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Hypertension in adults: diagnosis and treatment Offer lifestyle advice and continue to offer it periodically Clinic BP ABPM or HBPM Use clinical judgement for people with frailty or multimorbidity • Check BP at least every 5 years and more often if clinic BP close to Under Check BP at least every 5years and Under 140/90 mmHg 140/90 mmHg more often if close to 140/90 mmHg 135/85 mmHg • If evidence of target organ damage, consider alternative causes Offer lifestyle advice. Discuss the person’s CVD risk and In addition, for the following groups: preferences for Age >80 with clinic BP >150/90 mmHg: • Consider drug treatment treatment, including no treatment. Age <80 with target organ damage, CVD, • Offer ABPM (or HBPM if ABPM is renal disease, diabetes or 10-year CVD See NICE’s patient declined or not tolerated) 135/85 to decision aid for 140/90 to 149/94 mmHg risk ≥10%: hypertension 179/119 mmHg • Investigate for target organ damage • Discuss starting drug treatment • Assess cardiovascular risk (Stage 1) See next page for Age <60 with 10-year CVD risk <10%: choice of drug, • Consider drug treatment monitoring and BP Age <40: targets. Assess for target organ damage as soon as possible: • Consider specialist evaluation of • Offer annual review • Consider starting drug treatment secondary causes and assessment long- immediately without ABPM/HBPM if term benefits and risks of treatment • Support adherence target organ damage to treatment • Repeat clinic BP in 7 days if no target organ damage 150/95 mmHg 180/120 mmHg Offer lifestyle advice and drug treatment or more or more Refer for same-day specialist review if: (Stage 2) Age <40: • retinal haemorrhage or papilloedema • Consider specialist evaluation of secondary causes and assessment long- (accelerated hypertension) or term benefits and risks of treatment • life-threatening symptoms or • suspected pheochromocytoma This is a summary of the recommendations on diagnosis and treatment from NICE’s guideline on Abbreviations: ABPM, ambulatory blood pressure monitoring; BP, blood pressure; CVD, cardiovascular disease; HBPM, home blood pressure monitoring. guidance at www.nice.org.uk/guidance/NG136Choice of antihypertensive drug , monitoring treatment and BP targets Hypertension with Hypertension without type 2 diabetes Monitoring treatment type 2 diabetes Use clinic BP to monitor treatment. Age <55 and not of Age 55 or over Black African or black African orAfrican– African–Caribbean Measure standing and sitting BP in people Caribbean family origin family origin (any age) Use clinical judgement for people with frailty or multimorbidity • type 2 diabetes or Offer lifestyle advice and continue to offer it periodically • symptoms of postural hypotension or Step 1 ACEi or ARB 2,3 CCB • aged 80 and over. Advise people who want to self-monitor to use HBPM. Provide training and advice. Consider ABPM or HBPM, in addition to clinic BP, for people with white-coat effect or ACEi or ARB 2,3 CCB masked hypertension. Step 2 + + 2,3 CCB or thiazide-like diuretic ACEi or ARB or thiazide-like diuretic BP targets Reduce and maintain BP to the following targets: Step 3 ACEi or ARB 2,+ CCB + thiazide-like diuretic Age <80 years: • Clinic BP <140/90 mmHg • ABPM/HBPM <135/85 mmHg Age ≥80 years: • Clinic BP <150/90 mmHg Confirm resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypotension and discuss adherence • ABPM/HBPM <145/85 mmHg Step 4 Consider seeking expert advice radding a: Postural hypotension: • low-dose spironolactoneif blood potassium level is ≤4.5 mmol/l • alpha-blocker or beta-blocker if blood potassium level is >4.5 mmol/l • Base target on standing BP Seek expert advice if BP is uncontrolled on optimal tolerated doses of 4 drugs Frailty or multimorbidity: • Use clinical judgement For women considering pregnancy or who are pregnant or breastfeeding, see NICE’s guideline on hypertension in pregnancy. For people with chronic kidney disease, see NICE’s guideline on chronic kidney disease. For people with heart failure, see NICE’s guideline on chronic heart failure See MHRA drug safety updates on ACE inhibitors and angiotensin-II receptor antagonists: not for use in pregnancy, which states ‘Use in women who are planning pregnancy should be avoided unless absolutely necessary, in which case the potential risks and benefits should be discussed’, ACE inhibitors and angiotensin II receptor antagonists: use during breastfeeding and clarification: ACE inhibitors and angiotensin II receptor antagonists. See also NICE’s guideline on hypertension in pregnancy. Consider an ARB, in preference to an ACE inhibitor in adults of African and Caribbean family origin. This visual summary builds on and updates previous work on At the time of publication (August 2019), not all preparations of spironolactone have a UK marketing authorisation for this indication. treatment published by the BIHS (formerly BHS) Abbreviations: ABPM, ambulatory blood pressure monitoring; ACEi, ACE inhibitor; ARB, angiotensin-II receptor blocker; BP, blood pressure; CCB, calcium-channel blocker; HBPM, home blood pressure monitoring. © NICE 2019. All rights reserved. Subject to Notice of rights. Published: August 2019