Hypertension is defined as a persistent elevation in blood pressure, with clinic BP ≥140/90 mmHg, confirmed using ABPM or HBPM ≥135/85 mmHg. 📊 Diagnosis should always be confirmed with out-of-office readings to exclude white-coat hypertension. 👉 Stage 1 HTN: 140–159 / 90–99 mmHg 👉 Stage 2 HTN: ≥160 / 100 mmHg 👉 Severe HTN: ≥180 / 120 mmHg (urgent assessment required 🚨) 💡 Around 90–95% is essential hypertension; secondary causes (5–10%) must be actively considered in appropriate patients.

🧠 Pathophysiology (Why BP Causes Damage)

🧬 Chronic ↑ systemic vascular resistance → endothelial dysfunction & nitric oxide depletion
🫀 Pressure overload → left ventricular hypertrophy → diastolic dysfunction → HFpEF
🧠 Lipohyalinosis of small vessels → lacunar stroke & vascular dementia
🧪 Glomerular hypertension → proteinuria & CKD progression
⚡ Accelerated atherosclerosis → MI, PAD

Teaching point: Hypertension is best understood as a chronic vascular injury syndrome, not just a number.

⚠️ Who to Treat (NICE NG136)

🔴 Stage 2 HTN: Treat all patients
🟡 Stage 1 HTN: Treat if:
- 🧠 Target organ damage (LVH, CKD, retinopathy)
- 💔 Established cardiovascular disease
- 🧪 Diabetes
- 📊 QRISK ≥10%
- 👤 Age <80 years
👵 ≥80 years → individualised decision (consider frailty, falls risk)

🎯 Blood Pressure Targets (NICE)

Group	Clinic Target	ABPM/HBPM Target
🧑 <80 years	<140/90 mmHg	<135/85 mmHg
👵 ≥80 years	<150/90 mmHg	<145/85 mmHg

⚠️ NICE does not mandate lower targets purely for diabetes or CKD, unlike some international guidelines.

⚠️ Risk Factors for Essential Hypertension

🌍 Ethnicity (higher prevalence in Black populations)
🧬 Genetic predisposition
🧂 High salt intake → volume expansion
⚖️ Obesity → RAAS activation + insulin resistance
🍷 Excess alcohol
🛌 Poor sleep (e.g. OSA → sympathetic overactivity)

🔎 Clinical Clues to Secondary Hypertension

🦵 Radio–femoral delay → coarctation of aorta
🎧 Renal bruit → renal artery stenosis
😰 Episodic headache + sweating → phaeochromocytoma
🧂 Hypokalaemia → primary hyperaldosteronism
🫣 Resistant HTN (≥3 drugs) → secondary cause likely
💊 Drugs: NSAIDs, steroids, COCP, sympathomimetics

🧪 Baseline Investigations (NICE)

🩸 Lipids + HbA1c → CV risk
🧪 U&E, eGFR → renal function
🧾 Urine ACR → proteinuria
📈 ECG → LVH, AF
🫀 Echo if clinically indicated

📑 Stepwise Pharmacological Treatment (ABCD Algorithm)

Step	Recommendation
1️⃣	A (ACEi/ARB) if <55 years OR diabetes C (CCB) if ≥55 years or Black ethnicity
2️⃣	A + C
3️⃣	A + C + D (thiazide-like diuretic, e.g. indapamide)
4️⃣	Resistant HTN: • Add spironolactone if K⁺ ≤4.5 mmol/L • Otherwise consider α-blocker or β-blocker • Seek specialist advice

💡 Avoid ACEi + ARB combination (no added benefit, ↑ harm).

