 2 diabetes. Evidence for lower targets in people with type 2 diabetes was also limited, with some evidence to suggest that lower blood pressure targets did not reduce the rate of cardiovascular events. Previous recommendations for people with type 2 diabetes (in NICE’s guideline on type 2 diabetes in adults ) suggested a blood pressure target below 130/80 mmHg in the presence of target organ damage such as kidney, cerebrovascular or eye disease. The committee noted that the evidence behind this recommendation was based on 2 small studies in people without hypertension. They also had concerns about the relevance of the study design. The committee were also aware of trial data showing less benefit in populations with type 2 diabetes with fewer additional risk factors. The committee therefore agreed that there was insufficient evidence to recommend a different blood pressure target for this subgroup. It was noted that people with later-stage chronic kidney disease are covered by other NICE guidelines.

Overall, the committee agreed that the evidence was unclear and insufficient to determine whether a lower target would be beneficial and whether it would outweigh the associated harms. Therefore, the 2011 clinic blood pressure target of 140/90 mmHg for adults under 80 years was retained and applies to people with or without type 2 diabetes. The corresponding HBPM and ambulatory blood pressure monitoring (ABPM) targets were also retained at 135/85 mmHg. The recommendations emphasise the importance of achieving and maintaining a level consistently below the person’s blood pressure target, whether this target be based on clinic blood pressure, HBPM or ABPM.

Based on their experience, the committee members felt that people with postural hypotension are at risk of adverse events if a sitting or lying blood pressure is used for monitoring, because this measurement would overestimate daytime blood pressure and result in overtreatment. For example, a patient with a sitting systolic blood pressure of 140 mmHg might have a much lower blood pressure when standing and be at an increased risk of falls if treated based on their sitting blood pressure. The committee decided to recommend that 3 groups who are at risk of postural hypotension (people over 80 years, with type 2 diabetes and with symptoms of postural hypotension) should have their standing blood pressure measured, and their treatment modified accordingly if they have postural hypotension. The standing blood pressure should be used for future monitoring.

The recommendations should reinforce current good practice. However, the new recommendations place more emphasis on maintaining blood pressure consistently below the blood pressure targets. As a result, this could lead to a higher use of antihypertensive drugs and an increase in consultations to maintain target blood pressure. For people with type 2 diabetes and target organ damage (not covered by other guidelines), the slightly higher target blood pressure compared to that recommended previously may reduce adverse events and may lead to fewer appointments and reduced drug use.

Blood pressure targets for people with cardiovascular disease

Recommendation 1.4.23

Why the committee made the recommendation

The evidence did not show a robust or consistent clinical benefit from using lower blood pressure targets for people with cardiovascular disease compared with standard blood pressure targets.

The vast majority of people in the control arms of the studies achieved blood pressures well below 140/90 mmHg. In the committee’s experience of practice, some people with hypertension can have their blood pressure maintained at 140/90 mmHg, rather than below this level. To address this issue, the committee amended the 2019 recommendations on blood pressure targets to emphasise the importance of reducing and maintaining blood pressure below 140/90 mmHg.

• People aged over 80 , because there was no evidence specifically for this group. The only evidence was from mixed age groups, and the committee agreed that this evidence was too limited to support a new practice recommendation.
• People with aortic aneurysm , because there was no evidence for this group.
• People who have had a stroke , because there was limited evidence that lower blood pressure targets reduced the risk of future strokes, but there was also evidence on the possible harms of lower targets. Evidence for both potential benefit and harm was too limited to inform a recommendation.

The new recommendation reflects current practice for most types of cardiovascular disease, so there should be no change in practice or increase in resource use.

The Royal College of Physicians Intercollegiate Stroke Working Party guideline recommends a lower blood pressure target for people after stroke. However, the national quality indicators used in primary care do not use a lower blood pressure target for people with cardiovascular disease (including stroke and transient ischaemic attack).

Return to recommendation

Choosing antihypertensive drug treatment for people with cardiovascular disease

Recommendation 1.4.31

New evidence in this area was not reviewed as part of the 2022 update. Instead, the evidence from previous versions of the guideline was reassessed to look at outcomes for people with cardiovascular disease. Only evidence up to 2010 was re-analysed, because the 2019 update did not review evidence for people with cardiovascular disease.

There was no difference in clinically relevant outcomes between people with and without cardiovascular disease.

Evidence was limited for people with stroke, transient ischaemic attack, or coronary artery disease. This evidence did not cover enough treatment comparisons to allow the committee to draw any firm conclusions.

There are NICE guidelines on acute coronary syndromes and chronic heart failure , and these guidelines make recommendations on drug treatment that overlap with treatment for hypertension. To avoid confusion over the treatment pathway, the committee highlighted that these condition-specific recommendations should be applied first (for example, when prescribing an ACE inhibitor or an ARB for secondary prevention of myocardial infarction).

The recommendation reflects current practice for most types of cardiovascular disease.

The committee were aware that, after a stroke, the thiazide-like diuretic indapamide is sometimes used first, rather than a calcium channel blocker. However, it is unclear how common this is. As people with cardiovascular disease are commonly prescribed more than 1 antihypertensive drug, any impact on prescribing would be limited.

Recommendations 1.4.32 to 1.4.39

The committee reviewed the evidence for starting treatment for primary hypertension with a single antihypertensive medicine compared with starting with 2 antihypertensive medicines at once (dual therapy). Additionally, the committee reviewed the evidence on whether specific subgroups of people with hypertension might benefit from starting on dual therapy, for example people with type 2 diabetes, older people, or those of particular family origins.

Some limited evidence from a single study showed that initial dual therapy may reduce cardiovascular events in people with hypertension and type 2 diabetes, but the committee members were disappointed that more comprehensive data was not available. The committee discussed the benefits of optimising treatment for hypertension early and agreed that this can substantially improve quality of life. However, there was not enough evidence to determine confidently the benefits or harms of starting treatment with dual therapy. In response to the lack of available evidence, the committee developed a recommendation for research on step 1 treatment to determine if particular subgroups would benefit from starting dual therapy, to inform future guidance.

In the absence of compelling new evidence on step 1 dual therapy, the committee agreed that the previous recommendations for step 1 treatment should be retained (with minor changes for clarity), because they were based on robust clinical and cost-effectiveness evidence. One exception to this was the 2006 recommendation for considering beta-blockers in certain groups of younger people. The committee discussed this recommendation and agreed that beta-blockers are rarely used as step 1 antihypertensive treatment in current practice and there is no established relationship between beta-blocker use in primary hypertension and a reduction in cardiovascular events. For these reasons, the committee decided that the recommendation should not be retained. The committee noted that this is consistent with most international guidelines.

This guideline also updates and replaces the section on blood pressure management from NICE’s guideline on type 2 diabetes in adults . That guideline recommended that adults with type 2 diabetes of any age should start on an angiotensin-converting enzyme (ACE) inhibitor as step 1 treatment (except women with a possibility of becoming pregnant and people of Black African or African–Caribbean family origin). The committee discussed the evidence for this and agreed that it was sufficient to support and retain this recommendation. The committee agreed it should be broadened to include the choice of an ACE inhibitor or an angiotensin II receptor blocker (ARB; also referred to as A-type drugs), because they are now cost equivalent, and the committee also agreed they are clinically equivalent.

For people of Black African or African–Caribbean family origin with type 2 diabetes, the previous recommendation was to offer step 1 dual therapy with an ACE inhibitor and either a diuretic (D-type drug) or a calcium channel blocker (CCB; C-type drug). However, these recommendations were based on monotherapy studies and when the committee looked at this evidence alongside the new dual therapy evidence review, they concluded that it was insufficient to recommend starting dual therapy in any subgroup of people with type 2 diabetes. The committee noted that people with type 2 diabetes who are older or are of Black African or African–Caribbean family origin may not achieve their target blood pressure on ACE inhibitor or ARB monotherapy and may need to start step 2 drug therapy in the short term.

Overall, the recommendations for step 1 treatment reflect current practice for people who do not have type 2 diabetes. For people of Black African or African–Caribbean family origin who have type 2 diabetes, the recommendation to start antihypertensive monotherapy rather than dual therapy may result in an extra clinical appointment if the dose needs to be adjusted. However, it may also reduce potential harms from initial overtreatment of blood pressure.

Step 2 and 3 treatment

Recommendations 1.4.40 to 1.4.45

No evidence for step 2 or step 3 treatment was identified that was relevant to determining the best sequence for step 2 and step 3 antihypertensive treatment. Some of the studies available on drug treatments for hypertension were not included in this review because they were designed to inform step 1 treatment. Others did not reflect UK clinical practice. For details of these studies see evidence review F: step 2 and step 3 treatment .

Based on evidence from the previous version of the guideline and their clinical expertise, the committee members agreed to retain the same choice of drugs from the 2011 guideline, which reflect current best practice. The committee agreed that, in the absence of evidence of which treatment(s) are most effective for step 2 or step 3, the recommendation should be to offer any of these treatments based on an individualised approach informed by risks and benefits of each treatment and the person with hypertension’s preference.

The committee noted that the changes to the step 1 recommendations for some people with type 2 diabetes do not necessitate a change in the step 2 recommendations since the same options for combination treatment at step 2 are available.

The committee agreed that the choice of drug should be discussed and agreed with the person, based on the person’s step 1 treatment, the risks and benefits of each treatment option, and taking into account the person’s preferences and other clinical factors. The updated recommendations reflect this, giving the choice of possible treatment options. A NICE patient decision aid on treatment choices for high blood pressure has been developed to support healthcare professionals and people with hypertension to discuss their treatment options and make informed decisions.

