UK hypertension guideline overview
Hypertension is managed in the UK with confirmed out-of-office readings, NICE-based thresholds for treatment, and defined referral points.
Applies to adults (including older adults) in UK clinical practice.
Hypertension management in the UK is guided by a systematic approach focused on accurate diagnosis, cardiovascular risk assessment, and individualised treatment to reduce the long-term risks of cardiovascular events, stroke, and chronic kidney disease. Diagnosis should not be based on a single reading; instead, clinic blood pressure (BP) readings of 140/90 mmHg or higher should prompt confirmation through ambulatory blood pressure monitoring (ABPM) or, if ABPM is unsuitable, home blood pressure monitoring (HBPM), with a threshold of 135/85 mmHg for hypertension confirmation using these out-of-office methods. For individuals under 80, the treatment goal is to maintain clinic BP below 140/90 mmHg, and for those under 60 with diabetes or chronic kidney disease, a more ambitious target of below 130/80 mmHg may be considered, though out-of-office targets remain below 135/85 mmHg or below 130/80 mmHg respectively. A formal assessment of overall cardiovascular disease (CVD) risk using the QRISK2 or QRISK3 tool is integral to management decisions, as this helps stratify patients and guides the intensity of intervention. First-line pharmacological treatment for adults under 55 typically involves an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-II receptor blocker (ARB) if the ACE inhibitor is not tolerated, while for those aged 55 and over, or of Black African or Caribbean family origin of any age, a calcium-channel blocker (CCB) is the preferred initial choice. If the initial agent does not achieve target BP, treatment should be escalated in a stepwise manner, usually by adding a CCB to an ACE inhibitor/ARB (or vice versa), followed by the addition of a thiazide-like diuretic such as chlortalidone or indapamide if a third drug is required; a fourth-line agent like spironolactone or an alpha- or beta-blocker may be considered if targets are still not met, with careful monitoring of renal function and electrolytes, particularly potassium, during therapy. Lifestyle advice—including salt reduction, healthy eating, weight management, regular physical activity, moderating alcohol intake, and smoking cessation—should be offered and reinforced at every opportunity to all patients, as this can significantly lower BP and enhance the effectiveness of drug therapy. Special consideration is required for specific groups: in pregnancy, antihypertensive treatment is indicated for severe hypertension (BP ≥160/110 mmHg) or for non-severe hypertension if there are other indications, with labetalol being the first-line choice, followed by nifedipine or methyldopa; for individuals aged 80 and over, the treatment threshold and target is a clinic BP below 150/90 mmHg, balancing the benefits of treatment against the risks of side effects and postural hypotension; and in secondary hypertension, suspected in cases of resistant hypertension, young onset, or suggestive symptoms, appropriate investigation for causes such as renal artery stenosis, primary aldosteronism, or phaeochromocytoma is warranted. Resistant hypertension, defined as BP remaining above target despite adherence to optimal or best-tolerated doses of three antihypertensive drugs including a diuretic, should prompt a review for true resistance, investigation of secondary causes, and consideration of specialist referral. Regular follow-up is essential to monitor BP control, assess for adverse effects of medication, reinforce lifestyle measures, and review cardiovascular risk, ensuring that management remains patient-centred and aligned with their overall health goals.
Blood pressure thresholds and targets
Hypertension management in the UK requires a nuanced approach to blood pressure thresholds and targets, guided by evidence-based principles that balance cardiovascular risk reduction with patient safety and adherence. For the general population aged under 80 years, the threshold for diagnosing hypertension is a clinic blood pressure of 140/90 mmHg or higher, confirmed through ambulatory blood pressure monitoring (ABPM) or, if ABPM is unsuitable, home blood pressure monitoring (HBPM). The target for treatment in this group is to achieve and maintain a clinic blood pressure below 140/90 mmHg, with a corresponding target for ABPM/HBPM of below 135/85 mmHg. For patients under 60 with hypertension, or those of any age with diabetes or chronic kidney disease (CKD), a more stringent target of below 130/80 mmHg is recommended when measured by ABPM/HBPM (below 140/90 mmHg in clinic) to confer greater protection against renal and cardiovascular complications. In patients aged 80 years and over, the treatment threshold remains a clinic reading of 150/90 mmHg or higher, with a treatment goal of maintaining clinic blood pressure below 150/90 mmHg, acknowledging the increased risk of adverse events like falls and orthostatic hypotension with intensive treatment in this demographic.
It is critical to recognise that these are general targets, and clinical judgement must individualise therapy based on comorbidities, frailty, tolerability, and patient preferences; for instance, in patients with significant comorbidities or frailty, a less stringent target may be appropriate to avoid harm. The process of achieving these targets should be gradual, with regular review and titration of lifestyle interventions and antihypertensive medication, prioritising well-tolerated regimens to support long-term adherence. Clinicians should also be aware of white-coat hypertension and masked hypertension, which underscore the necessity of out-of-office monitoring for accurate diagnosis and management, ensuring treatment is appropriately targeted to those who will benefit most. Ultimately, the goal is to reduce the long-term risk of stroke, myocardial infarction, and heart failure through sustained blood pressure control, while minimising treatment-related side effects and respecting individual patient circumstances.