💊 Drug Class Insights (Clinical Reasoning)

🧬 ACEi/ARB: RAAS blockade → best for CKD, diabetes, younger patients
💊 CCB: vasodilation → particularly effective in elderly/Black patients
🧪 Thiazides: volume reduction → useful in salt-sensitive HTN
💊 Beta-blockers: not first-line unless compelling indication (e.g. IHD, AF, HF)

💊 Typical Antihypertensive Drug Titration Examples (NICE NG136)

🧬 ACE Inhibitor (e.g. Ramipril)

Step	Dose	Notes
Start	2.5 mg OD	Lower (1.25 mg) if elderly/frail or CKD
2–4 weeks	5 mg OD	Check U&E before up-titration
Target	10 mg OD	Maximal BP effect usually here

🧪 Check U&E and K⁺ at baseline and after each dose increase
⚠️ Acceptable: creatinine rise ≤30%
❌ Avoid in bilateral renal artery stenosis, pregnancy

💊 ARB (e.g. Losartan)

Step	Dose	Notes
Start	50 mg OD	Use if ACEi not tolerated (e.g. cough)
2–4 weeks	100 mg OD	Typical max dose

🧪 Same monitoring as ACEi (K⁺, creatinine)
💡 No added benefit combining ACEi + ARB ❌

💊 Calcium Channel Blocker (e.g. Amlodipine)

Step	Dose	Notes
Start	5 mg OD	First-line in ≥55 or Black ethnicity
2–4 weeks	10 mg OD	Max dose

⚠️ Common: ankle oedema, flushing, headache
💡 If oedema problematic → add ACEi rather than stop

🧪 Thiazide-like Diuretic (e.g. Indapamide)

Formulation	Dose	Notes
Modified release	1.5 mg OD	Preferred option
Standard	2.5 mg OD	Alternative

🧪 Monitor Na⁺, K⁺, renal function
⚠️ Risk: hyponatraemia, hypokalaemia, gout

💊 Step 4 (Resistant Hypertension)

Drug	Dose	When to Use
Spironolactone	25 mg → 50 mg OD	K⁺ ≤4.5 mmol/L
Alternative	Alpha- or beta-blocker	If K⁺ high or intolerant

🧪 Monitor K⁺ closely (hyperkalaemia risk)
💡 Particularly effective in aldosterone-driven (resistant) HTN

🔁 Practical Titration Strategy

📅 Review every 4 weeks after starting or changing dose
📊 Use home BP or ABPM where possible
⬆️ Up-titrate to max tolerated dose before adding next drug
➕ Combine drugs with different mechanisms (A + C + D)
🧠 If uncontrolled → check adherence, lifestyle, secondary causes

💡 High-Yield Prescribing Pearls

🧬 ACEi/ARB → expect small creatinine rise (haemodynamic effect, not damage)
💊 Amlodipine oedema = capillary leak → not fluid overload
🧪 Hyponatraemia on thiazide = common exam trap
⚡ Resistant HTN often = hyperaldosteronism physiology
📉 Biggest benefit = stroke reduction, not just BP lowering

🚨 Hypertensive Crisis

BP ≥180/120 mmHg
Assess for end-organ damage:
- 🧠 encephalopathy
- 👁 papilloedema
- 🫀 acute heart failure
- 🧪 AKI
👉 Emergency = admit calm quiet area + IV BP control e.g. Labetalol
👉 No damage = gradual oral reduction

🥗 Lifestyle Management (ALL Patients)

⚖️ Weight loss (most effective non-drug intervention)
🧂 Reduce salt intake (<6g/day)
🏃 Exercise ≥150 min/week
🍷 Limit alcohol
🚭 Smoking cessation

💡 Clinical Pearls

📊 Always confirm with ABPM - avoids overtreatment
🧠 Most benefit comes from stroke reduction, not just MI prevention
👵 In elderly → avoid overtreatment → falls risk
🫀 Think organ protection not just BP numbers
💊 Poor control? → check adherence, technique, secondary causes

🩺 Case Insight (Exam Favourite)

A 65-year-old Black man with BP 162/96 mmHg → start CCB (NOT ACEi first-line). If uncontrolled → add ACEi → then thiazide. 👉 This reflects low-renin physiology seen in salt-sensitive hypertension.

