Hypertension: Management

Key points

• Stages: stage 1 clinic ≥ 140/90 and ABPM/HBPM ≥ 135/85 · stage 2 clinic ≥ 160/100 and ABPM/HBPM ≥ 150/95 · severe clinic BP ≥ 180/120 mmHg
• Treat stage 1 if < 80 y AND any of: target organ damage, established CVD, renal disease, diabetes, or 10-year CV risk ≥ 10% · also consider treatment if < 60 y with 10-year risk < 10% · treat stage 2 at any age · < 40 y: consider specialist referral for secondary causes
• Lifestyle: salt < 6 g/day (ideally 3 g; UK average 8-12 g; cutting 6 g/day lowers SBP by 10 mmHg) · reduce caffeine · stop smoking, less alcohol, exercise, lose weight
• Drugs: step 1 A (ACE inhibitor or ARB if < 55 y, or type 2 diabetes at any age) or C (CCB if ≥ 55 y without T2DM, or Black African/African-Caribbean family origin of any age without T2DM) → step 2 A+C or A+D → step 3 A+C+D (thiazide-like: indapamide in preference to bendroflumethiazide)
• Resistant HTN = clinic ≥ 140/90 on optimal A+C+D — first confirm with ABPM/HBPM, assess postural hypotension and check adherence · step 4: K ≤ 4.5 mmol/l add low-dose spironolactone · K > 4.5 add an alpha- or beta-blocker · targets < 80 y: 140/90 (135/85 ABPM); ≥ 80 y: 150/90 (145/85 ABPM)

Decision points in this pathway

• Stage 2 hypertension (or severe)?
• Step 1 — aged under 55 and no type 2 diabetes?
• Step 4 — potassium ≤ 4.5 mmol/l?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.