Adult Hypertension ✅

🩺 Adult hypertension means persistently raised blood pressure in adults. It is a major modifiable risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, atrial fibrillation, vascular dementia and premature death. NICE NG136 was updated in February 2026 and remains the key UK reference for diagnosis and management.

Adult Hypertension 🩺

Hypertension is usually asymptomatic, so accurate measurement and confirmation are essential. The key exam principle is: do not diagnose hypertension from one clinic reading unless it is severe with concerning features. Confirm with ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) where appropriate.

Pathophysiology 🧠

Blood pressure reflects cardiac output and systemic vascular resistance. In primary hypertension, ageing, arterial stiffness, sympathetic activation, renal sodium handling, obesity, insulin resistance, endothelial dysfunction and genetic factors all contribute. Long-term pressure damages vessels and target organs, leading to left ventricular hypertrophy, nephropathy, retinopathy and cerebrovascular disease.

Correct BP measurement ✅

• Use a validated and calibrated blood pressure device.
• Use the correct cuff size.
• Ensure the patient is seated, relaxed, quiet and supported.
• Palpate the pulse first; if irregular, measure BP manually.
• Measure BP in both arms when considering a diagnosis.
• If the difference between arms is more than 15 mmHg, repeat it.
• If the difference remains more than 15 mmHg, use the arm with the higher reading for future measurements.

Postural hypotension 🧍

Check lying or seated and standing BP in patients with falls, dizziness, type 2 diabetes, symptoms of postural hypotension, or age 80 and over. A fall in systolic BP of 20 mmHg or more, or diastolic BP of 10 mmHg or more, after standing suggests postural hypotension.

• Review antihypertensives, diuretics, nitrates and alpha-blockers.
• Assess hydration, autonomic neuropathy and frailty.
• Treat to a standing BP target if there is a significant postural drop.

Diagnosis 🔍

• If clinic BP is 140/90 mmHg or higher, take a second reading during the consultation.
• If readings differ substantially, take a third reading.
• Record the lower of the last 2 readings as the clinic BP.
• If clinic BP is 140/90 to 179/119 mmHg, offer ABPM to confirm hypertension.
• If ABPM is unsuitable or not tolerated, offer HBPM.
• Confirm hypertension if clinic BP is 140/90 mmHg or higher and daytime ABPM or HBPM average is 135/85 mmHg or higher.

Home BP monitoring method 🏠

• Take 2 consecutive readings at least 1 minute apart.
• Record BP twice daily, ideally morning and evening.
• Continue for at least 4 days, ideally 7 days.
• Discard day 1 readings.
• Use the average of the remaining readings.

Hypertension stages 📊

Initial investigations 🧪

Investigations look for target organ damage, renal disease, diabetes, hyperlipidaemia and secondary causes. They also provide a baseline before treatment.

• Urine albumin:creatinine ratio.
• Urine dipstick for haematuria.
• U&Es, creatinine and eGFR.
• HbA1c.
• Total cholesterol and HDL cholesterol.
• Fundoscopy for hypertensive retinopathy.
• 12-lead ECG for left ventricular hypertrophy, ischaemia or arrhythmia.
• Formal cardiovascular risk assessment, such as QRISK, using clinic BP.

When to think of secondary hypertension 🚩

• Age under 40 with hypertension.
• Sudden onset or rapidly worsening hypertension.
• Resistant hypertension despite 3 drugs.
• Hypokalaemia suggesting hyperaldosteronism.
• Renal bruit or asymmetric kidneys suggesting renovascular disease.
• Symptoms of phaeochromocytoma: headaches, sweating, palpitations.
• Cushingoid features.
• Obstructive sleep apnoea.
• Drug causes: NSAIDs, steroids, cocaine, ciclosporin, tacrolimus, SNRIs, combined hormonal contraception.

Same-day specialist review 🚑

Severe hypertension is not automatically a hypertensive emergency. The key question is whether there is acute target organ damage or life-threatening symptoms.

• Refer same day if clinic BP is 180/120 mmHg or higher with retinal haemorrhage or papilloedema.
• Refer same day if BP is 180/120 mmHg or higher with new confusion, chest pain, signs of heart failure or acute kidney injury.
• If BP is 180/120 mmHg or higher without these features, investigate target organ damage promptly and arrange urgent review/confirmation.

