Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

Diagnosing hypertension

  • If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [2011]

  • When using ABPM to confirm a diagnosis of hypertension, ensure that at least two 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]

  • When using home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension, ensure that:

    • for each blood pressure recording, two 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]

Initiating and monitoring antihypertensive drug treatment, including blood pressure targets

Initiating treatment

  • Offer antihypertensive drug treatment to people 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. [2011]

  • Offer antihypertensive drug treatment to people of any age with stage 2 hypertension. [2011]

  • For people 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 of secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people. [2011]

Monitoring treatment and blood pressure targets

  • For people identified as having a 'white-coat effect'[1], consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor the response to antihypertensive treatment with lifestyle modification or drugs. [2011]

Choosing antihypertensive drug treatment

  • Offer people aged 80 years and over the same antihypertensive drug treatment as people aged 55–80 years, taking into account any comorbidities. [2011]

Step 1 treatment

  • Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged over 55 years and to black people of African or Caribbean family origin of any age. 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. [2011]

  • If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [2011]

  • 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. [2011]

Step 4 treatment

  • For treatment of resistant hypertension at step 4:

    • Consider further diuretic therapy with low-dose spironolactone (25 mg once daily)[2] if the blood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia.

    • Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5 mmol/l. [2011]

[1] 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.

[2] At the time of publication (August 2011), spironolactone did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented.

  • National Institute for Health and Care Excellence (NICE)