📚 NICE References

Hypertension in adults: diagnosis and management (NG136) 👉 Core guideline covering diagnosis (ABPM/HBPM), thresholds, targets, and pharmacological treatment View NICE NG136
Hypertension in adults – Quality Standard (QS28) 👉 Emphasises use of ABPM for diagnosis and structured care delivery View NICE QS28
Chronic kidney disease: assessment and management (NG203) 👉 Guidance on BP targets and ACEi/ARB use in CKD with proteinuria View NICE NG203
Cardiovascular disease: risk assessment and reduction, including lipid modification (NG238) 👉 QRISK-based treatment decisions and lipid management alongside hypertension View NICE NG238
Type 2 diabetes in adults: management (NG28) 👉 Integration of BP control in diabetes care and ACEi/ARB indications View NICE NG28
Medicines optimisation (NG5) 👉 Adherence, polypharmacy, and safe prescribing principles View NICE NG5

Additional related clinical topics

Adult Hypertension ✅

🩺 Adult hypertension means persistently raised blood pressure in adults. It is a major modifiable risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, atrial fibrillation, vascular dementia and premature death. NICE NG136 remains the key UK reference for diagnosis and management.

🩺 Adult Hypertension

Hypertension is usually asymptomatic, so accurate measurement and confirmation are essential. The key exam principle is: do not diagnose hypertension from one clinic reading unless it is severe with concerning features. Confirm with ambulatory blood pressure monitoring - ABPM or home blood pressure monitoring - HBPM where appropriate.

🧠 Pathophysiology

Blood pressure reflects cardiac output and systemic vascular resistance. In primary hypertension, ageing, arterial stiffness, sympathetic activation, renal sodium handling, obesity, insulin resistance, endothelial dysfunction and genetic factors all contribute. Long-term pressure damages vessels and target organs, leading to left ventricular hypertrophy, nephropathy, retinopathy and cerebrovascular disease.

✅ Correct BP Measurement

🩺 Use a validated and calibrated blood pressure device.
📏 Use the correct cuff size.
🪑 Ensure the patient is seated, relaxed, quiet and supported.
🫀 Palpate the pulse first; if irregular, measure BP manually.
💪 Measure BP in both arms when considering a diagnosis.
↔️ If the difference between arms is more than 15 mmHg, repeat it.
⬆️ If the difference remains more than 15 mmHg, use the arm with the higher reading for future measurements.

🧍 Postural Hypotension

Check lying or seated and standing BP in patients with falls, dizziness, type 2 diabetes, symptoms of postural hypotension, or age 80 and over. A fall in systolic BP of 20 mmHg or more, or diastolic BP of 10 mmHg or more, after standing suggests postural hypotension.

💊 Review antihypertensives, diuretics, nitrates and alpha-blockers.
💧 Assess hydration, autonomic neuropathy and frailty.
🎯 Treat to a standing BP target if there is a significant postural drop.

🔍 Diagnosis

📌 If clinic BP is 140/90 mmHg or higher, take a second reading during the consultation.
📌 If readings differ substantially, take a third reading.
📉 Record the lower of the last 2 readings as the clinic BP.
🏥 If clinic BP is 140/90 to 179/119 mmHg, offer ABPM to confirm hypertension.
🏠 If ABPM is unsuitable or not tolerated, offer HBPM.
✅ Confirm hypertension if clinic BP is 140/90 mmHg or higher and daytime ABPM or HBPM average is 135/85 mmHg or higher.

🏠 Home BP Monitoring Method

📏 Take 2 consecutive readings at least 1 minute apart.
🌅🌙 Record BP twice daily, ideally morning and evening.
📅 Continue for at least 4 days, ideally 7 days.
🗑️ Discard day 1 readings.
🧮 Use the average of the remaining readings.

📊 Hypertension Stages

Stage	Clinic BP	ABPM / HBPM average
🟡 Stage 1 hypertension	140/90 to 159/99 mmHg	135/85 to 149/94 mmHg
🟠 Stage 2 hypertension	160/100 to 179/119 mmHg	150/95 to 179/119 mmHg
🔴 Severe hypertension	180/120 mmHg or higher	Usually urgent clinical assessment rather than routine confirmation

🧪 Initial Investigations

Investigations look for target organ damage, renal disease, diabetes, hyperlipidaemia and secondary causes. They also provide a baseline before treatment.

