Why this threshold matters

Clear thresholds help clinicians answer "when do I act?" for hypertension, aligning expectations between NICE, ESC, and SIGN. Use this side-by-side view to decide when to refer, escalate, monitor, or initiate treatment.

Decision areaTreatment targets

SpecialtyCardiovascular

PopulationAdults

SettingPrimary & Secondary

Decision typeTarget

UrgencyRoutine

Clinical Context

Hypertension affects approximately one in four adults in the UK, making it the most common cardiovascular condition in primary care. The clinical challenge lies in balancing aggressive blood pressure control against the risks of overtreatment, particularly in elderly patients and those with multiple comorbidities. Missed hypertension thresholds contribute significantly to stroke, myocardial infarction, and chronic kidney disease progression, while inappropriate overtreatment can cause symptomatic hypotension, falls, and acute kidney injury.

NICE adopts a pragmatic UK-primary-care-focused approach, ESC provides comprehensive European cardiology perspectives with stronger emphasis on total cardiovascular risk, while SIGN offers Scotland-specific adaptations considering local healthcare delivery patterns. These philosophical differences manifest in subtle but clinically important variations in target recommendations.

Guideline Scope Comparison

Guideline	Primary Focus	Typical Setting	Publication Date
NICE	UK primary care implementation	Primary care with secondary care integration	August 2023 (NG136 update)
ESC	European cardiovascular prevention	Secondary care cardiology with primary care outreach	June 2023 (2023 ESH Guidelines)
SIGN	Scottish healthcare system adaptation	Integrated Scottish primary-secondary care	March 2024 (SIGN 149 revision)

Use NICE as your default for general UK primary care practice, ESC when managing complex cardiovascular cases or high-risk patients, and SIGN when working within Scottish healthcare systems. Cross-reference between guidelines when patients have multiple comorbidities or when treatment response is suboptimal.

Guideline comparison

Guideline body	Position	Population & urgency
NICE	Position on Treatment targets for Hypertension	Adults \| Urgency: Routine \| Setting: Primary & Secondary
ESC	Position on Treatment targets for Hypertension	Adults \| Urgency: Routine \| Setting: Primary & Secondary
SIGN	Position on Treatment targets for Hypertension	Adults \| Urgency: Routine \| Setting: Primary & Secondary

Clinical cues: Confirm patient population and care setting, then align with the most urgent recommendation shown. Escalate to the strictest threshold if the patient deteriorates or if local policy mandates the fastest response.

Core Blood Pressure Threshold Values

Patient Population	NICE Target	ESC Target	SIGN Target	Clinical Notes
Under 80 years without diabetes	<140/90 mmHg	<140/90 mmHg	<140/90 mmHg	All bodies agree on this baseline target
Under 80 years with diabetes	<140/90 mmHg	<130/80 mmHg	<140/90 mmHg	ESC recommends tighter control for diabetics
Over 80 years	<150/90 mmHg	<140/90 mmHg	<150/90 mmHg	ESC maintains standard targets for elderly
Chronic kidney disease	<140/90 mmHg	<130/80 mmHg	<140/90 mmHg	ESC recommends lower targets for renal protection
Secondary prevention CVD	<140/90 mmHg	<130/80 mmHg	<140/90 mmHg	ESC specifies <130/80 for established CVD

Key Alignment: All three bodies consistently recommend <140/90 mmHg for adults under 80 without comorbidities. The main differences emerge in diabetic, elderly, and high cardiovascular risk populations where ESC advocates for more intensive control.

Monitoring Intervals and Assessment Frequency

NICE Approach

NICE recommends:

Initial treatment: Review within 4 weeks of medication initiation
Stable control: 6-monthly reviews for maintained targets
Treatment adjustment: Reassess within 2-4 weeks after dose changes
Home monitoring: Encourage for treatment titration between visits

Special populations: For patients over 80, conduct orthostatic BP measurements at each review. In diabetes, coordinate BP monitoring with diabetes reviews.

ESC Approach

ESC emphasizes:

Initial phase: Fortnightly reviews until target approached
Stable patients: 3-6 monthly reviews based on total CV risk
High-risk patients: Monthly monitoring until controlled
Ambulatory monitoring: Recommended for treatment-resistant cases

Unique perspective: ESC integrates BP monitoring with comprehensive cardiovascular risk assessment, recommending more frequent reviews for patients with high SCORE2 risk.

SIGN Approach

SIGN specifies:

Routine monitoring: Aligns with Scottish QOF requirements
Treatment initiation: Review within 4-6 weeks
Stable patients: Annual review minimum
Complex cases: 3-monthly reviews in multidisciplinary settings

Scottish adaptation: SIGN emphasizes integration with local chronic disease management pathways and digital health solutions.

Monitoring Difference: ESC recommends the most intensive monitoring schedule, particularly for high-risk patients, while SIGN aligns with structured chronic disease management programmes. NICE provides the most pragmatic primary-care-focused intervals.

