Cardiology: Hypertension

• Basics: What Is Hypertension? | Measuring Blood Pressure | Diagnosis and Stages | White-coat and Masked Hypertension | Assessing the Patient
• Treatment: Who to Treat | Lifestyle | Drug Treatment: the NICE Steps | Antihypertensive Drugs: What to Know | Targets and Monitoring | Resistant Hypertension
• Secondary hypertension: Secondary Causes | Primary Aldosteronism | Renovascular Hypertension | Drug-induced Hypertension
• Special groups: Young Adults | Older People and Frailty | Diabetes and CKD | Hypertension in Pregnancy | Pre-eclampsia | Postural Hypotension | Severe Hypertension and Emergencies
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 Hypertension affects about 1 in 3 UK adults and is the single biggest modifiable risk factor for stroke, heart attack, heart failure, kidney disease and dementia. Most people have no symptoms - so it is found by measuring. Treating it well is one of the most effective things in medicine: every 10 mmHg fall in systolic pressure cuts major cardiovascular events by about a fifth.
Your four questions for every patient: Is the diagnosis confirmed with ambulatory or home readings? Is there organ damage or high cardiovascular risk? Could there be a secondary cause? Is the treatment right for this person's age, ethnicity, comorbidities and pregnancy plans?

What Is Hypertension?

Definition: Persistently raised arterial blood pressure - clinic BP of 140/90 mmHg or more, confirmed by ambulatory or home BP of 135/85 or more (NICE NG136).

Mechanism:

• BP = cardiac output × peripheral resistance.
• In most people - "essential" or primary hypertension (about 90%) - no single cause is found. It results from genes, salt intake, obesity, inactivity, alcohol, ageing (stiffer arteries) and overactivity of the renin–angiotensin and sympathetic systems.
• About 10% have a secondary (identifiable) cause.

Why it matters - target organ damage:

• Brain: Stroke (ischaemic and haemorrhagic), vascular dementia.
• Heart: LV hypertrophy, coronary disease, heart failure (especially HFpEF), AF.
• Kidneys: CKD, proteinuria.
• Eyes: Hypertensive retinopathy.
• Arteries: Aortic aneurysm and dissection, peripheral arterial disease.

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Measuring Blood Pressure

• Technique:
  • Validated device.
  • Patient seated and relaxed for 5 minutes, arm supported at heart level.
  • Correct cuff size - too small a cuff over-reads.
  • No talking.
• Manual measurement if the pulse is irregular (AF), as automated devices can be inaccurate.
• Both arms at first assessment. If the difference is more than 15 mmHg, repeat. If it is still more than 15 mmHg, use the arm with the higher reading - a large difference suggests subclavian stenosis (and higher CV risk).
• Repeat readings: If the first clinic reading is 140/90 or more, take a second and third, and record the lower of the last two.
• Ambulatory BP monitoring (ABPM) - the preferred test to confirm diagnosis: At least 14 daytime readings; use the daytime average.
• Home BP monitoring (HBPM) if ABPM is unsuitable:
  • Two readings, 1 minute apart, morning and evening, for at least 4 (ideally 7) days.
  • Discard day 1 and average the rest.
• Standing BP: Also measure standing BP in people with diabetes, symptoms of postural hypotension, or aged 80 and over.

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Diagnosis and Stages

Key rules:

• Confirm with ABPM or HBPM before diagnosing (unless severe). Out-of-office readings are about 5 mmHg lower than clinic readings.
• Clinic BP of 180/120 or more:
  • Assess for target organ damage urgently - and look for features needing same-day referral (see Severe Hypertension and Emergencies).
  • If organ damage is present, consider starting treatment straight away, before ABPM.
  • If there is no organ damage, repeat the clinic BP within 7 days.

