Synopsis
Recognise, confirm and stage adult hypertension; identify same-day emergencies; start evidence-based treatment and monitor safely in UK practice.
- Measure BP with the person seated, relaxed, arm supported and an appropriately sized cuff; check the pulse first and use manual auscultation if it is irregular.
- Measure both arms initially. If the difference remains greater than 15 mmHg after repeat measurement, use the arm with the higher reading thereafter.
- Clinic BP 140/90 to 179/119 mmHg should usually be confirmed by ABPM; use HBPM if ABPM is unsuitable or not tolerated.
Key red flags
BP 180/120 mmHg or higher but no retinal haemorrhage/papilloedema and no life-threatening symptoms: promptly test for target-organ damage. If none is found, confirm with ABPM/HBPM or repeat clinic BP and complete clinical review within 7 days.
Investigation priorities
Confirm the initial reading and identify an inter-arm difference.
Preferred confirmation for clinic BP 140/90 to below 180/120 mmHg.
Management branches
Clinic BP 140/90 to below 180/120 mmHg without emergency features.
- Repeat clinic BP correctly, arrange ABPM or HBPM, and simultaneously investigate target-organ damage; do not wait for out-of-office confirmation before investigating.
- Document stage, standing BP where indicated, comorbidity, medicines/substances, family history, lifestyle and QRISK3.
Confirmed hypertension requiring pharmacological treatment.
Key medicines
RamiprilUsually 2.5 mg orally once daily; start 1.25 mg once daily with marked renin-angiotensin activation or relevant diuretic use, then double at 2–4-week intervals to a maximum 10 mg/day according to response and tolerance.
Losartan50 mg orally once daily; consider 25 mg once daily if intravascularly depleted, and increase to 100 mg once daily after response review, typically from about 1 month.