The recommendations are unlikely to alter current practice. The options for drug treatment remain the same and most step 2 or 3 treatment decisions are already based on an individualised approach.

Recommendations 1.4.46 to 1.4.52

No evidence on step 4 treatment was identified that could be used to formulate new recommendations. However, the committee reviewed the 2011 recommendations and agreed that they should be retained and updated to reflect current best practice.

The committee discussed the importance of confirming resistant hypertension before starting step 4 treatment. Based on their clinical experience and knowledge of best current practice, the committee members agreed that a recommendation to highlight this would help prevent overtreatment and ensure that people receive the right care.

Despite the lack of evidence formally reviewed, the committee discussed the recommendation based on their clinical experience, taking the 2011 recommendations into account. The committee agreed that although the evidence for spironolactone did not meet the criteria for inclusion in the updated review for the guideline because the key study had a very short follow up and did not report any of the cardiovascular outcomes specified in this review protocol, the use of an aldosterone antagonist is now common clinical practice. Therefore, there was no reason to suggest that this recommendation should be changed.

In the 2011 guideline, high-dose thiazide diuretics were recommended as a potential step 4 treatment in people with high blood potassium levels. The committee felt that there was a lack of evidence for this approach and noted that the studies did not show an improvement in cardiovascular outcomes at higher doses, albeit in people without resistant hypertension. The committee agreed that the recommendation for considering alpha- or beta-blockers should be retained based on significant clinical experience of their safe and effective use and because adding a further drug is likely to have a greater effect on blood pressure than increasing the thiazide diuretic dose.

The recommendations represent current good practice and so should not change practice. High-dose thiazide diuretics are not commonly used as step 4 therapy and so removing this should not change practice.

There might be a small reduction in step 4 treatment with more thorough checks to confirm resistant hypertension. However, this may also result in an increase in blood pressure measurements to appropriately confirm resistant hypertension where this is not already being done.

Identifying who to refer for same-day specialist review

Recommendations 1.5.1 to 1.5.3

There was no evidence identified to inform recommendations on this topic. The committee reviewed the 2011 recommendations and agreed that they should be updated by consensus based on their clinical expertise. In particular they agreed it would be helpful to clarify which features warranted same-day referral, which would need further investigation and when repeat blood pressure measurement should be taken.

The committee noted that it can be difficult to differentiate between accelerated hypertension and severe hypertension. They discussed the advantages and disadvantages of broader criteria for same-day referral, which would increase referrals to hospital but reduce the risk of missing people who need urgent treatment. The committee decided it would be beneficial to add some emergency symptoms to the existing recommendation, which will help healthcare professionals to decide when to refer.

Based on their experience, the committee members agreed that some people with severe hypertension could be receiving unnecessary treatment because the 2011 guideline recommended treatment based on severe hypertension alone. The committee agreed that this could be prevented if investigations for target organ damage were carried out quickly before offering treatment in people with severely raised blood pressure and no other symptoms of concern. The committee also agreed that checking blood pressure again within 7 days in people with no target organ damage would ensure that people with severe hypertension are followed up and offered suitable treatment.

The committee agreed that further research is needed in this area, particularly for people with extreme hypertension (220/120 mmHg or higher) or emergency symptoms. The committee members developed a recommendation for research on same-day hospital specialist assessment to help inform future recommendations.

The emergency symptoms listed in the recommendation may lead to more referrals to hospital. However, people with emergency symptoms will benefit from urgent treatment because accelerated hypertension can be fatal if untreated.

There may be some additional resource use from doing target organ damage tests more quickly and re-measuring blood pressure within 7 days. However, the number of people started on treatment immediately may be reduced because of undertaking investigations first.

The population with severe hypertension is very small, and the proportion with severe hypertension and additional symptoms that suggest accelerated hypertension is even smaller; therefore, resource impact is unlikely to be substantial.

High blood pressure (hypertension) is one of the most important, treatable causes of premature morbidity and mortality in the world. It is a major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. In 2015, it was reported that high blood pressure affected more than 1 in 4 adults in England (31% of men; 26% of women) – around 13.5 million people – and contributed to 75,000 deaths. The clinical management of hypertension accounts for 12% of visits to primary care and up to £2.1 billion of healthcare expenditure. Managing the cardiovascular events caused by hypertension also consumes considerable resources.

The guideline covers adults (over 18 years) with suspected or diagnosed hypertension, including those with type 2 diabetes.

2019 update

Between 2010 and 2020, progress has been made to improve the diagnosis and management of hypertension: the population average blood pressure in England has fallen by about 3 mmHg systolic and the proportion of adults with untreated high blood pressure has decreased. However, the Public Health England Blood Pressure Action Plan called for further action to reduce the population average blood pressure by 5 mmHg through improved prevention, detection and management ( Public Health England’s Tackling high blood pressure: from evidence into action , 2015 and Tackling high blood pressure: an update , 2018).

Since the publication of the 2011 NICE guideline on hypertension, new studies have been published in key areas of management; in particular, the optimal method and threshold for diagnosis of hypertension, managing blood pressure in lower risk populations and reducing blood pressure to lower targets in people with hypertension (including those with type 2 diabetes). The updated guideline makes new recommendations in these areas, based on the evidence, that aim to improve care and reduce variation in current practice.

Treating resistant hypertension (when more than 3 drugs are needed to treat hypertension) remains challenging. New data was also reviewed in this area and the recommendations updated.

There is uncertainty in current practice about which people with symptomatic very high blood pressure (accelerated hypertension) to refer for immediate assessment. The available evidence was reviewed and new recommendations made to provide guidance for primary care on when to refer.

• Finding more information and committee details

To find NICE guidance on related topics, including guidance in development, see the NICE topic page on hypertension .

For full details of the evidence and the guideline committee’s discussions, see the evidence reviews . You can also find information about how the guideline was developed , including details of the committee .

NICE has produced tools and resources to help you put this guideline into practice . For general help and advice on putting our guidelines into practice, see resources to help you put NICE guidance into practice .

• Update information

November 2023 : We updated recommendations 1.1.5 , 1.1.6 and 1.4.16 and made 2 new recommendations (1.1.7 and 1.1.8 ) on how to measure and manage postural hypotension (see the February 2023 surveillance report ). We also added 2 tables to the section on monitoring treatment and blood pressure targets to summarise blood pressure targets in this guideline and NICE’s guidelines on type 1 diabetes and chronic kidney disease (see the November 2023 surveillance report ).

March 2022: We have reviewed the evidence on blood pressure targets for people with cardiovascular disease, and made a new recommendation. This is marked [2022] .

We have also reassessed the evidence on antihypertensive drug treatment, and made a new recommendation for people with cardiovascular disease. This is marked [2022] .

For recommendations ending [2019, amended 2022] , we have not reviewed the evidence for people without cardiovascular disease. We have made minor changes to the wording of the recommendations without changing the intent. For an explanation of these changes, see the rationale and impact section on blood pressure targets for people with cardiovascular disease .

August 2019: We have reviewed the evidence and made new recommendations on diagnosis, monitoring and drug treatment for hypertension, and identifying who to refer for same-day specialist review. These recommendations are marked [2019] .

• the information on cuff size for measuring blood pressure was moved to avoid repetition
• plasma glucose testing was replaced with glycated haemoglobin (HbA1C) to reflect current practice
• a note was added because of concerns about the risks of salt substitutes in some groups
• the information on when to refer to the hypertension in pregnancy guideline was made clearer.

These recommendations are marked [2004, amended 2019] or [2011, amended 2019] .

Recommendations marked [2004] , [2006] , [2008] , [2009] and [2011] last had an evidence review in that year. In some cases minor changes have been made to the wording to bring the language and style up to date, without changing the meaning.

Recommendations 1.2.11 and 1.4.24 (marked [2009] ) were originally published in section 1.4 of NICE’s guideline on type 2 diabetes in adults , which was updated by this guideline.

Minor changes since publication

October 2023 : We corrected a link to an evidence review.

July 2022: In recommendation 1.5.1 we clarified the options for people with a blood pressure of 180/120 mmHg or more and no target organ damage.

November 2021: We added a link to the blood pressure@home scheme in recommendation 1.4.17 .

December 2019: Recommendation 1.4.13 was amended to clarify that it applies to adults over 80 with stage 1 hypertension. We also made changes to introductory text to clarify that recommendations apply to all adults, including those with type 2 diabetes, unless links to other NICE guidelines indicate that treatment differs.

Your responsibility : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme .

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Created: August 28, 2019; Last Update: November 21, 2023.

• Cite this Page Hypertension in adults: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2023 Nov 21. (NICE Guideline, No. 136.)
• PDF version of this title (306K)

In this Page

Other titles in this collection.