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White-coat and Masked Hypertension

• White-coat hypertension:
  • Clinic BP raised (140/90 or more) but ambulatory or home BP normal (below 135/85).
  • Common, especially in older people.
  • No drug treatment, but check BP at least yearly (some go on to develop hypertension) and manage other risk factors.
• White-coat effect in treated patients: A difference of more than 20/10 mmHg between clinic and home readings. Use home or ambulatory readings to guide treatment - this avoids over-treatment.
• Masked hypertension:
  • Clinic BP normal but home or ambulatory BP raised.
  • It carries the same risk as sustained hypertension.
  • Suspect it in people with organ damage (e.g. LVH, proteinuria) despite "normal" clinic readings.
• Nocturnal hypertension and "non-dipping": BP that fails to fall at night (seen on ABPM) - linked to OSA, CKD, diabetes and autonomic failure, and to higher risk.

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Assessing the Patient

For everyone with hypertension (NICE NG136):

• Urine albumin:creatinine ratio (ACR) and dipstick for blood (kidney damage).
• U&E and eGFR (including potassium - low potassium suggests aldosteronism).
• HbA1c.
• Lipids (total and HDL cholesterol).
• 12-lead ECG (LV hypertrophy, AF, previous MI).
• Fundoscopy (hypertensive retinopathy).
• Cardiovascular risk - QRISK3.

History and examination:

• Symptoms of organ damage (chest pain, breathlessness, TIA).
• Drugs (see Drug-induced Hypertension).
• Alcohol; salt intake.
• Snoring and sleepiness (OSA).
• Family history; pregnancy plans.
• Clues to secondary causes:
  • Episodic headaches, sweating and palpitations (phaeochromocytoma).
  • Cushingoid features.
  • Radio-femoral delay (coarctation).
  • Renal bruits.
  • Enlarged kidneys (polycystic kidney disease).

Hypertensive retinopathy (Keith–Wagener grades):

• Grade 1: Arteriolar narrowing ("silver wiring").
• Grade 2: AV nipping.
• Grade 3: Flame haemorrhages and cotton wool spots.
• Grade 4: Papilloedema.

Grades 3–4 mean accelerated (malignant) hypertension - a same-day referral.

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Who to Treat

• Lifestyle advice for everyone with raised BP.
• Stage 2 hypertension: Offer drug treatment to everyone, whatever their age.
• Stage 1 hypertension: Offer drug treatment to people aged under 80 who have any of:
  • Target organ damage.
  • Established cardiovascular disease.
  • Kidney disease.
  • Diabetes.
  • 10-year QRISK3 of 10% or more.
• Consider treatment for stage 1 hypertension in people:
  • Aged under 60 with QRISK3 below 10% - QRISK3 underestimates lifetime risk in younger people.
  • Aged over 80 if clinic BP is above 150/90.
• Under 40 with hypertension: Consider specialist evaluation for secondary causes and a detailed assessment of long-term risk.

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Lifestyle

Lifestyle changes can lower BP by as much as one drug - and help all other risk factors.

• Salt: Reduce to below 6 g a day (most salt is hidden in processed food, bread and ready meals). Avoid salt substitutes containing potassium if on ACE inhibitors or ARBs and with CKD.
• Weight loss: About 1 mmHg lower per kg lost.
• Exercise: Regular aerobic activity (150 minutes a week).
• Alcohol: Within 14 units a week; avoid binges.
• Diet: Plenty of fruit and vegetables, low-fat dairy (DASH-style diet).
• Caffeine: Avoid excessive coffee, tea and cola.
• Stop smoking - it does not raise long-term BP, but it greatly multiplies cardiovascular risk.
• Relaxation therapies are not routinely funded, but stress management may help some.

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Drug Treatment: the NICE Steps

NICE NG136 uses the letters A (ACE inhibitor or ARB), C (calcium channel blocker) and D (thiazide-like diuretic).

