Treatment initiation thresholds for hypertension vary by blood pressure level and cardiovascular risk. This page compares when to start pharmacological treatment according to NICE, European Society of Cardiology (ESC), and SIGN.
Hypertension affects approximately 1 in 4 adults in the UK, with prevalence increasing to over 50% in those aged 60+. It remains the leading modifiable risk factor for cardiovascular disease, stroke, and chronic kidney disease. The clinical challenge lies in balancing early intervention benefits against potential overtreatment harms, particularly in borderline cases.
Treatment threshold decisions are critical because delayed intervention increases cardiovascular event risk, while unnecessary medication exposes patients to side effects and polypharmacy burdens. Hypertension management requires individualised assessment considering age, comorbidities, and cardiovascular risk profile rather than blood pressure values alone.
The three major guideline bodies approach this challenge differently: NICE provides evidence-based UK primary care guidance, ESC offers comprehensive European cardiology perspectives, and SIGN delivers Scotland-specific recommendations. Understanding these differences ensures appropriate threshold application across diverse clinical settings and patient populations.
| Guideline | Primary Focus | Typical Setting | Publication/Update |
|---|---|---|---|
| NICE NG136 | UK primary care hypertension management | Primary care, general practice | 2019 (updated 2023) |
| ESC/ESH | European cardiovascular risk management | Secondary care, cardiology | 2024 |
| SIGN 149 | Scottish cardiovascular prevention | Primary care (Scotland) | 2017 (reviewed 2024) |
Practical Implication: Use NICE as your default for English/Welsh primary care, ESC for complex cardiovascular cases or specialty practice, and SIGN for Scottish populations. Cross-reference guidelines when managing patients with significant comorbidities or borderline risk profiles where different approaches may impact management decisions.
| Scenario | NICE | ESC | SIGN |
|---|---|---|---|
| Stage 1 (140-159/90-99) + low CV risk | Lifestyle modification (treat if target organ damage, CVD, renal disease, diabetes, or QRISK ≥10%) | Consider treatment earlier | Lifestyle modification |
| Stage 1 + high CV risk | Treat | Treat | Treat |
| Stage 2 (≥160/100) | Treat all | Treat all | Treat all |
| Older adults (≥80 years) | Treat if ≥150/90 | Individualised, consider if ≥140/90 | Similar to NICE |
| Population | NICE | ESC | SIGN |
|---|---|---|---|
| Adults <80 years | <140/90 (clinic BP) | <130/80 if tolerated | <140/90 |
| Adults ≥80 years | <150/90 (clinic BP) | <140/90 if tolerated | <150/90 |
| Diabetes | <140/90 (or <130/80 if end-organ damage) | <130/80 | <140/90 |
| CKD | <140/90 (or <130/80 if ACR ≥70) | <130/80 | <140/90 |
NICE recommends confirming hypertension diagnosis with ambulatory or home monitoring before treatment initiation. For Stage 1 hypertension without high risk, repeat BP measurements every 4-6 months during lifestyle intervention. Once treatment begins, review within 4 weeks of starting or changing medication, then every 6 months once controlled. Increase frequency to monthly if BP remains above target despite treatment adjustments.
ESC emphasizes more frequent monitoring, particularly during treatment titration. Recommend 2-4 week intervals during medication adjustment until target BP achieved. For high-risk patients, consider monthly reviews even when controlled. ESC integrates cardiovascular risk reassessment into monitoring intervals, suggesting annual formal risk calculation for all hypertensive patients.
SIGN aligns more closely with NICE timing but emphasizes Scottish population considerations. Recommend 3-monthly reviews during lifestyle modification in Stage 1 hypertension. For treated patients, suggests 6-monthly reviews but acknowledges remote monitoring options. SIGN specifically addresses rural access challenges with flexible timing recommendations.
| Trigger Scenario | NICE | ESC | SIGN |
|---|---|---|---|
| Resistant hypertension (≥3 drugs) | Refer to specialist | Refer for secondary investigation | Consider specialist referral |
| BP >180/110 with symptoms | Urgent same-day assessment | Emergency evaluation | Immediate medical attention |
| Young onset (<40 years) | Consider secondary causes | Investigate for secondary hypertension | Assess for underlying causes |
| Rapid BP rise (>30/15 mmHg) | Urgent review | Immediate assessment | Prompt investigation |
| Treatment intolerance | Review and consider alternatives | Specialist input if multiple failures | Medication review |
| Pregnancy hypertension | Obstetric referral | Immediate specialist management | Obstetric team involvement |
Patient: 52-year-old male, clinic BP 148/92, non-smoker, BMI 28, cholesterol 5.2 mmol/L, no diabetes or CKD. QRISK3 8%.
Analysis: NICE would recommend lifestyle modification only, as QRISK3 <10% and no high-risk features. ESC would consider pharmacological treatment given borderline-high BP. SIGN aligns with NICE's lifestyle-first approach. In this borderline case, the conservative NICE/SIGN approach is appropriate given low absolute risk, with 6-month review to reassess.
Patient: 82-year-old female, BP 162/88, type 2 diabetes, mild cognitive impairment. ABPM average 148/84.
Analysis: All guidelines recommend treatment for Stage 2 hypertension. NICE targets <150/90, ESC would aim for <140/90 if tolerated, SIGN aligns with NICE. Given cognitive impairment and frailty concerns, NICE's conservative target is safest to avoid overtreatment and orthostatic hypotension risks.
Patient: 38-year-old female, BP 142/88, strong family history of premature CVD, otherwise healthy. HBPM average 138/86.
Analysis: NICE would recommend lifestyle modification unless high risk features present. ESC might consider earlier treatment given family history. SIGN would follow NICE approach. Given young age and only Stage 1 hypertension, 3-6 months of lifestyle intervention with reassessment is appropriate before considering medication.
QRISK3 (NICE): Calculates 10-year cardiovascular disease risk incorporating ethnicity, social deprivation, and multiple comorbidities. Threshold of ≥10% triggers treatment consideration in Stage 1 hypertension. Remember QRISK3 may underestimate risk in young patients with strong family history.
SCORE2/SCORE2-OP (ESC): Estimates fatal and non-fatal cardiovascular event risk across European populations. Uses region-specific charts with age adjustments. ESC considers high risk as ≥5% for older populations, influencing treatment decisions even in Stage 1 hypertension.
ASSIGN (SIGN): Scotland-specific score incorporating social deprivation factors. Aligns with QRISK methodology but optimised for Scottish population data. Use ASSIGN when managing Scottish patients for most accurate risk assessment.
Practical Application: Calculate risk using your local recommended tool. For borderline cases (QRISK3 8-12%), consider repeating calculation with alternative tools or incorporating additional risk factors like family history to guide individualised decisions.
All three bodies support ambulatory or home BP monitoring to confirm diagnosis before starting treatment (except in severe/urgent cases). Thresholds for diagnosis via ABPM/HBPM are lower than clinic readings.
Disclaimer: This comparison is intended for clinical decision support and education. Always refer to the full published guidelines for definitive recommendations and the most up-to-date evidence. Clinical decisions should be individualized based on patient context and preferences.