• National Institute for Health and Care Excellence: Guidelines

Related NICE guidance and evidence

• NICE Clinical Guideline 127: Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34
• Evidence review for diagnosis: Hypertension in adults: diagnosis and management: Evidence review A
• Evidence review for monitoring: Hypertension in adults: diagnosis and management: Evidence review B
• Evidence review for initiating treatment: Hypertension in adults: diagnosis and management: Evidence review C
• Evidence review for targets: Hypertension in adults: diagnosis and management: Evidence review D
• Evidence review for step 1 treatment: Hypertension in adults: diagnosis and management: Evidence review E
• Evidence review for step 2 and step 3 treatment: Hypertension in adults: diagnosis and management: Evidence review F
• Evidence review for step 4 treatment: Hypertension in adults: diagnosis and management: Evidence review G
• Evidence review for relaxation therapies: Hypertension in adults: diagnosis and management: Evidence review H
• Evidence review for same-day specialist review: Hypertension in adults: diagnosis and management: Evidence review I
• Evidence review for blood pressure targets: Hypertension in adults (update): Evidence review J
• Evidence summary for pharmacological treatment in CVD: Hypertension in adults (update): Evidence review K

Supplemental NICE documents

• NICE Quality Standard QS28: Hypertension in adults (PDF)
• NICE Quality Standard QS181: Air pollution: outdoor air quality and health (PDF)
• NG136 Visual summary (PDF)

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Hypertension

• An estimated 1.28 billion adults aged 30–79 years worldwide have hypertension, most (two-thirds) living in low- and middle-income countries
• An estimated 46% of adults with hypertension are unaware that they have the condition.
• Less than half of adults (42%) with hypertension are diagnosed and treated.
• Approximately 1 in 5 adults (21%) with hypertension have it under control.
• Hypertension is a major cause of premature death worldwide.
• One of the global targets for noncommunicable diseases is to reduce the prevalence of hypertension by 33% between 2010 and 2030.

Hypertension (high blood pressure) is when the pressure in your blood vessels is too high (140/90 mmHg or higher). It is common but can be serious if not treated.

People with high blood pressure may not feel symptoms. The only way to know is to get your blood pressure checked.

Things that increase the risk of having high blood pressure include:

• older age 
• being overweight or obese
• not being physically active 
• high-salt diet
• drinking too much alcohol

Lifestyle changes like eating a healthier diet, quitting tobacco and being more active can help lower blood pressure. Some people may still need to take medicines.

Blood pressure is written as two numbers. The first (systolic) number represents the pressure in blood vessels when the heart contracts or beats. The second (diastolic) number represents the pressure in the vessels when the heart rests between beats. Hypertension is diagnosed if, when it is measured on two different days, the systolic blood pressure readings on both days is ≥140 mmHg and/or the diastolic blood pressure readings on both days is ≥90 mmHg.

Risk factors

Modifiable risk factors include unhealthy diets (excessive salt consumption, a diet high in saturated fat and trans fats, low intake of fruits and vegetables), physical inactivity, consumption of tobacco and alcohol, and being overweight or obese. In addition, there are environmental risk factors for hypertension and associated diseases, where air pollution is the most significant.  Non-modifiable risk factors include a family history of hypertension, age over 65 years and co-existing diseases such as diabetes or kidney disease.

Most people with hypertension don’t feel any symptoms. Very high blood pressures can cause headaches, blurred vision, chest pain and other symptoms. 

Checking your blood pressure is the best way to know if you have high blood pressure. If hypertension isn’t treated, it can cause other health conditions like kidney disease, heart disease and stroke.

People with very high blood pressure (usually 180/120 or higher) can experience symptoms including:

• severe headaches
• difficulty breathing
• blurred vision or other vision changes
• buzzing in the ears
• abnormal heart rhythm

If you are experiencing any of these symptoms and a high blood pressure, seek care immediately.

The only way to detect hypertension is to have a health professional measure blood pressure. Having blood pressure measured is quick and painless. Although individuals can measure their own blood pressure using automated devices, an evaluation by a health professional is important for assessment of risk and associated conditions.

Lifestyle changes can help lower high blood pressure. These include:

• eating a healthy, low-salt diet
• losing weight
• being physically active
• quitting tobacco.

If you have high blood pressure, your doctor may recommend one or more medicines. Your recommended blood pressure goal may depend on what other health conditions you have. 

Blood pressure goal is less than 130/80 if you have:

• cardiovascular disease (heart disease or stroke)
• diabetes (high blood sugar)
• chronic kidney disease
• high risk for cardiovascular disease.

For most people, the goal is to have a blood pressure less than 140/90. 

There are several common blood pressure medicines: 

• ACE inhibitors including enalapril and lisinopril relax blood vessels and prevent kidney damage.
• Angiotensin-2 receptor blockers (ARBs) including losartan and telmisartan relax blood vessels and prevent kidney damage.
• Calcium channel blockers including amlodipine and felodipine relax blood vessels.
• Diuretics including hydrochlorothiazide and chlorthalidone eliminate extra water from the body, lowering blood pressure.

Lifestyle changes can help lower high blood pressure and can help anyone with hypertension. Many who make these changes will still need to take medicine. 

These lifestyle changes can help prevent and lower high blood pressure. 

• Eat more vegetables and fruits.
• Get at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity.
• Do strength building exercises 2 or more days each week.
• Lose weight if you’re overweight or obese.
• Take medicines as prescribed by your health care professional.
• Keep appointments with your health care professional.

Don’t:

• eat too much salty food (try to stay under 2 grams per day)
• eat foods high in saturated or trans fats
• smoke or use tobacco
• drink too much alcohol (1 drink daily max for women, 2 for men)
• miss or share medication.

Reducing hypertension prevents heart attack, stroke and kidney damage, as well as other health problems.

Reduce the risks of hypertension by:

• reducing and managing stress
• regularly checking blood pressure
• treating high blood pressure
• managing other medical conditions
• reducing exposure to polluted air.

Complications of uncontrolled hypertension

Among other complications, hypertension can cause serious damage to the heart. Excessive pressure can harden arteries, decreasing the flow of blood and oxygen to the heart. This elevated pressure and reduced blood flow can cause:

• chest pain, also called angina;
• heart attack, which occurs when the blood supply to the heart is blocked and heart muscle cells die from lack of oxygen. The longer the blood flow is blocked, the greater the damage to the heart;
• heart failure, which occurs when the heart cannot pump enough blood and oxygen to other vital body organs; and
• irregular heart beat which can lead to a sudden death.

Hypertension can also burst or block arteries that supply blood and oxygen to the brain, causing a stroke.

In addition, hypertension can cause kidney damage, leading to kidney failure.

Hypertension in low- and middle-income countries

The prevalence of hypertension varies across regions and country income groups. The WHO African Region has the highest prevalence of hypertension (27%) while the WHO Region of the Americas has the lowest prevalence of hypertension (18%).

The number of adults with hypertension increased from 594 million in 1975 to 1.13 billion in 2015, with the increase seen largely in low- and middle-income countries. This increase is due mainly to a rise in hypertension risk factors in those populations.

WHO response

The World Health Organization (WHO) supports countries to reduce hypertension as a public health problem.

In 2021, WHO released a new guideline for on the pharmacological treatment of hypertension in adults. The publication provides evidence-based recommendations for the initiation of treatment of hypertension, and recommended intervals for follow-up. The document also includes target blood pressure to be achieved for control, and information on who, in the health-care system, can initiate treatment.

To support governments in strengthening the prevention and control of cardiovascular disease, WHO and the United States Centers for Disease Control and Prevention (U.S. CDC) launched the Global Hearts Initiative in September 2016, which includes the HEARTS technical package. The six modules of the HEARTS technical package (Healthy-lifestyle counselling, Evidence-based treatment protocols, Access to essential medicines and technology, Risk-based management, Team-based care, and Systems for monitoring) provide a strategic approach to improve cardiovascular health in countries across the world.

In September 2017, WHO began a partnership with Resolve to Save Lives, an initiative of Vital Strategies, to support national governments to implement the Global Hearts Initiative. Other partners contributing to the Global Hearts Initiative are the CDC Foundation, the Global Health Advocacy Incubator, the Johns Hopkins Bloomberg School of Public Health, the Pan American Health Organization (PAHO) and the U.S. CDC. Since implementation of the programme in 2017 in  31 countries low- and middle-income countries, 7.5 million people have been put on protocol-based hypertension treatment through person-centred models of care. These programmes demonstrate the feasibility and effectiveness of standardized hypertension control programmes.

• More on hypertension

High blood pressure (hypertension)

On this page, when to see a doctor, risk factors, complications.

• What is hypertension? A Mayo Clinic expert explains.

High blood pressure is a common condition that affects the body's arteries. It's also called hypertension. If you have high blood pressure, the force of the blood pushing against the artery walls is consistently too high. The heart has to work harder to pump blood.

Blood pressure is measured in millimeters of mercury (mm Hg). In general, hypertension is a blood pressure reading of 130/80 mm Hg or higher.

The American College of Cardiology and the American Heart Association divide blood pressure into four general categories. Ideal blood pressure is categorized as normal.)

• Normal blood pressure.  Blood pressure is 120/80 mm Hg or lower.
• Elevated blood pressure.  The top number ranges from 120 to 129 mm Hg and the bottom number is below, not above, 80 mm Hg.
• Stage 1 hypertension.  The top number ranges from 130 to 139 mm Hg or the bottom number is between 80 and 89 mm Hg.
• Stage 2 hypertension.  The top number is 140 mm Hg or higher or the bottom number is 90 mm Hg or higher.

Blood pressure higher than 180/120 mm Hg is considered a hypertensive emergency or crisis. Seek emergency medical help for anyone with these blood pressure numbers.

Untreated, high blood pressure increases the risk of heart attack, stroke and other serious health problems. It's important to have your blood pressure checked at least every two years starting at age 18. Some people need more-frequent checks.

Healthy lifestyle habits —such as not smoking, exercising and eating well — can help prevent and treat high blood pressure. Some people need medicine to treat high blood pressure.