• Step 1:
  • ACE inhibitor or ARB (A) for people:
    • Aged under 55 (and not of Black African or African-Caribbean family origin), or
    • With type 2 diabetes - at any age and of any family origin.
  • Calcium channel blocker (C) (e.g. amlodipine) for people:
    • Aged 55 or over, or
    • Of Black African or African-Caribbean family origin (without diabetes).
  • If a CCB is unsuitable (e.g. oedema, heart failure): a thiazide-like diuretic (D) - indapamide.
• Step 2: A + C, or A + D, or C + D (for people already on C, add A or D).
  • For people of Black African or African-Caribbean origin, use an ARB rather than an ACE inhibitor when adding A (higher risk of angioedema with ACE inhibitors).
• Step 3: A + C + D, at optimal tolerated doses.
• Step 4 - resistant hypertension: First confirm with ABPM or HBPM, check adherence and look for postural hypotension. Then, guided by potassium:
  • Potassium 4.5 mmol/L or less: Add low-dose spironolactone (watch potassium and renal function).
  • Potassium above 4.5 mmol/L: Add an alpha-blocker (doxazosin) or a beta-blocker.
  • Seek specialist advice if BP is still uncontrolled on four drugs.

Other points:

• Beta-blockers are not first-line for uncomplicated hypertension. They are useful with another indication (angina, heart failure, AF), or in younger women planning pregnancy, intolerant of ACE inhibitors and ARBs.
• Never combine an ACE inhibitor with an ARB (more kidney injury and hyperkalaemia, no extra benefit).
• Single-pill combinations improve adherence.

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Antihypertensive Drugs: What to Know

• ACE inhibitors (ramipril, lisinopril):
  • Dry cough (about 1 in 10) - switch to an ARB.
  • Angioedema (rare, can occur years later; more common in Black people).
  • Hyperkalaemia.
  • Creatinine rise - check U&E 1–2 weeks after starting. A rise of up to 30% is acceptable. A larger rise suggests renal artery stenosis.
  • Teratogenic - avoid in pregnancy.
• ARBs (losartan, candesartan): Like ACE inhibitors but no cough. Also teratogenic.
• Calcium channel blockers (amlodipine): Ankle oedema (not heart failure - diuretics don't help), flushing, headache, gum hypertrophy.
• Thiazide-like diuretics (indapamide; chlortalidone):
  • Hyponatraemia (especially older women).
  • Hypokalaemia.
  • Gout (raised urate).
  • Raised glucose; erectile dysfunction.
  • Photosensitivity.
• Spironolactone: Hyperkalaemia (especially with ACE inhibitor or ARB plus CKD), gynaecomastia, menstrual upset.
• Alpha-blockers (doxazosin): Postural hypotension (start at night); useful with prostatic symptoms.
• Beta-blockers: Fatigue, cold hands, bradycardia, bronchospasm in asthma; can mask hypoglycaemia.
• Women of childbearing age: Discuss contraception and pregnancy plans. If pregnancy is possible, labetalol or nifedipine may be preferred over ACE inhibitors and ARBs. Stop ACE inhibitors and ARBs as soon as pregnancy is confirmed (ideally within 2 days).

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Targets and Monitoring

• Frailty and multimorbidity: Use clinical judgement - lower targets may cause falls, AKI and syncope.
• After starting or changing treatment: Review monthly until at target, using home readings where possible.
• Annual review once stable:
  • BP.
  • Adherence and side effects.
  • U&E.
  • Other cardiovascular risk factors (statin if QRISK3 is 10% or more).
• Lower targets (e.g. systolic around 120–130) reduce events further in some trials (SPRINT). Some international guidelines recommend them for fit, high-risk patients if tolerated.

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Resistant Hypertension

Definition: BP above target despite three drugs (including a diuretic) at optimal doses, confirmed with ABPM or HBPM.

First exclude "pseudo-resistance":

• White-coat effect - check out-of-office readings.
• Poor technique (cuff too small).
• Non-adherence - very common; consider urine or blood drug-level testing (specialist), single-pill combinations, and an honest conversation.
• Under-dosing.

Then look for contributing factors:

• Salt; alcohol; obesity.
• OSA.
• Drugs (NSAIDs, decongestants, the combined pill, steroids, liquorice).
• CKD; volume overload.