🧫 Urine albumin:creatinine ratio.
🩸 Urine dipstick for haematuria.
🫘 U&Es, creatinine and eGFR.
🍬 HbA1c.
🧈 Total cholesterol and HDL cholesterol.
👁️ Fundoscopy for hypertensive retinopathy.
📟 12-lead ECG for left ventricular hypertrophy, ischaemia or arrhythmia.
🧮 Formal cardiovascular risk assessment, such as QRISK, using clinic BP.

🚩 When to Think of Secondary Hypertension

👶 Age under 40 with hypertension.
⚡ Sudden onset or rapidly worsening hypertension.
💊 Resistant hypertension despite 3 drugs.
🍌 Hypokalaemia suggesting hyperaldosteronism.
🫘 Renal bruit or asymmetric kidneys suggesting renovascular disease.
😰 Symptoms of phaeochromocytoma: headaches, sweating, palpitations.
🌕 Cushingoid features.
😴 Obstructive sleep apnoea.
💊 Drug causes: NSAIDs, steroids, cocaine, ciclosporin, tacrolimus, SNRIs and combined hormonal contraception.

🚑 Same-Day Specialist Review

Severe hypertension is not automatically a hypertensive emergency. The key question is whether there is acute target organ damage or life-threatening symptoms.

🚨 Refer same day if clinic BP is 180/120 mmHg or higher with retinal haemorrhage or papilloedema.
🚨 Refer same day if BP is 180/120 mmHg or higher with new confusion, chest pain, signs of heart failure or acute kidney injury.
⚠️ If BP is 180/120 mmHg or higher without these features, investigate target organ damage promptly and arrange urgent review/confirmation.

🌿 Lifestyle Management

⚖️ Weight reduction if overweight or obese.
🚶 Regular aerobic exercise.
🧂 Reduce salt intake.
🍷 Reduce excessive alcohol intake.
🚭 Stop smoking and address cardiovascular risk.
🥗 Eat a healthy diet rich in fruit, vegetables and fibre.
☕ Discourage excessive coffee and caffeine-rich products.
❌ Do not offer calcium, magnesium or potassium supplements solely to lower BP.

💊 When to Start Drug Treatment

🟠 Stage 2 hypertension: offer antihypertensive drug treatment plus lifestyle advice.
🟡 Stage 1 hypertension under 80: discuss drug treatment if target organ damage, established cardiovascular disease, renal disease, diabetes, or 10-year CVD risk of 10% or more.
👤 Stage 1 hypertension under 60 with CVD risk below 10%: consider drug treatment because 10-year risk may underestimate lifetime risk.
👵 Age over 80 with stage 1 hypertension: consider drug treatment if clinic BP is over 150/90 mmHg, using clinical judgement for frailty and multimorbidity.
👶 Age under 40: consider specialist evaluation for secondary causes and long-term treatment balance.

💊 Stepwise Medication Treatment

Step	Medication choice	Key notes
Step 1	ACE inhibitor or ARB	Use if aged under 55 and not of Black African or African-Caribbean family origin, or if type 2 diabetes at any age.
Step 1	Calcium-channel blocker	Use if aged 55 or over and no type 2 diabetes, or Black African/African-Caribbean family origin and no type 2 diabetes.
If ACE inhibitor not tolerated	ARB	Useful if ACE inhibitor causes cough.
If CCB not tolerated	Thiazide-like diuretic	Use agents such as indapamide. NICE prefers thiazide-like diuretics over bendroflumethiazide or hydrochlorothiazide when starting or changing diuretic treatment.
Step 2	Two-drug therapy	ACE inhibitor or ARB plus either CCB or thiazide-like diuretic. If starting from CCB, add ACE inhibitor, ARB or thiazide-like diuretic.
Step 3	Three-drug therapy	ACE inhibitor or ARB plus CCB plus thiazide-like diuretic.
Step 4 resistant hypertension	Add further drug or seek specialist advice	If potassium is 4.5 mmol/L or less, consider low-dose spironolactone. If potassium is above 4.5 mmol/L, consider alpha-blocker or beta-blocker.