Blood pressure is measured in millimeters of mercury (mm Hg). In general, hypertension is a blood pressure reading of 130/80 millimeters of mercury (mm Hg) or higher.

The American College of Cardiology and the American Heart Association divide blood pressure into four general categories. Ideal blood pressure is categorized as normal.

• Normal blood pressure. Blood pressure is lower than 120/80 mm Hg .
• Elevated blood pressure. The top number ranges from 120 to 129 mm Hg and the bottom number is below, not above, 80 mm Hg .
• Stage 1 hypertension. The top number ranges from 130 to 139 mm Hg or the bottom number is between 80 and 89 mm Hg .
• Stage 2 hypertension. The top number is 140 mm Hg or higher or the bottom number is 90 mm Hg or higher.

Blood pressure higher than 180/120 mm Hg is considered a hypertensive emergency or crisis. Seek emergency medical help for anyone with these blood pressure numbers.

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Most people with high blood pressure have no symptoms, even if blood pressure readings reach dangerously high levels. You can have high blood pressure for years without any symptoms.

A few people with high blood pressure may have:

• Shortness of breath

However, these symptoms aren't specific. They usually don't occur until high blood pressure has reached a severe or life-threatening stage.

More Information

• Pulse pressure: An indicator of heart health?

Blood pressure screening is an important part of general health care. How often you should get your blood pressure checked depends on your age and overall health.

Ask your provider for a blood pressure reading at least every two years starting at age 18. If you're age 40 or older, or you're 18 to 39 with a high risk of high blood pressure, ask for a blood pressure check every year.

Your care provider will likely recommend more-frequent readings if have high blood pressure or other risk factors for heart disease.

Children age 3 and older may have blood pressure measured as a part of their yearly checkups.

If you don't regularly see a care provider, you may be able to get a free blood pressure screening at a health resource fair or other locations in your community. Free blood pressure machines are also available in some stores and pharmacies. The accuracy of these machines depends on several things, such as a correct cuff size and proper use of the machines. Ask your health care provider for advice on using public blood pressure machines.

From Mayo Clinic to your inbox

Blood pressure is determined by two things: the amount of blood the heart pumps and how hard it is for the blood to move through the arteries. The more blood the heart pumps and the narrower the arteries, the higher the blood pressure.

There are two main types of high blood pressure.

Primary hypertension, also called essential hypertension

For most adults, there's no identifiable cause of high blood pressure. This type of high blood pressure is called primary hypertension or essential hypertension. It tends to develop gradually over many years. Plaque buildup in the arteries, called atherosclerosis, increases the risk of high blood pressure.

Secondary hypertension

This type of high blood pressure is caused by an underlying condition. It tends to appear suddenly and cause higher blood pressure than does primary hypertension. Conditions and medicines that can lead to secondary hypertension include:

• Adrenal gland tumors
• Blood vessel problems present at birth, also called congenital heart defects
• Cough and cold medicines, some pain relievers, birth control pills, and other prescription drugs
• Illegal drugs, such as cocaine and amphetamines
• Kidney disease
• Obstructive sleep apnea
• Thyroid problems

Sometimes just getting a health checkup causes blood pressure to increase. This is called white coat hypertension.

• Medications and supplements that can raise your blood pressure
• Anxiety: A cause of high blood pressure?
• Blood pressure readings: Why higher at home?
• Blood pressure: Does it have a daily pattern?
• Caffeine and hypertension
• Can having vitamin D deficiency cause high blood pressure?
• Sleep deprivation: A cause of high blood pressure?

High blood pressure has many risk factors, including:

• Age. The risk of high blood pressure increases with age. Until about age 64, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
• Race. High blood pressure is particularly common among Black people. It develops at an earlier age in Black people than it does in white people.
• Family history. You're more likely to develop high blood pressure if you have a parent or sibling with the condition.
• Obesity or being overweight. Excess weight causes changes in the blood vessels, the kidneys and other parts of the body. These changes often increase blood pressure. Being overweight or having obesity also raises the risk of heart disease and its risk factors, such as high cholesterol.
• Lack of exercise. Not exercising can cause weight gain. Increased weight raises the risk of high blood pressure. People who are inactive also tend to have higher heart rates.
• Tobacco use or vaping. Smoking, chewing tobacco or vaping immediately raises blood pressure for a short while. Tobacco smoking injures blood vessel walls and speeds up the process of hardening of the arteries. If you smoke, ask your care provider for strategies to help you quit.
• Too much salt. A lot of salt — also called sodium — in the body can cause the body to retain fluid. This increases blood pressure.
• Low potassium levels. Potassium helps balance the amount of salt in the body's cells. A proper balance of potassium is important for good heart health. Low potassium levels may be due to a lack of potassium in the diet or certain health conditions, including dehydration.
• Drinking too much alcohol. Alcohol use has been linked with increased blood pressure, particularly in men.
• Stress. High levels of stress can lead to a temporary increase in blood pressure. Stress-related habits such as eating more, using tobacco or drinking alcohol can lead to further increases in blood pressure.
• Certain chronic conditions. Kidney disease, diabetes and sleep apnea are some of the conditions that can lead to high blood pressure.
• Pregnancy. Sometimes pregnancy causes high blood pressure.

High blood pressure is most common in adults. But kids can have high blood pressure too. High blood pressure in children may be caused by problems with the kidneys or heart. But for a growing number of kids, high blood pressure is due to lifestyle habits such as an unhealthy diet and lack of exercise.

The excessive pressure on the artery walls caused by high blood pressure can damage blood vessels and body organs. The higher the blood pressure and the longer it goes uncontrolled, the greater the damage.

Uncontrolled high blood pressure can lead to complications including:

• Heart attack or stroke. Hardening and thickening of the arteries due to high blood pressure or other factors can lead to a heart attack, stroke or other complications.
• Aneurysm. Increased blood pressure can cause a blood vessel to weaken and bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.
• Heart failure. When you have high blood pressure, the heart has to work harder to pump blood. The strain causes the walls of the heart's pumping chamber to thicken. This condition is called left ventricular hypertrophy. Eventually, the heart can't pump enough blood to meet the body's needs, causing heart failure.
• Kidney problems. High blood pressure can cause the blood vessels in the kidneys to become narrow or weak. This can lead to kidney damage.
• Eye problems. Increased blood pressure can cause thickened, narrowed or torn blood vessels in the eyes. This can result in vision loss.
• Metabolic syndrome. This syndrome is a group of disorders of the body's metabolism. It involves the irregular breakdown of sugar, also called glucose. The syndrome includes increased waist size, high triglycerides, decreased high-density lipoprotein (HDL or "good") cholesterol, high blood pressure and high blood sugar levels. These conditions make you more likely to develop diabetes, heart disease and stroke.
• Changes with memory or understanding. Uncontrolled high blood pressure may affect the ability to think, remember and learn.
• Dementia. Narrowed or blocked arteries can limit blood flow to the brain. This can cause a certain type of dementia called vascular dementia. A stroke that interrupts blood flow to the brain also can cause vascular dementia.
• High blood pressure and sex
• High blood pressure dangers
• Hypertensive crisis: What are the symptoms?

Feb 29, 2024

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Hypertension

Learn about the nursing care management of patients with hypertension .

Table of Contents

• What is Hypertension? 

Classification

Pathophysiology, epidemiology, clinical manifestations, complications, diagnostic tests, pharmacologic therapy.

• Nursing Assessment 
• Diagnosis 
• Nursing Care Plan and Goals

Nursing Priorities

Nursing interventions, discharge and home care guidelines, documentation guidelines, what is hypertension.

Hypertension is one of the most common lifestyle diseases to date. It affects people from all walks of life. Let us get to know hypertension more by its definitions.

• Hypertension is defined as a systolic blood pressure greater than 140 mmHg and a diastolic pressure of more than 90 mmHg .
• This is based on the average of two or more accurate blood pressure measurements during two or more consultations with the healthcare provider.
• The definition is taken from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure .

In 2017, the American College of Cardiology and the American Heart Association revised their hypertension guidelines . The previous guidelines set the threshold at 140/90 mm Hg for younger people and 150/80 mm Hg for those ages 65 and older.

• Normal . The normal range for blood pressure is between, less than 120 mmHg and less than 80 mmHg.
• Elevated . Elevated stage starts from 120 mmHg to 129 mmHg for systolic blood pressure and less than 80 mmHg for diastolic pressure.
• Stage 1 hypertension . Stage 1 starts when the patient has a systolic pressure of 130 to 139 mmHg and a diastolic pressure of 80 to 89 mmHg.
• Stage 2 hypertension . Stage 2 starts when the systolic pressure is already more than or equal than 140 mmHg and the diastolic is more than or equal than 90 mmHg.

In a normal circulation, pressure is transferred from the heart muscle to the blood each time the heart contracts and then pressure is exerted by the blood as it flows through the blood vessels.

The pathophysiology of hypertension follows.

• Hypertension is a multifactorial
• When there is excess sodium intake , renal sodium retention occurs, which increases fluid volume resulting in increased preload and increase in contractility.
• Obesity is also a factor in hypertension because hyperinsulinemia develops and structural hypertrophy results leading to increased peripheral vascular resistance.
• Genetic alteration also plays a role in the development of hypertension because when there is cell membrane alteration, functional constriction may follow and also results in increased peripheral vascular resistance.

Hypertension is slowly rising to the top as one of the primary causes of morbidity in the world . Here are the current statistics of the status of hypertension in some of the leading countries.

