NICE vs RCP: Management of Hypertension (2025)

Hypertension guidance in the UK is anchored by NICE NG136 and complemented by recommendations from the Royal College of Physicians (RCP). While RCP supports the NICE thresholds and overall framework, it often provides additional cardiovascular risk context, making it valuable when managing multimorbidity. This article compares both perspectives so clinicians can apply the right emphasis in practice.

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Audience: GPs, practice nurses, pharmacists, and secondary-care teams who need a concise but practical synthesis of how to diagnose, treat, and risk-stratify patients with hypertension in line with 2025 expectations.

Scope and intent

NICE defines diagnostic thresholds and stepwise treatment (A-C-D sequence), emphasising cost-effectiveness, documented ambulatory/home blood pressure, and clear numeric triggers for intervention.

RCP reinforces NICE thresholds while expanding the lens on total cardiovascular risk: statins, smoking cessation, weight, and comorbidity (diabetes, CKD, heart failure). It provides narrative rationale for when to intensify or individualise therapy beyond numeric thresholds alone.

Practical takeaway: NICE tells you what to do and when; RCP helps explain why, especially when balancing polypharmacy, statins, and multimorbidity.

Diagnosis and thresholds

NICE (NG136)

• Requires ambulatory blood pressure monitoring (ABPM) or, if unavailable/unsuitable, home blood pressure monitoring (HBPM) to confirm diagnosis.
• Clinic BP ≥140/90 mmHg prompts confirmation with ABPM/HBPM. Treatment consideration typically starts at ≥150/95 (ABPM/HBPM ≥135/85) for most adults; lower thresholds for higher-risk groups (e.g., diabetes, target organ damage).
• Clear numeric thresholds for staging and follow-up intervals.

RCP

• Supports ABPM/HBPM confirmation and NICE thresholds.
• Places greater focus on overall cardiovascular risk (QRISK/QRISK3), target organ damage, and comorbidities when deciding how aggressively to treat.
• Emphasises routine risk-factor modification even when BP is borderline, to prevent progression.

Key difference: Both use the same numbers; RCP layers more narrative on risk context and comorbidities, while NICE remains algorithmic.

Treatment sequencing: A-C-D core

NICE maintains the A-C-D stepwise model:

• Step 1: ACEi/ARB (A) if <55 years or not of Black African/Caribbean heritage; calcium channel blocker (C) first-line in patients ≥55 or of Black African/Caribbean heritage.
• Step 2: A + C.
• Step 3: A + C + thiazide-like diuretic (D).
• Step 4: Consider further diuretic (e.g., low-dose spironolactone if K+ allows) or specialist referral.

RCP

• Aligns with A-C-D but consistently emphasises statins (per risk) and lifestyle as co-equal pillars, not afterthoughts.
• Flags multimorbidity: diabetes, CKD, heart failure influence drug selection and sequencing.
• Encourages revisiting adherence, side effects, and drug–drug interactions before escalating.

Practical takeaway: The drug ladder is the same; RCP adds a risk-management layer (statins, lifestyle, multimorbidity) at each step.

Monitoring and follow-up

NICE offers structured monitoring intervals tied to control and stage. It recommends annual reviews once stable, with more frequent review during titration.

RCP aligns but adds focus on lipid management, smoking cessation, weight, and glycaemic control during follow-up. It encourages opportunistic cardiovascular risk review at each visit.

Special populations

• Diabetes/CKD: Both endorse tighter thresholds and ACEi/ARB prioritisation. RCP underlines albuminuria management and lipid lowering.
• Older adults/frailty: Individualise targets; RCP emphasises falls risk, postural hypotension checks, and medication simplification.
• Black African/Caribbean heritage: Both start with C (CCB) in Step 1 unless another indication for ACEi/ARB.

Risk and complexity

NICE is clear on when to start treatment based on BP thresholds and absolute risk factors. It provides concise advice on secondary causes but focuses on primary hypertension for most pathways.

RCP underscores global cardiovascular risk, advocating statins and lifestyle in parallel with BP control. It offers narrative rationale for intensifying therapy when risk is high even if BP is borderline, and for considering specialist referral when multimorbidity complicates choices.

Key difference: NICE defines thresholds and steps; RCP contextualises risk and comorbidity to justify “why now” and “how far” to treat.

Practical flow to apply

1. Confirm diagnosis: ABPM preferred; HBPM acceptable. Stage and record targets.
2. Assess risk: QRISK, target organ damage, diabetes/CKD, lifestyle factors.
3. Start therapy: Follow A-C-D; add statins and lifestyle where indicated.
4. Review adherence/technique: Check side effects, interactions, postural hypotension; reinforce home monitoring.
5. Step up or refer: Escalate per A-C-D; consider specialist input for resistant hypertension, multimorbidity, or suspected secondary causes.
6. Maintain: Annual review once stable; keep lipids, weight, smoking cessation, and kidney health on the agenda.

FAQs: fast answers

Do NICE and RCP use different thresholds? No. RCP supports NICE thresholds but adds risk/context narrative.

Is ABPM mandatory? NICE prefers ABPM; HBPM if ABPM unsuitable. RCP agrees.

When to start statins? Per cardiovascular risk (e.g., QRISK) and comorbidities; RCP reinforces considering statins alongside BP therapy.

How to handle multimorbidity? Align A-C-D with renal, diabetes, and heart failure considerations; simplify regimens and monitor for interactions.

When to refer? Resistant hypertension, secondary cause suspicion, recurrent postural hypotension, or complex multimorbidity.

Source links (official)

• NICE NG136 – Hypertension in adults
• Royal College of Physicians – Hypertension and cardiovascular risk resources
• CliniSearch hypertension guideline page

Why this matters

Hypertension is a leading modifiable risk factor for stroke, MI, CKD progression, and heart failure. NICE gives precise thresholds and treatment steps; RCP helps integrate blood pressure control into broader cardiovascular prevention. Using both ensures patients receive evidence-based BP control plus comprehensive risk modification.