⚠️ Important Prescribing Cautions

❌ Do not combine an ACE inhibitor with an ARB for hypertension.
🤰 Avoid ACE inhibitors and ARBs in pregnancy, breastfeeding or planning pregnancy unless specialist advice says otherwise.
🫘 Check renal function and potassium after starting or increasing ACE inhibitors, ARBs or diuretics.
🦶 CCBs can cause ankle oedema, flushing and headache.
🧂 Thiazide-like diuretics can cause hyponatraemia, hypokalaemia, gout and metabolic disturbance.
⚡ Spironolactone can cause hyperkalaemia, especially in reduced eGFR.

🎯 BP Targets

Group	Clinic BP target	ABPM / HBPM target
Adults under 80	Below 140/90 mmHg	Below 135/85 mmHg
Adults 80 and over	Below 150/90 mmHg	Below 145/85 mmHg
CKD or type 1 diabetes with ACR 70 mg/mmol or more	Below 130/80 mmHg	Use specialist/local guidance

📅 Annual Review

🩺 Review BP control at least annually.
💊 Ask about adherence and side effects.
🌿 Review lifestyle, smoking, alcohol, weight and exercise.
🫘 Check renal function and electrolytes where medication requires monitoring.
🧮 Review CVD risk and statin indication.
🧍 Check for postural symptoms in older people, diabetes or frailty.

❌ Common Exam and Ward Pitfalls

❌ Diagnosing hypertension from a single clinic reading.
❌ Forgetting ABPM or HBPM confirmation.
❌ Not checking both arms at diagnosis.
❌ Missing postural hypotension in older or diabetic patients.
❌ Starting an ACE inhibitor in pregnancy or in someone planning pregnancy.
❌ Combining ACE inhibitor and ARB.
❌ Not checking U&Es after ACE inhibitor, ARB or diuretic changes.
❌ Ignoring target organ damage or secondary causes in young patients.
❌ Treating severe BP numbers without looking for emergency features.

🎯 Makindo Exam Summary

🧠 For exams, think: measure correctly, confirm with ABPM or HBPM, assess target organ damage and CVD risk, give lifestyle advice, then treat according to stage, age, diabetes, ethnicity and comorbidity. Hypertension management is not just lowering a number; it is prevention of stroke, MI, heart failure, CKD and vascular dementia.

📚 References

NICE. Hypertension in adults: diagnosis and management. NICE guideline NG136. Published 28 August 2019. Last updated 26 February 2026.
NICE NG136 recommends confirming hypertension with ABPM or HBPM when clinic BP is 140/90 mmHg or higher and below 180/120 mmHg.
NICE NG136 recommends assessing target organ damage with urine ACR, haematuria testing, HbA1c, renal function, lipid profile, fundoscopy and ECG.
NICE NG136 recommends clinic BP targets below 140/90 mmHg for adults under 80 and below 150/90 mmHg for adults aged 80 and over.
NICE NG136 recommends ACE inhibitor or ARB step 1 treatment for adults under 55 or adults with type 2 diabetes, and CCB step 1 treatment for adults aged 55 or over or adults of Black African or African-Caribbean family origin without type 2 diabetes.

📚 Disclaimer

This article is for medical education and revision only. Hypertension diagnosis and prescribing should follow NICE NG136, local guidelines, the BNF, renal function, potassium results, pregnancy status, comorbidities, patient preference and senior clinical advice where needed.

The content on this website is provided for educational and informational purposes only to support exam preparation (e.g., MLA, MRCP, USMLE) and learning. This is NOT medical advice, diagnosis, treatment, or professional guidance. It does not replace consultation with a qualified healthcare professional, official guidelines (e.g., NICE, GMC, BNF), or supervised clinical practice. Always verify information with current, authoritative sources. Makindo and its contributors accept no liability for any reliance on this content, including errors, omissions, or any resulting harm, loss, or consequences. By using this site, you agree to these terms.

Essential Hypertension ✅