• About 31% of the adults in the United States have hypertension.
• African-Americans have the highest prevalence rate of 37%.
• In the total US population of persons with hypertension, 90% to 95% have primary hypertension or high blood pressure from an unidentified cause.
• The remaining 5% to 10% of this group have secondary hypertension or high blood pressure related to identified causes.
• Hypertension is also termed as the “silent killer” because 24% of people who had pressures exceeding 140/90 mmHg were unaware that their blood pressures were elevated.

Hypertension has a lot of causes just like how  fever has many causes. The factors that are implicated as causes of hypertension are:

• Increased sympathetic nervous system activity . Sympathetic nervous system activity increases because there is dysfunction in the autonomic nervous system .
• Increase renal reabsorption . There is an increase reabsorption of sodium , chloride, and water which is related to a genetic variation in the pathways by which the kidneys handle sodium.
• Increased RAAS activity . The renin-angiotensin-aldosterone system increases its activity leading to the expansion of extracellular fluid volume and increased systemic vascular resistance.
• Decreased vasodilation of the arterioles . The vascular endothelium is damaged because of the decrease in the vasodilation of the arterioles.

Many people who have hypertension are asymptomatic at first. Physical examination may reveal no abnormalities except for an elevated blood pressure, so one must be prepared to recognize hypertension at its earliest.

• Headache . The red blood cells carrying oxygen is having a hard time reaching the brain because of constricted vessels , causing headache.
• Dizziness occurs due to the low concentration of oxygen that reaches the brain.
• Chest pain . Chest pain occurs also due to decreased oxygen levels .
• Blurred vision . Blurred vision may occur later on because of too much constriction in the blood vessels of the eye that red blood cells carrying oxygen cannot pass through.

Prevention of hypertension mainly relies on a healthy lifestyle and self-discipline.

• Weight reduction . Maintenance of normal body weight can help prevent hypertension.
• Adopt DASH . DASH or the Dietary Approaches to Stop Hypertension includes consummation of a diet rich in fruits, vegetable, and low-fat dairy .
• Dietary sodium retention . Sodium contributes to an elevated blood pressure, so reducing the dietary intake to no more than 2.4 g sodium per day can be really helpful.
• Physical activity . Engage in regular aerobic physical activity for 30 minutes thrice every week.
• Moderation of alcohol consumption . Limit alcohol consumption to no more than 2 drinks per day in men and one drink for women and people who are lighter in weight.

If hypertension is left untreated, it could progress to complications of the different body organs.

• Heart failure . With increased blood pressure, the heart pumps blood faster than normal until the heart muscle goes weak from too much exertion.
• Myocardial infarction . Decreased oxygen due to constriction of blood vessels may lead to MI.
• Impaired vision. Ineffective peripheral perfusion affects the eye, causing problems in vision because of decreased oxygen.
• Renal failure. Blood carrying oxygen and nutrients could not reach the renal system because of the constricted blood vessels .

Assessment and Diagnostic Findings

Assessment of the patient with hypertension must be detailed and thorough. There are also diagnostic tests that can be performed to establish the diagnosis of hypertension.

• Assess the patient’s health history
• Perform physical examination as appropriate.
• The retinas are examined to assess possible organ damage .
• Laboratory tests are also taken to check target organ damage .
• Urinalysis is performed to check the concentration of sodium in the urine though the specific gravity.
• Blood chemistry (e.g. analysis of sodium, potassium , creatinine , fasting glucose , and total and high density lipoprotein cholesterol levels). These tests are done to determine the level of sodium and fat in the body.
• 12-lead ECG . ECG needs to be performed to rule presence of cardiovascular damage .
• Echocardiography . Echocardiography assesses the presence of left ventricular hypertrophy .
• Creatinine clearance . Creatinine clearance is performed to check for the level of BUN and creatinine that can determine if there is renal damage or not.
• Renin level . Renin level should be assessed to determine how RAAS is coping.
• Hemoglobin /hematocrit:  Not diagnostic but assesses relationship of cells to fluid volume (viscosity) and may indicate risk factors such as hypercoagulability, anemia .
• Blood urea nitrogen (BUN)/creatinine:  Provides information about renal perfusion/function.
• Glucose:   Hyperglycemia ( diabetes mellitus is a precipitator of hypertension) may result from elevated catecholamine levels (increases hypertension).
• Serum potassium :   Hypokalemia may indicate the presence of primary aldosteronism (cause) or be a side effect of diuretic ­therapy.
• Serum calcium :  Imbalance may contribute to hypertension.
• Lipid panel (total lipids, high-density lipoprotein [HDL], low-density lipoprotein [LDL], cholesterol, triglycerides , phospholipids):  Elevated level may indicate predisposition for/presence of atheromatous plaques.
• Thyroid studies:  Hyperthyroidism may lead or contribute to vasoconstriction and hypertension.
• Serum/urine aldosterone level:  May be done to assess for primary aldosteronism (cause).
• Urinalysis:  May show blood, protein, or white blood cells ; or glucose suggests renal dysfunction and/or presence of diabetes .
• Creatinine clearance:  May be reduced, reflecting renal damage.
• Urine vanillylmandelic acid (VMA) (catecholamine metabolite):  Elevation may indicate presence of pheochromocytoma (cause); 24-hour urine VMA may be done for assessment of pheochromocytoma if hypertension is intermittent.
• Uric acid:  Hyperuricemia has been implicated as a risk factor for the development of hypertension.
• Renin:  Elevated in renovascular and malignant hypertension, salt-wasting disorders.
• Urine steroids:  Elevation may indicate hyperadrenalism, pheochromocytoma, pituitary dysfunction, Cushing’s syndrome.
• Intravenous pyelogram (IVP):  May identify cause of secondary hypertension, e.g., renal parenchymal disease, renal/ureteral ­calculi.
• Kidney and renography nuclear scan:  Evaluates renal status (TOD).
• Excretory urography:  May reveal renal atrophy, indicating chronic renal disease.
• Chest x-ray :  May demonstrate obstructing calcification in valve areas; deposits in and/or notching of aorta ; cardiac enlargement.
• Computed tomography (CT) scan:  Assesses for cerebral tumor , CVA, or encephalopathy or to rule out pheochromocytoma.
• Electrocardiogram (ECG):  May demonstrate enlarged heart, strain patterns, conduction disturbances. Note: Broad, notched P wave is one of the earliest signs of hypertensive heart disease.

Medical Management

Main Topic: Antihypertensive Drugs

The goal of hypertension treatment is to prevent complications and death by achieving and maintaining arterial blood pressure at or below 130/80 mmHg.

• The medications used for treating hypertension decrease peripheral resistance , blood volume , or the strength and rate of myocardial contraction .
• For uncomplicated hypertension, the initial medications recommended are diuretics and beta blockers.
• Only low doses are given, but if blood pressure still exceeds 140/90 mmHg, the dose is increased gradually.
• Thiazide diuretics decrease blood volume , renal blood flow, and cardiac output.
• ARBs are competitive inhibitors of aldosterone binding .
• Beta blockers block the sympathetic nervous system to produce a slower heart rate and a lower blood pressure.
• ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II and lowers peripheral resistance.

Stage 1 Hypertension

• Thiazide diuretic is recommended for most and angiotensin-converting enzyme-1, aldosterone receptor blocker , beta blocker , or calcium channel blocker is considered.

Stage 2 Hypertension

• Two-drug combination is followed, usually including thiazide diuretic and angiotensin-converting enzyme-1, or beta-blocker , or calcium channel blocker.

Nursing Management

The goal of nursing management is to help achieve a normal blood pressure through independent and dependent interventions.

Nursing Assessment

Nursing assessment must involve careful monitoring of the blood pressure at frequent and routinely scheduled intervals.

• If patient is on antihypertensive medications, blood pressure is assessed to determine the effectiveness and detect changes in the blood pressure.
• Complete history should be obtained to assess for signs and symptoms that indicate target organ damage.
• Pay attention to the rate, rhythm, and character of the apical and peripheral pulses.

Based on the assessment data, nursing diagnoses may include the following:

• Deficient knowledge regarding the relation between the treatment regimen and control of the disease process.
• Noncompliance with the therapeutic regimen related to side effects of the prescribed therapy.
• Risk for activity intolerance related to imbalance between oxygen supply and demand.
• Risk- prone health behavior related to condition requiring change in lifestyle.

Nursing Care Plan and Goals

Main article: Hypertension Nursing Care Plans

The major goals for a patient with hypertension are as follows:

• Understanding of the disease process and its treatment.
• Participation in a self-care program.
• Absence of complications.
• BP within acceptable limits for individual.
• Cardiovascular and systemic complications prevented/minimized.
• Disease process/prognosis and therapeutic regimen understood.
• Necessary lifestyle/behavioral changes initiated.
• Plan in place to meet needs after discharge.
• Maintain/enhance cardiovascular functioning.
• Prevent complications.
• Provide information about disease process/prognosis and treatment regimen.
• Support active patient control of condition.

The objective of nursing care focuses on lowering and controlling the blood pressure without adverse effects and without undue cost.

• Encourage the patient to consult a dietitian to help develop a plan for improving nutrient intake or for weight loss .
• Encourage restriction of sodium and fat
• Emphasize increase intake of fruits and vegetables .
• Implement regular physical activity .
• Advise patient to limit alcohol consumption and avoidance of tobacco.
• Assist the patient to develop and adhere to an appropriate exercise regimen.  

