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Management of Hypertension

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

See related separate articles Hypertension and Hypertension in Pregnancy, and the NICE Hypertension Pathway.1,2

Lifestyle interventions

Advise lifestyle measures in patients with hypertension and high normal blood pressure (BP), i.e. clinic BP 130-139/85-89 mm Hg. Inform about any local initiatives, and supplement advice with leaflets or audiovisual information.

Preventing or treating obesity3

Weight reduction should be suggested if necessary, to maintain ideal body mass index (BMI) of 20-25 kg/m2. Offer a diet sheet and/or dietetic appointment. Dietary self-help, e.g. dieting clubs, may be appropriate.

  • The National Institute for Health and Clinical Excellence (NICE) recommends basing meals on starchy foods (potatoes, bread, rice and pasta) - using wholegrain bread, and brown rice if possible, but watch the portion size of meals and cut down on snacks.
  • Eat foods rich in fibre, i.e. cereals, pulses (beans, peas, lentils, grains, seeds), fruit and vegetables.
  • Have at least five portions of fruit and vegetables a day.
  • Select low-fat foods - avoid foods containing a lot of fat and sugar (e.g. fried food, sweetened drinks, crisps, confectionery).
  • Reduce any excessive caffeine consumption and have a low dietary sodium intake (reduce or substitute any sodium salt). Calcium, magnesium or potassium supplements are not recommended.
  • Ensure you eat breakfast.
  • Cut alcohol intake to no more than 21 units (male) or 14 units (female) of alcohol per week. Be careful not to take too many calories in the form of alcohol.

See the Dietary Approaches to Stop Hypertension (DASH) eating plan.4

Stopping smoking

Patients should stop smoking (offer help ± nicotine replacement therapy) - see separate article Smoking Cessation.

Encouraging exercise

  • Make physical activities part of everyday life (e.g. walk or cycle to work, use stairs instead of lift, walk at lunchtime), and build in enjoyable activities to leisure time every week (e.g walking, cycling, gardening, swimming, aerobics, etc.) .
  • Minimise sedentary activities, e.g limit television watching or sitting at a computer or playing video games.
  • Once more, look for local activities, join a sporting group, take advantage of taster sessions and get used to exercising regularly, ideally several times a week.

Starting treatment1

Consider treating immediately if BP in clinic is ≥180/110 mm Hg; otherwise, consider after results of ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), blood tests and cardiovascular risk assessment are available.

Diagnose hypertension if average of ABPM or HBPM readings is ≥135/85 mm Hg, (ignore first day readings and average the rest - see Hypertension article).

  • Stage 1 hypertension - clinic readings ≥140/90 mm Hg and ABPM/HBPM ≥135/85 mm Hg.
  • Stage 2 hypertension - clinic readings ≥160/100 mm Hg and ABPM/HBPM ≥150/95 mm Hg.

Drug treatment should be commenced in patients aged under 80 years with stage 1 hypertension plus signs of end organ damage (known cardiovascular or renal disease), or with diabetes mellitus or a 10-year cardiovascular disease (CVD) risk ≥20%.

Treatment should be started in all patients (any age) with stage 2 hypertension. Treat isolated systolic hypertension in the same way.

Initial Drug Choices1
If the patient is young (≤55 years) and non-black, start with:
  • (A) Angiotensin-converting enzyme (ACE) inhibitor or low-cost Angiotensin-II receptor antagonist (AIIRA).
  • Beta-blocker may be appropriate in younger adults if ACE not tolerated, in women who may become pregnant or if evidence of increased sympathetic drive.
If the patient is aged >55 years or a black person of African or Caribbean family origin, use:
Stage 2 Drug Choices

  • (A+C) ACE inhibitor or Angiotensin-II receptor antagonist with Calcium-channel blocker.
  • Use ACE/AIIRA and thiazide-like Diuretic (D) if CCB not tolerated (or if any evidence of heart failure).
  • If initially started on beta-blocker, add CCB rather than thiazide-like Diuretic second-line (reduce diabetic risk).
  • Consider AIIRA rather than ACE with CCB in black (African or Caribbean) patients.
Stage 3 Drug Choices

  • (A+C+D) ACE inhibitor or Angiotensin-II receptor antagonist and Calcium-channel blocker and thiazide-like Diuretic (chlortalidone or indapamide).
Stage 4 Drug Choices

  • (A+C+D) ACE inhibitor or Angiotensin-II receptor antagonist and Calcium-channel blocker and thiazide-like Diuretic plus further diuretic (higher-dose thiazide-like diuretic or spironolactone, depending on potassium).
    If higher-dose diuretic is not tolerated, consider alpha- or beta-blocker, or seek expert advice.

The combination of angiotensin-converting enzyme (ACE) inhibitor with an angiotensin-II receptor antagonist (AIIRA) is not recommended for the treatment of hypertension.1

Treatment targets1

  • People aged <80 years: clinic <140/90 mm Hg, ABPM/HBPM <135/85 mm Hg.
  • People aged ≥80 years: clinic <150/90 mm Hg, ABPM/HBPM <145/85 mm Hg.

Monitor regularly with BP checks plus appropriate blood tests (e.g. U&E and renal function on ACE inhibitor). Consider cholesterol-lowering treatment if CVD risk is ≥20% (see separate article Lipid-regulating Drugs). Further ABPM/HBPM may be needed to avoid overtreatment due to 'white coat hypertension'.

Specialist referral

Refer if hypertension is difficult to control in spite of the steps above.

Consider seeking specialist evaluation of patients aged <40 years who appear to have stage 1 hypertension without target organ damage or diabetes, either for exclusion of secondary causes of hypertension or a more detailed assessment of cardiovascular risk, as standard assessments can underestimate the lifetime risk in these people. 1

Document references

  1. Hypertension: management of hypertension in adults in primary care, NICE Clinical Guideline (August 2011)
  2. Hypertension, NICE Pathway (August 2011)
  3. Obesity, NICE Clinical Guideline (2006); Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children
  4. DASH (Dietary Approaches to Stop Hypertension) Diet

Internet and further reading

© EMIS 2011Author: Dr Huw ThomasReviewer: Dr Hannah Gronow
Document ID: 486Document Version: 24Last Reviewed: 27 Sep 2011
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