Escalation Triggers and Referral Criteria

Trigger Scenario	NICE Response	ESC Response	SIGN Response
BP persistently >180/110 mmHg	Immediate same-day assessment	Urgent specialty referral	Immediate primary care assessment
Treatment resistance (3 drugs)	Refer to specialist hypertension service	Comprehensive secondary care workup	Refer to local hypertension pathway
Secondary hypertension suspicion	Urgent specialist referral	Immediate endocrine/renal assessment	Refer according to local guidelines
Hypertensive emergency symptoms	Emergency department referral	Immediate hospital admission	Emergency secondary care access
Age <40 with hypertension	Consider specialist assessment	Comprehensive secondary evaluation	Refer for secondary causes exclusion
Pregnancy with hypertension	Immediate obstetric referral	Obstetric medicine consultation	Urgent maternity assessment

Clinical Nuance: ESC demonstrates the lowest threshold for specialist referral, particularly for young hypertensive patients and treatment-resistant cases. NICE provides more graded escalation pathways suitable for UK primary care constraints.

Clinical Scenarios

Scenario 1: Borderline Control in Diabetes

Presentation: 58-year-old male with type 2 diabetes, current BP 138/88 mmHg on two antihypertensives. HbA1c 7.2%, no microvascular complications.

Analysis: NICE would maintain current therapy as target achieved. ESC would intensify treatment toward <130/80 mmHg given diabetic status. SIGN would align with NICE. The ESC approach may be preferable given evidence for tighter control in diabetes, but requires careful monitoring for side effects.

Scenario 2: Elderly Patient with Frailty

Presentation: 82-year-old female with moderate frailty (Rockwood score 5), BP 148/92 mmHg on low-dose thiazide. No orthostatic symptoms.

Analysis: NICE and SIGN would accept current control as meeting <150/90 mmHg target. ESC would recommend additional treatment to reach <140/90 mmHg. Given frailty and fall risk, the NICE/SIGN approach balances benefit and harm more appropriately in this population.

Scenario 3: Young Treatment-Resistant Hypertension

Presentation: 35-year-old male, BP 162/98 mmHg despite triple therapy including diuretic. Normal renal function, no endocrine features.

Analysis: All guidelines recommend specialist referral. ESC would trigger the most comprehensive secondary cause workup. NICE suggests hypertension specialist service. In this age group, thorough exclusion of secondary causes aligns with ESC's more aggressive diagnostic approach.

Risk Prediction and Decision Support Tools

QRISK3: All three guidelines acknowledge QRISK3 for cardiovascular risk assessment. NICE specifically integrates QRISK3 scores into treatment decisions, particularly for borderline hypertension. ESC prefers SCORE2 but accepts QRISK3 for UK practice. SIGN mandates QRISK3 within Scottish cardiovascular prevention pathways.

Ambulatory Blood Pressure Monitoring (ABPM): NICE recommends ABPM for diagnostic confirmation. ESC advocates for ABPM in treatment-resistant hypertension and white coat effect. SIGN follows NICE position with specific Scottish ABPM service integration.

Home Blood Pressure Monitoring (HBPM): All guidelines encourage HBPM for treatment titration. NICE provides specific HBPM targets (clinic target minus 10/5 mmHg). ESC offers similar adjustments with emphasis on proper device validation.

Common Clinical Pitfalls

Overtreatment in the elderly: Aggressive pursuit of <140/90 mmHg in patients over 80 without considering frailty and fall risk. Can lead to symptomatic hypotension and reduced quality of life.
Undertreatment in diabetes: Accepting <140/90 mmHg in diabetic patients when tighter control may provide additional microvascular protection. Missed opportunity for renal and retinal risk reduction.
Ignoring white coat hypertension: Initiating treatment based solely on clinic readings without confirming with ABPM or HBPM. Leads to unnecessary medication in 15-20% of patients.
Delaying specialist referral: Persisting with primary care management in young hypertensive patients or true treatment resistance. Misses secondary causes and delays appropriate intervention.
Not assessing orthostatic hypotension: Failing to check standing BP in elderly patients before intensifying treatment. Increases fall risk and medication intolerance.
Inadequate medication titration: Stopping at suboptimal doses due to mild side effects rather than trying alternative agents. Results in persistent uncontrolled hypertension.
Ignoring lifestyle interventions: Focusing solely on pharmacological treatment without addressing salt intake, weight, and exercise. Misses synergistic non-pharmacological benefits.

Practical Takeaways

Hypertension Management Checklist

✓ Use NICE as your default framework for most UK primary care patients
✓ Apply ESC's tighter targets (<130/80 mmHg) for diabetic and high cardiovascular risk patients when tolerated
✓ Follow SIGN guidelines when working within Scottish healthcare systems
✓ Key threshold: <140/90 mmHg for adults under 80 without comorbidities
✓ Red flag: BP >180/110 mmHg requires immediate assessment
✓ Don't miss: Secondary hypertension in young patients or treatment resistance
✓ Remember: Frailty assessment precedes intensification in elderly patients
✓ Consider ABPM for diagnostic uncertainty and white coat hypertension
✓ Timing: Review within 4 weeks after treatment initiation or changes
✓ Document: Rationale when deviating from standard targets for individual patients

Sources

NICE guidance on Hypertension (Treatment targets)
ESC guidance on Hypertension (Treatment targets)
SIGN guidance on Hypertension (Treatment targets)

Refer to the full guidelines for exact wording and local adaptations. This summary is for rapid orientation and multidisciplinary alignment.

Full Guideline References

NICE NG136: Hypertension in adults: diagnosis and management (August 2023 update)
ESC/ESH 2023: 2023 ESH Guidelines for the management of arterial hypertension
SIGN 149: Management of hypertension (March 2024 revision)

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.

Blood pressure targets: NICE vs ESC vs SIGN (2025)