At the end of the treatment regimen, the following are expected to be achieved:

• Maintain blood pressure at less than 140/90 mmHg with lifestyle modifications, medications, or both.
• Demonstrate no symptoms of angina , palpitations, or visual changes.
• Has stable BUN and serum creatinine levels.
• Has palpable peripheral pulses.
• Adheres to the dietary regimen as prescribed.
• Exercises regularly.
• Takes medications as prescribed and reports side effects.
• Measures blood pressure routinely.
• Abstains from tobacco and alcohol intake.
• Exhibits no complications.

Following discharge, the nurse should promote self-care and independence of the patient.

• The nurse can help the patient achieve blood pressure control through education about managing blood pressure.
• Assist the patient in setting goal blood pressures .
• Provide assistance with social support.
• Encourage the involvement of family members in the education program to support the patient’s efforts to control hypertension.
• Provide written information about expected effects and side effects.
• Encourage and teach patients to measure their blood pressures at home.
• Emphasize strict compliance of follow-up check up .

These are the following data that should be documented for the patient’s record:

• Effects of behavior on health status/condition.
• Plan for adjustments and interventions for achieving the plan and the people involved.
• Client responses to the interventions, teaching, and action plan performed.
• Attainment or progress towards desired outcome.
• Modifications to plan care.
• Individual findings including deviation from prescribed treatment plan.
• Consequences of actions to date.

Posts related to Hypertension:

• Pregnancy Induced Hypertension
• 6 Hypertension Nursing Care Plans
• Antihypertensive Drugs
• Cardiovascular Care Nursing Mnemonics and Tips

6 thoughts on “Hypertension”

I want some NMC questions to solve

Question regarding Stage 1 HTN is incorrect. Stage 1 HTN is BP reading 140-159/90-99.

In new version of Brunner & Suddath’s medical surgical nursing textbook (2022), stage 1 HTN is BP reading 130-139/80-89. (pp: 866, vol 1)

I don’t understand the explanation for the classification of hypertension, the explanation is not matching with the table, why?

“Medical Management Main Topic: Antihypertensive Drugs

The goal of hypertensive treatment I to prevent complications and death by achieving and maintaining the arterial blood pressure at 40/90 mmHg or lower.”

I think need to correct the above sentence as follows;

The goal of hypertensive treatment is to prevent complications and death by achieving and maintaining the arterial blood pressure at 140/90 mmHg or lower.”

please there is a place you wrote BP 40/90,is that correct. Meanwhile, the article is educative.

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Hypertension

Apr 04, 2019

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Hypertension. 3.12 Cardiovascular health - covering BP management. After this talk you should; Know how to measure blood pressure accurately and consistently Know when to start and how to monitor drug treatment Feel confident about when to consider secondary hypertension

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• systolic hypertension
• clinical attention
• general principles
• antihypertensive drug treatment
• bendroflumethiazideor hydrochlorothiazide
• international hypertension society

Presentation Transcript

3.12 Cardiovascular health - covering BP management After this talk you should; • Know how to measure blood pressure accurately and consistently • Know when to start and how to monitor drug treatment • Feel confident about when to consider secondary hypertension • Know when to refer patients for further investigation and management.

What is hypertension? The world health organisation (WHO) and the international hypertension society defines hypertension as having a systolic blood pressure above 140 mm Hg, or a diastolic blood pressure above 90 mm Hg, or both, on at least 3 separate occasions.

Epidemiology Hypertension remains underdiagnosed, undertreated and poorly controlled in the UK. Prevalence in over 35s - 32% of Men - 27% of women This increases with age - 33% of men and 25% of women aged 45-54 years have hypertension. - 73% of men and 64% of women aged ≥75 years have hypertension. Screening for hypertension All adults should have their blood pressure measured, at least every five years up to the age of 80, and at least annually thereafter.

Why is hypertension important Risk factor for leading causes of deaths in the Western world Each 2 mmHg rise in systolic blood pressure associated with; - 7% increased risk of mortality from IHD - 10% increased risk of mortality from stroke vascular and renal damage caused by untreated hypertension can culminate in a treatment-resistant state. Data from therapeutic trials of antihypertensive drugs consistently show reductions in cardiovascular events and total mortality without adversely affecting quality of life.

How do patients come to clinical attention? • Usually asymptomatic and detected opportunstically • Alternatively, patients may present with complications • In the UK, the Quality and Outcomes Framework sets goals linked to GPs’ remuneration  encourages GPs to measure BP in asymptomatic patients • Increased availability of home BP monitoring / blood pressure measurement in pharmacies

Diagnosing hypertension • Measure BP in both arms. • If difference between arms >20 mmHg  repeat • If difference between arms remains >20 mmHg on the 2ndmeasurement, measure subsequent BPs in arm with higher reading • If BP measured is 140/90 mmHg or higher: • Take second measurement • If second substantially different  take a third • Record lower of the two measurements • Either automated machine or manual method • If pule is irregular - always use manual • Record to the nearest 2 mmHg

Confirming the diagnosis • If the 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 diagnosis, investigate target organ damage and assess cardiovascular risk • Those with high normal values (130-139/85-89 mm Hg) should be checked annually.

Ambulatory blood pressure monitoring • Ensure two measurements /hour taken during the person’s usual waking hours • Use the average value of at least 14 measurements to confirm the diagnosis. • Home blood pressure monitoring • Ensure that: • Two consecutive measurements are taken, at least 1 minute apart and with the person seated • BP is recorded twice daily • BP 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.

Defining Hypertension • Stage 1 hypertension • Clinic blood pressure is 140/90 mmHg or higher and subsequent ABP daytime average or HBPM average blood pressure is 135/85 mmHg or higher. • Stage 2 hypertension • Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher. • Severe hypertension • Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.

History • Risk factors for cardiovascular disease : • Age • Sex • Socioeconomic group • Smoking habits throughout the patient’s lifetime • Family history of cardiovascular disease • Personal history of diabetes, kidney disease, or elevated cholesterol. • Symptoms suggesting cardiac complications of hypertension • (ischaemia, infarction, or congestive cardiac failure) : • Chest pain • Breathlessness • Ankle swelling • Palpitations. • You should also check for clinical features that may suggest secondary hypertension.

Clinical Examination • Look for signs of hypertensive complications: • Fundoscopy • Observation of neck veins. • Assessment of the apex beat • Auscultation of the heart for murmurs • Auscultation of the lungs • Palpation of the radial, popliteal, and foot pulses. • Assessment of the ankles and sacrum • Auscultation of the carotid arteries

Investigations • Look for complications or possible secondary hypertension: • Urinalysis with dipstick testing • A resting 12-lead electrocardiogram (ECG) • Urea and electrolytes • Serum glucose (ideally fasting) • Serum lipid profile • Thyroid function tests • Glomerular filtration rate.

Secondary hypertension Around 5% of people with hypertension - high blood pressure is due to an underlying (secondary) disease. Causes include: • Chronic renal disease • Cushing’s syndrome • Primary aldosteronism • Thyrotoxicosis • Phaeochromocytoma. Common clinical features include: • Age younger than 30 • Sudden worsening of hypertension • Poor response to treatment.

Assessing cardiovascular risk NICE recommends; Using 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.

Initiating treatment • Aged under 80 years with stage 1 hypertension who have one or more of the following: • target organ damage • established cardiovascular disease • renal disease • diabetes • a 10-year cardiovascular risk equivalent to 20% or greater. • Any age with stage 2 hypertension • Aged under 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation.

Other considerations Malignant (accelerated) hypertension- severe hypertension (eg systolic >200 mm Hg, diastolic >130 mm Hg), encephalopathy or nephropathy, papilloedema and/or angiopathic haemolytic anaemia. Accelerated hypertension needs urgent (same day) assessment and treatment. Suspected phaeochromocytoma - Consider this diagnosis if there is labile or postural hypotension, headache, palpitations, pallor and profuse sweating - refer for urgent (same day) assessment. Hypertensive crisis- a systolic blood pressure (SBP) ≥180 mm Hg or a diastolic blood pressure (DBP) ≥120 mm Hg . Treatment should safely reduce BP. Immediate reduction in BP is required only in patients with acute end-organ damage

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 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 ACE inhibitor with an angiotensin II receptor blocker (ARB).

Lifestyle interventions • Ask people about their diet and exercise patterns, and promote lifestyle changes - 30 mins brisk exercise a day, (DASH) • Weight loss • Alcohol consumption - limit intake to 21/14 units a week • Discourage excessive consumption of coffee and other caffeine-rich products • Encourage people to keep their salt intake low • Offer people who smoke advice and help to stop smoking • It is not recommended that primary care teams provide relaxation therapies routinely • Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure

Step 1 treatment • under 55 years – ACE inhibitor or a low-cost ARB. • Over 55 or Afro-Carribean of any age - Calcium channel blocker • 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 diuretic treatment is to be initiated or changed, offer a thiazidelike diuretic, such as chlortalidoneor indapamidEin preference to a conventional thiazide diuretic such as bendroflumethiazideor 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.