Screen for secondary causes - especially primary aldosteronism (the commonest cause of resistant hypertension, up to 1 in 5).

Treatment:

• Step 4 drugs - spironolactone is the most effective (PATHWAY-2 trial).
• Specialist hypertension clinic referral.
• Renal denervation (catheter ablation of the renal nerves) is an option in specialist centres for selected patients with resistant hypertension.

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Secondary Causes

When to suspect a secondary cause:

• Age under 40.
• Sudden onset, or sudden worsening of previously controlled BP.
• Resistant or severe hypertension; accelerated hypertension.
• Hypokalaemia (spontaneous or diuretic-induced).
• Episodic symptoms.
• Organ damage out of proportion to the BP.
• Clinical clues.

Main causes:

• Kidney disease - CKD, glomerulonephritis, polycystic kidney disease - the commonest secondary cause.
• Primary aldosteronism (Conn's).
• Renovascular disease - atherosclerotic renal artery stenosis; fibromuscular dysplasia.
• Obstructive sleep apnoea.
• Phaeochromocytoma and paraganglioma - episodic headache, sweating, palpitations; plasma metanephrines.
• Cushing's syndrome.
• Coarctation of the aorta - young, arm BP higher than leg, radio-femoral delay, rib notching.
• Thyroid disease (hyper- and hypothyroidism); primary hyperparathyroidism; acromegaly.
• Drugs and substances.
• Pregnancy (pre-eclampsia).

Screening tests:

• U&E, urinalysis, ACR.
• Aldosterone:renin ratio.
• Plasma metanephrines.
• TFTs, calcium.
• Overnight dexamethasone suppression test (if Cushingoid).
• Renal ultrasound; renal artery imaging if indicated.
• Sleep study.

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Primary Aldosteronism

• Mechanism: The adrenal glands make too much aldosterone, independent of renin. This causes salt and water retention and potassium loss.
  • Unilateral adrenal adenoma (Conn's) - about a third.
  • Bilateral adrenal hyperplasia - about two-thirds.
• How common: Much commoner than once thought - 5–10% of all hypertension, and up to 20% of resistant hypertension. It carries a higher cardiovascular risk than essential hypertension at the same BP.
• Clues:
  • Resistant hypertension.
  • Hypokalaemia (present in only about a third).
  • Hypertension with an adrenal incidentaloma.
  • Young onset.
  • AF.
  • OSA.
• Screening:
  • Aldosterone:renin ratio - high aldosterone with suppressed renin.
  • Correct potassium first.
  • Some drugs affect the result (spironolactone, diuretics, beta-blockers, ACE inhibitors and ARBs) - interpret with specialist advice rather than delaying the test.
• Confirmation and subtyping (endocrinology): Saline suppression test; adrenal CT; adrenal vein sampling to show which side is producing aldosterone.
• Treatment:
  • Unilateral disease: Laparoscopic adrenalectomy.
  • Bilateral disease: Spironolactone (or eplerenone).
• See the Adrenal Disease chapter for detail.

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Renovascular Hypertension

• Atherosclerotic renal artery stenosis:
  • Who: Older smokers with widespread vascular disease.
  • Clues:
    • Resistant hypertension.
    • Unexplained CKD.
    • A creatinine rise of more than 30% after starting an ACE inhibitor or ARB.
    • Asymmetric kidneys (difference of more than 1.5 cm).
    • "Flash" pulmonary oedema.
    • Abdominal bruit.
  • Imaging: Doppler ultrasound, CT or MR angiography.
  • Treatment: Mainly medical - BP control, statin, antiplatelet, smoking cessation. Stenting does not usually help (ASTRAL, CORAL trials), except in flash pulmonary oedema or rapidly declining kidney function.
• Fibromuscular dysplasia (FMD):
  • Who: Typically young women.
  • Imaging: A "string of beads" appearance of the renal arteries.
  • May also affect carotid and other arteries - dissection, aneurysm, SCAD.
  • Treatment: Angioplasty is effective and can cure the hypertension.