Lifestyle management 🌿

• Weight reduction if overweight or obese.
• Regular aerobic exercise.
• Reduce salt intake.
• Reduce excessive alcohol intake.
• Stop smoking and address cardiovascular risk.
• Eat a healthy diet rich in fruit, vegetables and fibre.
• Discourage excessive coffee and caffeine-rich products.
• Do not offer calcium, magnesium or potassium supplements solely to lower BP.

When to start drug treatment 💊

• Stage 2 hypertension: offer antihypertensive drug treatment plus lifestyle advice.
• Stage 1 hypertension under 80: discuss drug treatment if target organ damage, established cardiovascular disease, renal disease, diabetes, or 10-year CVD risk of 10% or more.
• Stage 1 hypertension under 60 with CVD risk below 10%: consider drug treatment because 10-year risk may underestimate lifetime risk.
• Age over 80 with stage 1 hypertension: consider drug treatment if clinic BP is over 150/90 mmHg, using clinical judgement for frailty and multimorbidity.
• Age under 40: consider specialist evaluation for secondary causes and long-term treatment balance.

Stepwise medication treatment 💊

Important prescribing cautions ⚠️

• Do not combine an ACE inhibitor with an ARB for hypertension.
• Avoid ACE inhibitors and ARBs in pregnancy, breastfeeding or planning pregnancy unless specialist advice says otherwise.
• Check renal function and potassium after starting or increasing ACE inhibitors, ARBs or diuretics.
• CCBs can cause ankle oedema, flushing and headache.
• Thiazide-like diuretics can cause hyponatraemia, hypokalaemia, gout and metabolic disturbance.
• Spironolactone can cause hyperkalaemia, especially in reduced eGFR.

BP targets 🎯

Annual review 📅

• Review BP control at least annually.
• Ask about adherence and side effects.
• Review lifestyle, smoking, alcohol, weight and exercise.
• Check renal function and electrolytes where medication requires monitoring.
• Review CVD risk and statin indication.
• Check for postural symptoms in older people, diabetes or frailty.

Common exam and ward pitfalls ❌

• Diagnosing hypertension from a single clinic reading.
• Forgetting ABPM or HBPM confirmation.
• Not checking both arms at diagnosis.
• Missing postural hypotension in older or diabetic patients.
• Starting an ACE inhibitor in pregnancy or in someone planning pregnancy.
• Combining ACE inhibitor and ARB.
• Not checking U&Es after ACE inhibitor, ARB or diuretic changes.
• Ignoring target organ damage or secondary causes in young patients.
• Treating severe BP numbers without looking for emergency features.

Makindo exam summary 🎯

For exams, think: measure correctly, confirm with ABPM or HBPM, assess target organ damage and CVD risk, give lifestyle advice, then treat according to stage, age, diabetes, ethnicity and comorbidity. Hypertension management is not just lowering a number; it is prevention of stroke, MI, heart failure, CKD and vascular dementia.

References 📚

• NICE. Hypertension in adults: diagnosis and management. NICE guideline NG136. Published 28 August 2019. Last updated 26 February 2026.
• NICE NG136 recommends confirming hypertension with ABPM or HBPM when clinic BP is 140/90 mmHg or higher and below 180/120 mmHg.
• NICE NG136 recommends assessing target organ damage with urine ACR, haematuria testing, HbA1c, renal function, lipid profile, fundoscopy and ECG.
• NICE NG136 recommends clinic BP targets below 140/90 mmHg for adults under 80 and below 150/90 mmHg for adults aged 80 and over.
• NICE NG136 recommends ACE inhibitor or ARB step 1 treatment for adults under 55 or adults with type 2 diabetes, and CCB step 1 treatment for adults aged 55 or over or adults of Black African or African-Caribbean family origin without type 2 diabetes.

Disclaimer 📚

This article is for medical education and revision only. Hypertension diagnosis and prescribing should follow NICE NG136, local guidelines, the BNF, renal function, potassium results, pregnancy status, comorbidities, patient preference and senior clinical advice where needed.