Step 2 treatment • - If blood pressure is not controlled by step 1 treatment • Offer with a CCB in combination with either an ACE inhibitor or ARB • If a CCB is not suitable , offer a thiazide-like diuretic (CCB intolerance, or if there is evidence of heart failure or a high risk of heart failure). • For black people of African or Caribbean family origin: • Consider an ARB in preference to an ACE inhibitor, in combination with a CCB • Step 3 treatment • Before considering step 3 treatment • review medication to ensure step 2 treatment is at optimal or best tolerated doses • Combination of three drugs: • ACE inhibitor or angiotensin II receptor blocker, • Calcium-channel blocker • And Thiazide-like diuretic should be used

Step 4 treatment If BP remains higher than 140/90 mmHg after treatment with the optimal or best tolerated doses of an ACE inhibitor or an ARB plus a CCB plus a diuretic as resistant hypertension, and consider adding a fourth antihypertensive drug & Or ( Alpha blocker or B-Blocker and seek expert advice ) Spironolactone (25 mg Od) if Potassium level is 4.5 mmol/l or lower. (Caution in pts with reduced GFR increased risk of hyperkalemia.) Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5mmol/l. (monitor Na , K, Renal function within one month & repeat as required.)  If BP uncontrolled with optimal or maximal tolerated doses of four drugs, Seek expert Advice

BP targets • Clinical Blood pressure: • People aged under 80 years: lower than 140/90 mm Hg • People aged over 80 years: lower than 150/90 mm Hg • Daytime average APBM OR average HBPM blood pressure during persona's usual waking hours. • People aged under 80 years: lower than 135/85 mm Hg • People aged over 80 years: lower than 145/85 mm Hg • lower BP targets are recommended for diabetics; • Type 1 diabetes: <135/85mmHg, or <130/80mmHg with nephropathy • Type 2 diabetes: <140/80mmHg, or <135/75mmHg if microalbuminuria or proteinuria is present

Indication for specialist referral Urgent treatment needed: accelerated hypertension, severe hypertension (>220/>120 mm Hg) or impending complications (egTIA, LVF). Possible underlying cause: low K+, Na+ elevated (possible Conn's syndrome); elevated creatinine, proteinuria or haematuria; sudden onset or rapidly worsening or resistant hypertension (ie needs >3 drugs); young age: patient aged <20 years, or <30 years needing treatment. Therapeutic problems: multiple drug intolerance or contra-indications, persistent noncompliance or treatment refusal (the reluctant hypertensive). Special situations: hypertension in pregnancy, unusual blood pressure (BP) variability.

Please collect a question sheet and get into groups of 3

Question 1 A 65 year old woman who is newly diagnosed with hypertension attends your morning surgery for initial assessment. Which of the following is NOT recommended as part of the initial assessment of a patient with hypertension? A - Measurement of weight, height, and waist circumference B - Resting 12-lead ECG C - Dipstick urinalysis D - Full blood count E - Urea and electrolytes

Question 1 – Answer D – Full Blood count

Question 2 What are current recommendations for choosing sphygmomanometer cuffs? A - The size of the cuff doesn’t matter: you should use the cuff that appears to be in the best condition B - You should chose the cuff based on the patient’s arm circumference: the rubber bladder within the cuff should have a length of 80% of the arm circumference and a width of 40% of the arm circumference C- You should chose the cuff based on the patient’s arm circumference: the rubber bladder within the cuff should have a length of 40% of the arm circumference and a width of 20% of the arm circumference D - You should chose the cuff based on the patient’s arm circumference: the rubber bladder within the cuff should have a length of 120% of the arm circumference and a width of 80% of the arm circumference

Question 2 - Answer B : You should chose the cuff based on the patient’s arm circumference: the rubber bladder within the cuff should have a length of 80% of the arm circumference and a width of 40% of the arm circumference Most manufacturers and the NICE guidelines recommend that the rubber bladder within the cuff be around 40% of the patient’s arm circumference in width and 80% of the arm circumference in length. Using a bladder that is too small may overestimate blood pressure, using one that is too large will underestimate it.

Question 3 You see a 45 year old man in the clinic. He reports headaches and palpitations and is worried because both his parents had “high blood pressure.” You take his blood pressure and it is 155/98 mm Hg. How should you confirm or refute a diagnosis of hypertension in this patient? The diagnosis is made by the blood pressure reading you have taken This patient will require 24 hour ambulatory blood pressure monitoring You should take a second reading after five minutes’ rest. If it is >140/90 mm Hg the diagnosis is confirmed You should ask the patient to return weekly for the next two weeks for further readings. If these three readings are all >140/90 mm Hg the diagnosis is confirmed

Question 3 - Answer B : This patient will require 24 hour ambulatory blood pressure monitoring Recent national guidelines recommend that you offer all patients with a clinic reading of greater than 140/90 mm Hg ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis. Home blood pressure monitoring (HBPM) with an ambulatory device is an acceptable alternative in patients intolerant of ABPM.

Question 4 • About what percentage of adults are hypertensive, as defined by WHO and the International • Society of Hypertension (blood pressure >140/90 mm Hg)? • A – 5% • B – 10% • C – 25% • D - 40%

Question 4 - Answer D : 40% According to the Heart of England Survey, 40% of adults in England have a blood pressure sustained at greater than 140/90 mm Hg, and would therefore be classified as hypertensive according to the WHO definition of hypertension

Question 5 You see a 47 year old woman for her first review appointment after being diagnosed with mild hypertension. She is keen to avoid drug treatment. Which one of the following statements about effective lifestyle measures is correct? They can lower blood pressure as much as a single antihypertensive agent They are more effective than beta blockers at reducing blood pressure They usually avoid the need for drug therapy They can be instituted effectively without good quality written information They can be discontinued if drug therapy is begun

Question 5 - Answer A : They can lower blood pressure as much as a single antihypertensive agent Evidence from clinical trials suggests that effective and sustained lifestyle measures (weight reduction, exercise, dietary changes) can lower blood pressure as much as a single antihypertensive agent.

Question 6 You have been seeing a 39 year old Afro-Caribbean woman in the clinic for high blood pressure for several months. The most recent reading on ambulatory blood pressure monitorings 155/97 mm Hg. Her only other past medical history is two episodes of gout. She does not takeallopurinol. According to evidence based guidance which drug should you offer her first? A calcium channel blocker A beta blocker A thiazide diuretic An alpha blocker

Question 6 - Answer A : A calcium channel blocker Afro-Caribbean patients are at increased risk of hypertension and hypertensive complications. For this reason, national guidelines recommend treating Afro-Caribbean patients younger than 55 the same as other patients older than 55. First choice therapy for this patient would be a calcium channel blocker. This patient’s past history of gout means that thiazides should be used with caution because they may provoke a further episode.

Question 7 • You see the same 39 year old Afro-Caribbean woman eight weeks after starting a calcium channel blocker. The dose of the calcium channel blocker had been increased at four weeks to the maximum recommended daily dose. She is feeling well and has experienced no side effects. • Her most recent blood pressure measurement on ambulatory blood pressure monitoring • (ABPM) was 148/96 mm Hg. What should you should now? • A - Substitute the calcium channel blocker for an alpha blocker • B - Refer to a hypertension specialist • C - Add an ACE inhibitor • D - Add a beta blocker • E - Continue and recheck the blood pressure in six months

Question 7 - Answer C : Add an ACE inhibitor For this patient, step 2 of the algorithm would support adding an ACE inhibitor or an ARB if ACE inhibitors are not tolerated.

Question 8 You see a 49 year old white man in the clinic and you confirm that he has stage II ( ≥150/95 mm Hg) hypertension on ambulatory blood pressure monitoring. He is otherwise well. According to evidence based guidance which drug should you offer him first? An ACE inhibitor An alpha blocker A thiazide diuretic A calcium channel blocker A combined preparation

Answer question 8 A : An ACE inhibitor According to national guidelines, if you are starting drug treatment in this patient you should begin with an ACE inhibitor. [5] If the patient cannot tolerate ACE inhibitors or if he has contraindications, the alternative treatment of choice would be an ARB.

Question 9 You have made a diagnosis of hypertension in a patient several weeks ago and started treatment, initially with an ACE inhibitor. Which of the following clinical features should most make you consider that the patient has secondary hypertension? The patient is 57 and had normal blood pressure measured four years ago The patient’s blood pressure responds poorly to treatment, despite escalating up the A/CD protocol The patient’s serum potassium is 4.9 mmol/l (reference range 3.5-5.1 mmol/l) The patient’s serum creatinine fell after starting treatment

Question 9 - Answer • B : The patient’s blood pressure responds poorly to treatment, despite escalating up the A/CD protocol • Clinical features that suggest secondary, as opposed to essential, hypertension are: • Age younger than 30 • Sudden deterioration of hypertension • Poor response to drug treatment.

Question 10 You see a 55 year old man in the clinic for a routine check up. He does not report any symptoms, although he says that things have become stressful in work recently due to several colleagues losing their jobs. As part of your examination you take his blood pressure, which is 223/121 mm Hg. You repeat the blood pressure measurement later in the consultation and obtain a similar result. Fundoscopy is normal. What is the most important thing you should you do next? Estimate the 10 year risk of cardiovascular disease using a risk chart or risk chart computer programme to help guide treatment Confirm the reading over one to two weeks before you consider treatment Begin treatment immediately Give the patient an intravenous bolus of methyldopa

Question 10 - Answer C : Begin treatment immediately This is the course of action recommended by evidence based guidelines. This level of hypertension is particularly severe and requires urgent treatment.

