Persistent BP ≥140/90 mmHg on ≥2 occasions. Major modifiable risk factor for stroke, IHD, heart failure, and CKD.
⚠ Red flags
- BP >180/120 — hypertensive emergency
- Headache, visual change, chest pain, focal neurology
- Acute kidney injury, flash pulmonary oedema, encephalopathy
Diagnostic criteria
Clinical
- Office BP ≥140/90 on ≥2 readings, ≥2 visits
- Often asymptomatic; headache, visual change, chest pain only if severe
Investigations
- ABPM or HBPM to confirm and exclude white-coat hypertension
- ECG: LVH (Sokolow-Lyon, Cornell)
Scoring tools
- ASCVD 10-year risk score
- QRISK3
Investigations
Essential
- ECG
- U&E, creatinine, eGFR
- Urinalysis + urine ACR (microalbuminuria)
- FBG / HbA1c
- Lipid profile
Optional
- Renal USS if secondary cause suspected
- Echo if LVH on ECG or symptoms of HF
- Plasma aldosterone:renin ratio (primary aldosteronism)
- 24h urinary metanephrines (phaeochromocytoma)
Management
Acute
- Hypertensive emergency (>180/120 + end-organ damage): admit; IV labetalol or GTN; lower MAP by 20–25% in the first hour
- Hypertensive urgency (>180/120 without end-organ damage): oral therapy, lower BP over 24–48h
Long-term
- Target <130/80 in general; <140/90 if >65y or frail
- Reassess BP every 3–6 months once at target
- Annual fundoscopy, urinalysis, U&E, lipid review
Non-pharmacological
- DASH-style diet (fruit, vegetables, low-fat dairy)
- Sodium <2 g/day
- Weight loss to BMI <25
- Aerobic exercise ≥150 min/week
- Limit alcohol; smoking cessation
Pharmacological
| Drug | Dose | Notes |
|---|---|---|
| Ramipril (ACEi) | 5–10 mg PO once daily | Preferred in DM, CKD, post-MI. Avoid in pregnancy and bilateral RAS. |
| Losartan (ARB) | 50–100 mg PO once daily | Use if ACEi-induced cough. |
| Amlodipine (CCB) | 5–10 mg PO once daily | First-line in elderly, isolated systolic HTN, Black ethnicity. |
| Indapamide | 2.5 mg PO once daily | Thiazide-like diuretic. Monitor K+, Na+, urate. |
| Bisoprolol | 5–10 mg PO once daily | Add when CAD, post-MI, HF; not first-line for uncomplicated HTN. |
Monitoring
- Home BP log fortnightly
- U&E + creatinine 2 weeks after starting or up-titrating ACEi/ARB or diuretic
- Annual urine ACR (microalbuminuria)
Referral criteria
- Resistant hypertension (BP uncontrolled on 3 drugs including a diuretic)
- Suspected secondary HTN (young, refractory, paroxysmal, hypokalaemia)
- Pregnancy with hypertension
Complications
- Stroke (ischaemic or haemorrhagic)
- Coronary artery disease, MI, heart failure
- Chronic kidney disease
- Hypertensive retinopathy
- Aortic dissection
Special populations
- Pregnancy
- Avoid ACEi/ARB (teratogenic). First-line: labetalol, nifedipine MR, methyldopa. Target <140/90; admit if BP >160/110.
- Renal impairment
- ACEi/ARB beneficial unless K+ >5.5 or Cr rise >30% from baseline; recheck U&E within 2 weeks of starting.
- Hepatic impairment
- Most antihypertensives safe; avoid methyldopa (hepatic adverse effects).
- Elderly
- Target <140/90 (>65y). Start low, go slow. Avoid diuretic monotherapy if frail (falls risk).
- Paediatric
- BP percentile-based diagnosis. Secondary causes more common — refer to paediatric nephrology.