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Drug-induced Hypertension

• NSAIDs - common, and they also blunt antihypertensive drugs.
• Combined oral contraceptive pill - consider progestogen-only or non-hormonal options.
• Corticosteroids and fludrocortisone.
• Decongestants (pseudoephedrine, phenylephrine).
• Antidepressants - venlafaxine, MAOIs (with tyramine).
• Ciclosporin and tacrolimus.
• Erythropoietin.
• VEGF inhibitors (bevacizumab, sunitinib) and other cancer drugs.
• Stimulants - amphetamines, methylphenidate, cocaine.
• Liquorice (excess) - mimics aldosteronism with low potassium.
• Alcohol excess; anabolic steroids.

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Young Adults

• Under 40: Secondary causes are more likely - check kidneys, aldosterone:renin ratio, metanephrines, coarctation (femoral pulses and leg BP), thyroid and drugs. NICE suggests specialist evaluation.
• Lifetime risk is high even if 10-year risk is low - treat based on organ damage and long-term risk, not only QRISK3.
• Women of childbearing potential:
  • Discuss pregnancy plans and contraception before starting ACE inhibitors or ARBs.
  • Labetalol, nifedipine (modified release) or methyldopa are safe in pregnancy.
• Lifestyle: Stimulant drinks, recreational drugs, alcohol, steroids (gym use).

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Older People and Frailty

• Benefit: Treating hypertension in people aged 80 and over reduces stroke, heart failure and death (HYVET trial - fitter older people, target 150/80).
• Isolated systolic hypertension (stiff arteries) is common - treat as for other hypertension.
• Targets: Below 150/90 in those aged 80 and over. Use the standing BP if there is postural hypotension.
• Frailty:
  • Weigh benefits against risks - falls, syncope, AKI, hyponatraemia (thiazides), hypokalaemia.
  • Deprescribing may be appropriate in severe frailty, low BP, recurrent falls or limited life expectancy.
  • Reduce doses if dehydrated or unwell (sick day rules).
• Start low, go slow, and check standing BP and U&E.

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Diabetes and CKD

• Type 2 diabetes:
  • Offer an ACE inhibitor or ARB first-line, regardless of age or family origin (ARB for Black African or African-Caribbean origin).
  • Add a CCB or thiazide-like diuretic as needed.
  • Measure standing BP.
• Type 1 diabetes (NICE NG17): Target below 135/85, or below 130/80 with albuminuria; ACE inhibitor or ARB if albuminuria.
• CKD (NICE NG203):
  • ACE inhibitor or ARB for people with CKD and an ACR of 30 mg/mmol or more (or 3 mg/mmol or more with diabetes), titrated to the highest tolerated dose.
  • SGLT2 inhibitors (dapagliflozin, empagliflozin) add kidney and heart protection in CKD.
  • Accept a creatinine rise of up to about 30% after starting.
  • Targets: Systolic 120–139 (diastolic below 90), or systolic 120–129 (diastolic below 80) if ACR is 70 mg/mmol or more.
• Finerenone (non-steroidal MRA) for CKD with type 2 diabetes reduces kidney and heart events (NICE TA877).

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Hypertension in Pregnancy

Types (NICE NG133):

• Chronic hypertension: Present before pregnancy or before 20 weeks.
• Gestational hypertension: New hypertension after 20 weeks, without proteinuria or organ involvement.
• Pre-eclampsia: New hypertension after 20 weeks with proteinuria or other organ involvement (see Pre-eclampsia).

Before and early in pregnancy:

• Women on ACE inhibitors, ARBs or thiazides who are planning pregnancy should be told of the risks. Stop them (ideally within 2 days of the pregnancy being confirmed) and switch to a safe alternative.
• Aspirin 75–150 mg daily from 12 weeks until birth, for women at high risk of pre-eclampsia:
  • One high-risk factor - chronic hypertension, hypertension in a previous pregnancy, CKD, autoimmune disease (SLE, antiphospholipid syndrome), diabetes.
  • Or two or more moderate-risk factors - first pregnancy, age 40 or over, more than 10 years since the last pregnancy, BMI 35 or more, family history of pre-eclampsia, multiple pregnancy.

