BP 180/120 or more with signs of end-organ damage (new confusion, chest pain, heart failure, AKI, papilloedema): same-day specialist assessment, not GP titration alone.
Diagnosis
- Clinic BP 140/90 or more: offer ABPM (or HBPM) to confirm
- Stage 1: clinic 140/90 or more and ABPM 135/85 or more
- Stage 2: clinic 160/100 or more and ABPM 150/95 or more
- Assess target-organ damage: urine ACR, dipstick, HbA1c, bloods, lipids, ECG, fundi, QRISK
Who to treat
- All stage 2
- Stage 1 under 80 with target-organ damage, CVD, diabetes, renal disease, or QRISK 10% or more
- BP target: under 140/90 clinic (under 150/90 if 80 or over)
- Tighter in type 1 diabetes or high ACR
Stage 1
- Clinic 140/90 to 159/99
- ABPM 135/85 to 149/94
- Treat if under 80 with risk or QRISK 10% or more
Stage 2
- Clinic 160/100 to 179/119
- ABPM 150/95 or higher
- Offer treatment to all ages
Severe (180/120 or higher)
- Same-day assessment if red flags
- Check for end-organ damage
- Refer if signs present
Management steps
1
1. Lifestyle
Salt and alcohol reduction, weight, exercise, smoking. Confirm it is not white-coat hypertension before labelling.
Salt and alcohol reduction, weight, exercise, smoking. Confirm it is not white-coat hypertension before labelling.
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2
2. Start treatment (step 1)
ACE inhibitor or ARB if under 55 and not of Black African or African-Caribbean origin, or if type 2 diabetes. CCB if 55 or over, or Black African or African-Caribbean origin without diabetes.
ACE inhibitor or ARB if under 55 and not of Black African or African-Caribbean origin, or if type 2 diabetes. CCB if 55 or over, or Black African or African-Caribbean origin without diabetes.
↓
3
3. Step up
Step 2: ACE/ARB plus CCB (or plus thiazide-like diuretic). Step 3: all three. Monitor renal function and K+ after starting or titrating ACE/ARB.
Step 2: ACE/ARB plus CCB (or plus thiazide-like diuretic). Step 3: all three. Monitor renal function and K+ after starting or titrating ACE/ARB.
↓
4
4. Resistant (step 4)
Confirm adherence. Add spironolactone if K+ is 4.5 or below, or an alpha- or beta-blocker. Consider a secondary cause and specialist referral.
Confirm adherence. Add spironolactone if K+ is 4.5 or below, or an alpha- or beta-blocker. Consider a secondary cause and specialist referral.
Secondary causes to consider
- Young, resistant, or hypokalaemic: primary hyperaldosteronism (Conn)
- Renal artery stenosis, renal disease
- Phaeochromocytoma, Cushing, coarctation
Pitfalls
- Treating a single high clinic reading without ABPM/HBPM
- ACE/ARB in pregnancy (avoid)
- Missing end-organ damage in severe hypertension
- Not rechecking U&E after ACE/ARB
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026