Question 11 You review an 82-year-old woman in clinic. Last month she had a one-off blood pressure reading of 150/92 mmHg and was offered ambulatory blood pressure monitoring. This shows an average reading of 146/94 mmHg. She has no significant past medical history of note other than hypothyroidism. Her 10-year cardiovascular risk is calculated to be 16%. What is the most appropriate management? Arrange further ambulatory blood pressure monitoring Start a thiazide-type diuretic Give lifestyle advice and repeat blood pressure in 6 months Start an ACE inhibitor Start a calcium channel blocker

Question 11 - Answer C. Give lifestyle advice and repeat blood pressure in 6 months NICE now only recommend diagnosing people over the age of 80 years as hypertensive if they have stage 2 hypertension (ABPM daytime average or HBPM average BP >= 150/95 mmHg). Remember that the diagnostic criteria are different from the blood pressure targets once treatment has started, which for people over the age of 80 years are: clinic readings < 150/90 mmHg ABPM/HBPM < 145/85 mmHg

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5 Things to Know About Hypertension in Pregnancy

Janet S. Wright, MD, MACC, FPCNA  Director, Division for Heart Disease and Stroke Prevention  National Center for Chronic Disease Prevention and Health Promotion  Centers for Disease Control and Prevention

In recent years, hypertension in pregnancy has increased, 4 which increases risk for mother and baby, both immediate and long-term. These risks may be reduced through timely detection and management of hypertension during and following pregnancy.

As we recognize National Women’s Blood Pressure Awareness Week and the importance of blood pressure control across the lifespan, here are five things women and their health care teams need to know about hypertension in pregnancy.

1. Hypertension in pregnancy threatens both mother and baby.

Hypertension can be a chronic condition predating pregnancy or developing during pregnancy. Types of pregnancy-associated hypertension include gestational hypertension , preeclampsia , eclampsia , and chronic hypertension with superimposed preeclampsia or eclampsia. The impact of hypertension in pregnancy does not end when the pregnancy and postpartum periods are over. Pregnant women with hypertension have about twice the risk of subsequent heart disease as pregnant women without hypertension. Children born to women with hypertension have a higher risk for hypertension themselves, 5 as well as an increased lifetime risk of dying from cardiovascular disease. 6, 7

2. Most pregnancy-related deaths stemming from hypertension are preventable.

Unfortunately, hypertension is often undetected or untreated during and following pregnancy. One study suggested that 60% of deaths attributed to preeclampsia/eclampsia had a ”good-to-strong” chance of being prevented. 8 To avoid preventable deaths, hypertension in pregnancy must be recognized early and effectively managed.

3. Prompt identification and management of rising blood pressure readings can be lifesaving.

Screening for hypertension during routine visits can be beneficial for all women across the lifespan. 9 Home monitoring of blood pressure is the best way for women to know and understand their blood pressure patterns.

Throughout pregnancy, most women see their health care teams regularly, providing opportunities for lifestyle counseling and medications if necessary for hypertension. Postpartum visits provide additional opportunities. By finding and treating individuals with undiagnosed hypertension “hiding in plain sight,” 10 health care teams can save lives and prevent life-changing complications for both mother and child.

4. Health care and public health professionals play pivotal roles in equity and safety during pregnancy.

Notable health disparities exist among different racial and ethnic groups. For instance, non-Hispanic Black (20.9%) and American Indian/Alaska Native (16.4%) women have the highest prevalence of hypertension during delivery hospitalization. 4 The prevalence of hypertension in pregnancy is also higher for women who are ≥ 35 years of age, live in the South and Midwest, live in rural counties, or live in areas with the lowest median household income. These disparities likely stem from underlying factors, such as health care access and quality; availability of nutritious, affordable food and safe places to be physically active; and structural racism, including systemic racial and gender bias within the health care system. 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18

Stratifying data by race and ethnicity, age, insurance status, preferred language, and other social drivers of health can help identify and address health care gaps in communities. Health care teams can implement policies and processes to train all patient-facing staff in respectful and culturally safe communication, being mindful of communication needs, such as health literacy and language barriers, as well as various family structures and cultural practices.

5. The Million Hearts® Hypertension in Pregnancy Change Package offers valuable resources for clinical teams in outpatient settings.

Developed by and for clinicians, the Hypertension in Pregnancy Change Package is a compilation of ready-to-implement strategies to improve hypertension management and reduce its complications. Strategies include self-measured (home or out-of-office) blood pressure monitoring, aspirin use to prevent preeclampsia, healthy lifestyle recommendations, and anti-hypertensive medications that are safe and effective during pregnancy and lactation. The change package also includes tools for implicit bias training, warning signs and symptoms, and more.

The Hypertension in Pregnancy Change Package was developed by CDC’s Division for Heart Disease and Stroke Prevention, with the Division of Reproductive Health and in partnership with the American Academy of Family Physicians, the American College of Nurse-Midwives, the American College of Obstetricians and Gynecologists, the American College of Osteopathic Obstetricians and Gynecologists, the American Medical Association, the National Association of Nurse Practitioners in Women’s Health, and the Society for Maternal-Fetal Medicine.

Additional Resources:

• Explore the Hypertension in Pregnancy Change Package
• Learn more about Hypertensive Disorders of Pregnancy
• Access CDC’s Hear Her campaign resources

Follow CDC’s Division for Heart Disease and Stroke Prevention on X . Follow Million Hearts® on LinkedIn .

References:

• Mills, K. T., Stefanescu, A., & He, J. (2020). The global epidemiology of hypertension. Nature reviews. Nephrology, 16(4), 223–237. https://doi.org/10.1038/s41581-019-0244-2 .
• National Center for Health Statistics. Multiple Cause of Death 2018–2022 on CDC WONDER Database. Accessed May 3, 2024. https://wonder.cdc.gov/mcd.html
• Weng X, Woodruff RC, Park S, Thompson-Paul AM, He S, Hayes D, Kuklina EV, Therrien NL, Jackson SL. Hypertension Prevalence and Control Among U.S. Women of Reproductive Age. Am J Prev Med. 2024 Mar;66(3):492-502. doi: 10.1016/j.amepre.2023.10.016. Epub 2023 Oct 24. PMID: 37884175; PMCID: PMC10922595.
• Ford ND, Cox S, Ko JY, et al. Hypertensive Disorders in Pregnancy and Mortality at Delivery Hospitalization - United States, 2017-2019. MMWR Morb Mortal Wkly Rep. 2022;71(17):585-591. Published 2022 Apr 29. doi:10.15585/mmwr.mm7117a1
• Dines VA, Kattah AG, Weaver AL, et al. Risk of Adult Hypertension in Offspring From Pregnancies Complicated by Hypertension: Population-Based Estimates. Hypertension . 2023;80(9):1940-1948. doi:10.1161/HYPERTENSIONAHA.123.20282
• Huang, C., Wei, K., Lee, P. M. Y., Qin, G., Yu, Y., & Li, J. (2022). Maternal hypertensive disorder of pregnancy and mortality in offspring from birth to young adulthood: national population based cohort study. BMJ (Clinical research ed.), 379, e072157. https://doi.org/10.1136/bmj-2022-072157. Corrected in Maternal hypertensive disorder of pregnancy and mortality in offspring from birth to young adulthood: national population based cohort study. (2022). BMJ (Clinical research ed.), 379, o2726. https://doi.org/10.1136/bmj.o2726
• Hammad IA, Meeks H, Fraser A, et al. Risks of cause-specific mortality in offspring of pregnancies complicated by hypertensive disease of pregnancy. Am J Obstet Gynecol. 2020;222(1):75.e1-75.e9. doi:10.1016/j.ajog.2019.07.024
• Main EK, McCain CL, Morton CH, Holtby S, Lawton ES. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstet Gynecol. 2015;125(4):938-947. doi:10.1097/AOG.0000000000000746
• ACOG Committee Opinion No. 755: Well-Woman Visit. Obstet Gynecol. 2018;132(4):e181-e186. doi:10.1097/AOG.0000000000002897
• Wall HK, Hannan JA, Wright JS. Patients with undiagnosed hypertension: hiding in plain sight. JAMA . 2014;312(19):1973-1974. doi:10.1001/jama.2014.15388
• Johnson JD, Louis JM. Does race or ethnicity play a role in the origin, pathophysiology, and outcomes of preeclampsia? An expert review of the literature. Am J Obstet Gynecol. 2022;226(2S):S876–S885.
• Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. J Womens Health (Larchmt). 2021 Feb;30(2):230–235.
• Meyerovitz CV, Juraschek SP, Ayturk D, Moore Simas TA, Person SD, Lemon SC, et al. Social determinants, blood pressure control, and racial inequities in childbearing age women with hypertension, 2001 to 2018. J Am Heart Assoc. 2023;12(5):e027169. CHANGE PACKAGE | 51
• Sharma G, Grandhi GR, Acquah I, Mszar R, Mahajan S, Khan SU, et al. Social determinants of suboptimal cardiovascular health among pregnant women in the United States. J Am Heart Assoc. 2022;11(2):e022837.
• Baiden D, Parry M, Nerenberg K, Hillan EM, Dogba MJ. Connecting the dots: structural racism, intersectionality, and cardiovascular health outcomes for African, Caribbean, and Black mothers. Health Equity. 2022;6(1):402–-405.
• Howell EA, Brown H, Brumley J, Bryant AS, Caughey AB, Cornell AM, et al. Reduction of peripartum racial and ethnic disparities: a conceptual framework and maternal safety consensus bundle [published correction appears in Obstet Gynecol. 2019 Jun;133(6):1288]. Obstet Gynecol. 2018;131(5):770–782.
• Keith MH, Martin MA. Social determinant pathways to hypertensive disorders of pregnancy among nulliparous U.S. women. Womens Health Issues. 2024;34(1):36–44.
• Mohamoud YA, Cassidy E, Fuchs E, Womack LS, Romero L, Kipling L, et al. Vital signs: maternity care experiences—United States, April 2023. MMWR Morb Mortal Wkly Rep. 2023;72(35):961–967
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