Treatment:

• Treat if BP is 140/90 or more; target 135/85.
• First-line: labetalol. Then nifedipine (modified release), then methyldopa.
• Severe hypertension (160/110 or more): Admit and treat urgently.
• Monitoring: BP, urine protein (protein:creatinine ratio), and fetal growth scans.

After birth:

• BP often peaks 3–5 days postpartum.
• Enalapril (with monitoring), nifedipine or amlodipine are suitable when breastfeeding. Avoid methyldopa after birth (depression).
• Long-term risk: Hypertensive disorders of pregnancy increase lifelong cardiovascular and kidney risk - annual BP checks and risk factor management.

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Pre-eclampsia

Mechanism: Abnormal development of the placenta releases factors that damage the mother's blood vessel lining throughout the body. It causes hypertension and multi-organ injury, and can affect fetal growth.

Definition: New hypertension after 20 weeks plus one or more of:

• Proteinuria - urine protein:creatinine ratio of 30 mg/mmol or more.
• Kidney injury - creatinine 90 µmol/L or more.
• Liver involvement - raised transaminases, right upper quadrant or epigastric pain.
• Neurological features - severe headache, visual disturbance (flashing lights), clonus, eclampsia (seizures), stroke.
• Haematological - low platelets, haemolysis, DIC.
• Uteroplacental dysfunction - fetal growth restriction, abnormal Doppler studies, stillbirth.

Tests: Placental growth factor (PlGF)-based testing helps rule pre-eclampsia in or out between 20 and 37 weeks.

Management:

• Obstetric-led, usually in hospital.
• Antihypertensives - labetalol, nifedipine; IV labetalol or hydralazine if severe.
• Magnesium sulfate to prevent and treat eclamptic seizures in severe pre-eclampsia. Monitor reflexes, breathing and urine output; calcium gluconate is the antidote for toxicity.
• Careful fluids - risk of pulmonary oedema.
• Timing of birth - the only cure. Usually at 37 weeks, or earlier if the mother or baby is unwell.
• HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets): A severe variant - urgent delivery.

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Postural Hypotension

• Definition: A fall in BP of 20 mmHg or more systolic (or 10 mmHg or more diastolic) within 3 minutes of standing.
• Symptoms: Dizziness, light-headedness, blurred vision, "coat-hanger" neck pain, falls and syncope - especially after meals, in the morning, or in heat.
• Causes:
  • Drugs - antihypertensives (especially alpha-blockers, diuretics, nitrates), antipsychotics, antidepressants, opioids, levodopa and dopamine agonists, SGLT2 inhibitors.
  • Dehydration and blood loss.
  • Autonomic failure - diabetes, Parkinson's disease, multiple system atrophy, Lewy body dementia, amyloidosis, B12 deficiency.
  • Adrenal insufficiency.
  • Prolonged bed rest; older age.
• Management:
  • Review and reduce culprit drugs - a common, simple fix.
  • Adequate fluid and salt intake (if not contraindicated).
  • Rise slowly; leg crossing and muscle tensing on standing; compression stockings or abdominal binders.
  • Raise the head of the bed; small, frequent meals.
  • Drugs if still symptomatic (specialist):
    • Midodrine - causes supine hypertension.
    • Fludrocortisone - causes hypokalaemia, oedema, supine hypertension.
  • For people with both hypertension and postural hypotension, use the standing BP for decisions.

