Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Hypertension
Cardiology · UK scope · Sources checked 25 Aug 2026 · Clinical review pending
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Escalate
Clinic BP 180/120 mmHg or higher requires an immediate target-organ-damage and symptom screen. Arrange same-day specialist assessment when this is accompanied by retinal haemorrhage or papilloedema, new confusion, chest pain, signs of heart failure or acute kidney injury; also refer same day if phaeochromocytoma is suspected. Treat the clinical emergency and organ injury, not the number alone.
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.
Diagnosis requires clinic BP at least 140/90 mmHg plus ABPM or HBPM average at least 135/85 mmHg.
Stage 1 is clinic 140/90 to 159/99 and home/daytime average 135/85 to 149/94; stage 2 is clinic at least 160/100 but below 180/120 and home/daytime average at least 150/95.
Offer antihypertensive treatment to adults with persistent stage 2 hypertension; discuss treatment for stage 1 under age 80 when target-organ damage, CVD, renal disease, diabetes or QRISK3 10-year risk at least 10% is present.
Usual clinic targets are below 140/90 if under 80 and below 150/90 if 80 or older; corresponding ABPM/HBPM targets are below 135/85 and below 145/85.
Resistant hypertension means uncontrolled BP despite tolerated optimal doses of an ACE inhibitor or ARB, a CCB and a thiazide-like diuretic; confirm with out-of-office BP and address adherence before step 4.
A postural fall of at least 20 mmHg systolic or 10 mmHg diastolic after standing for at least 1 minute is significant; review causes and base targets on standing BP if symptoms or a significant fall persist.
Key red flags
Severe hypertension without emergency features
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.
Hypertensive emergency
Severe BP elevation with acute encephalopathy, intracranial event, acute coronary syndrome, pulmonary oedema, aortic syndrome, acute kidney injury or malignant retinopathy. Absolute BP can be lower when the rise is abrupt.
Suspected phaeochromocytoma
Labile or postural hypertension with headache, palpitations, pallor, abdominal pain or diaphoresis requires same-day specialist assessment.
Investigation priorities
01
Repeat standardised clinic BP in both armsFirst step
Confirm the initial reading and identify an inter-arm difference.
02
ABPMPreferred
Preferred confirmation for clinic BP 140/90 to below 180/120 mmHg.
Management branches
NICE diagnosisConfirm and risk-stratify
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.
Offer lifestyle support to everyone; offer medication for persistent stage 2 and discuss it for stage 1 under 80 with target-organ damage, established CVD, renal disease, diabetes or QRISK3 at least 10%. Consider treatment in adults under 60 even when 10-year risk is below 10%, because lifetime risk may be underestimated.
Step 1: use an ACE inhibitor or ARB in type 2 diabetes at any age or in people under 55 who are not of Black African or African-Caribbean family origin. Use an ARB if ACE-inhibitor cough occurs; never combine an ACE inhibitor with an ARB.
Step 1: use a CCB in people aged 55 or older without type 2 diabetes and in people of Black African or African-Caribbean family origin without type 2 diabetes at any age. If a CCB is not tolerated, for example because of oedema, use a thiazide-like diuretic.
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.Contraindicated in pregnancy, previous ACE-inhibitor angioedema and significant bilateral renal-artery stenosis; monitor creatinine/eGFR, potassium and BP. Pause/review in acute volume depletion and avoid ACE inhibitor plus ARB.
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.Contraindicated in pregnancy and severe hepatic impairment; monitor renal function and potassium and avoid dual ACE inhibitor/ARB treatment.
Sources and review status12 sources · checked 25 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 25 Aug 2026; clinical approval remains outstanding.