Treatment and medication guidance
Hypertension management in the UK follows a structured, stepped-care approach aimed at achieving and maintaining optimal blood pressure control to reduce the long-term risk of cardiovascular events, with treatment initiation and intensification guided by the patient's absolute cardiovascular risk, the presence of target organ damage, and the severity of the hypertension itself. For adults under 80 years with stage 1 hypertension (clinic BP 140/90 mmHg or higher and ABPM/HBPM average 135/85 mmHg or higher) and an estimated 10-year cardiovascular disease risk of 10% or more, or for those with established cardiovascular disease, renal disease, or target organ damage, first-line pharmacological treatment is recommended, while for those with a lower risk profile, a period of lifestyle advice and monitoring is appropriate before considering medication. For adults with stage 2 hypertension (clinic BP 160/100 mmHg or higher and ABPM/HBPM average 150/95 mmHg or higher) or those with more severe hypertension, immediate pharmacological treatment is indicated alongside lifestyle interventions. The cornerstone of pharmacological management for most patients under 55 years and for Black patients of African or Caribbean family origin of any age is an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-II receptor blocker (ARB) if the ACE inhibitor is not tolerated; for patients over 55 years or Black patients of any age, a calcium-channel blocker (CCB) is the preferred first-line choice. If blood pressure remains uncontrolled on the initial monotherapy, the next step involves combining the first-line drug with a second agent from the other first-line class, typically resulting in an ACE inhibitor (or ARB) plus a CCB; if a CCB is not tolerated or is contraindicated, a thiazide-like diuretic, such as chlortalidone or indapamide, can be substituted.
When a two-drug combination fails to achieve target blood pressure, a third agent should be added, usually a thiazide-like diuretic if not already in use, creating a triple therapy regimen of an ACE inhibitor (or ARB), a CCB, and a diuretic. If blood pressure remains resistant to this triple therapy, a fourth agent may be considered, which could include a low-dose spironolactone (if potassium levels are normal), or alternatively an alpha-blocker or a beta-blocker, though beta-blockers are generally not preferred for routine hypertension management in the absence of specific comorbidities like heart failure or angina due to their less favourable metabolic profile and inferior performance in preventing stroke compared to other drug classes. Throughout treatment, the target clinic blood pressure for most patients under 80 years is below 140/90 mmHg, and for those with diabetes or chronic kidney disease, the target is below 130/80 mmHg; for patients aged 80 years and over, the target is below 150/90 mmHg. It is crucial to confirm a diagnosis of hypertension using ambulatory or home blood pressure monitoring before initiating lifelong treatment, to review medication adherence and potential side effects at each follow-up, and to consider secondary causes of hypertension in patients presenting with resistant hypertension, sudden onset, or suggestive clinical features.
Monitoring and follow-up
Following diagnosis and initiation of treatment, a structured and patient-centred approach to monitoring and follow-up is essential for the effective long-term management of hypertension, with the frequency and intensity of monitoring tailored to the individual's blood pressure level, overall cardiovascular risk, treatment response, and presence of any complications or comorbidities; after starting or titrating antihypertensive medication, blood pressure should be rechecked within 4 weeks to assess response and tolerability, with subsequent reviews scheduled every 4 to 6 weeks until the target blood pressure is consistently achieved, at which point the interval can be gradually extended to 3 to 6 monthly for stable patients, though more frequent review (e.g., every 3 months) may be warranted for those at higher cardiovascular risk, with complex regimens, or where adherence is a concern; all blood pressure measurements should ideally be taken in a clinical setting using a validated, regularly calibrated device, with the patient seated and rested for at least 5 minutes, and attention paid to correct cuff size and positioning, while out-of-office monitoring—specifically Ambulatory Blood Pressure Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM)—is strongly recommended to confirm the diagnosis of hypertension, to identify white-coat or masked hypertension, and to guide treatment decisions, as these methods provide a more reliable assessment of true blood pressure burden and are predictive of cardiovascular outcomes; at each follow-up appointment, clinicians should not only record blood pressure but also conduct a brief review that includes assessment for potential adverse effects of medication, evaluation of adherence through non-judgemental questioning, reinforcement of lifestyle advice (such as sodium reduction, moderation of alcohol, healthy diet, and regular physical activity), and screening for signs of target organ damage, particularly through enquiry about symptoms suggestive of heart failure, angina, or transient ischaemic attack, and by arranging periodic monitoring of renal function (urea and electrolytes) and, where appropriate, electrocardiograms to detect left ventricular hypertrophy; for patients with treatment-resistant hypertension (where blood pressure remains above target despite adherence to optimal doses of three antihypertensive drugs, including a diuretic), more intensive investigation and monitoring are required, including consideration of secondary causes, assessment of fluid status, and review by a specialist hypertension service; long-term follow-up should also incorporate opportunistic screening for associated conditions like diabetes and hyperlipidaemia, and ensure that statin therapy is offered where indicated based on overall cardiovascular risk assessment; patient education remains a cornerstone of follow-up, empowering individuals to understand their condition, the importance of adherence, and the role of self-monitoring where appropriate, with clear plans agreed for escalating contact if blood pressure readings become concerning or if new symptoms develop; ultimately, the goal of monitoring is to maintain blood pressure control to reduce the long-term risks of stroke, myocardial infarction, and renal disease, while minimising treatment burden and preserving quality of life.