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Severe Hypertension and Emergencies

Detailed management is in the Cardiac Emergencies chapter. In summary (NICE NG136):

• Refer for same-day specialist assessment if BP is 180/120 or more with:
  • Retinal haemorrhages or papilloedema (accelerated hypertension).
  • Life-threatening symptoms - new confusion, chest pain, signs of heart failure, AKI.
  • Suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor, sweating).
• Hypertensive emergency (severe BP with acute organ damage): IV treatment in HDU or ICU, lowering BP in a controlled way (usually by no more than about 25% in the first hours), with condition-specific targets (e.g. aortic dissection).
• Severe hypertension without organ damage: Oral treatment and repeat assessment within 7 days - do not lower BP rapidly.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 48-year-old white man has a clinic BP of 156/98. ABPM average is 148/92. QRISK3 is 12%.
Answer: Stage 1 hypertension with QRISK3 of 10% or more - offer treatment.

• Lifestyle advice.
• Under 55, so start an ACE inhibitor (e.g. ramipril). Check U&E at 1–2 weeks.
• Offer a statin.
• Target below 140/90 (clinic).

2. A 62-year-old woman of African-Caribbean origin without diabetes has stage 2 hypertension.
Answer: Start a CCB (amlodipine).

• If BP stays above target, add an ARB (preferred over an ACE inhibitor), then a thiazide-like diuretic.

3. A man on amlodipine, ramipril and indapamide at full doses has ABPM 152/94. Potassium is 3.9.
Answer: Resistant hypertension.

• Check adherence, NSAIDs, alcohol and OSA.
• Screen for primary aldosteronism (aldosterone:renin ratio).
• Add low-dose spironolactone (potassium 4.5 or less); monitor potassium.
• Specialist referral if still uncontrolled.

4. A 34-year-old woman on ramipril for hypertension is planning pregnancy.
Answer: ACE inhibitors are teratogenic.

• Switch to labetalol (or nifedipine MR) before conception - or stop within 2 days of a positive test.
• Aspirin 75–150 mg from 12 weeks (chronic hypertension is a high-risk factor for pre-eclampsia).
• Pre-pregnancy counselling; check for secondary causes given her age.

5. An 86-year-old with dementia and recurrent falls is on amlodipine, ramipril and doxazosin. BP is 128/70 sitting, 102/60 standing.
Answer: Postural hypotension from over-treatment in frailty.

• Stop doxazosin first, then review the others.
• Use standing BP for targets (below 150/90 is acceptable).
• Falls assessment.

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Key Points

• Diagnose with ABPM or HBPM: 135/85 or more confirms hypertension (clinic 140/90 or more).
• Stage 1 is 140/90; stage 2 is 160/100; severe is 180/120.
• Assess everyone: ACR, U&E, HbA1c, lipids, ECG, fundoscopy, QRISK3.
• Treat all stage 2; treat stage 1 if organ damage, CVD, CKD, diabetes or QRISK3 of 10% or more.
• Step 1: A if under 55 or type 2 diabetes; C if 55 or over, or Black African/African-Caribbean origin. Step 2: A+C or A+D. Step 3: A+C+D. Step 4: spironolactone if K 4.5 or less, otherwise alpha- or beta-blocker.
• Targets: below 140/90 if under 80; below 150/90 if 80 or over; use standing BP if postural hypotension.
• Suspect secondary causes in the young, resistant, sudden, severe or hypokalaemic - especially primary aldosteronism.
• A creatinine rise of more than 30% on an ACE inhibitor suggests renal artery stenosis.
• Pregnancy: stop ACE inhibitors and ARBs; labetalol first-line; aspirin from 12 weeks for high pre-eclampsia risk; target 135/85.
• Pre-eclampsia: magnesium sulfate for severe disease; delivery is the cure.
• Older and frail patients: weigh falls and AKI risk; deprescribe when appropriate.

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Guidelines and Further Reading

• NICE NG136: Hypertension in adults - diagnosis and management
• NICE NG133: Hypertension in pregnancy - diagnosis and management
• NICE NG203: Chronic kidney disease - assessment and management
• ESC Guidelines for the management of elevated blood pressure and hypertension (2024)
• Endocrine Society: Primary aldosteronism guideline
• British and Irish Hypertension Society: BP measurement and validated devices
• BNF - for current doses