Who / when
- Adults (18 and over) who are not pregnant. Raised BP in pregnancy: follow your national antenatal protocol.
- Measure blood pressure in every adult at their first visit, then every 1 to 5 years if normal.
- Check more often in people with a previous heart attack or stroke, diabetes, chronic kidney disease, obesity, tobacco use, or a family history of heart attack or stroke.
Red flags: refer now
- BP 180/110 or higher with headache, breathlessness, blurred vision, confusion, nausea or vomiting, or reduced urine output.
- Signs of a stroke: new weakness, numbness, difficulty speaking or facial droop.
- Chest pain or other signs of coronary heart disease.
- Very high BP with signs of organ damage.
Assess
Measure it properly
- Seated with back supported, legs uncrossed, bladder empty, rested and silent for 5 minutes.
- Use the right cuff: a large cuff if the upper arm is over 32 cm round.
- A validated automated device is best where there is power or batteries; otherwise a manual cuff and stethoscope.
- First time: measure at least twice, a few minutes apart, and record the second reading.
Look for risk and damage
- Ask about smoking, diabetes, previous heart attack, stroke or kidney disease, medicines, and pregnancy plans.
- Weight, waist, pulse, heart, chest, ankles.
- If available and it will not delay treatment: creatinine and electrolytes, lipids, HbA1c or fasting glucose, urine dipstick, ECG.
Classify
Diagnosis needs raised readings on two different days, unless BP is very high or there is organ damage.| Reading (mmHg) | What it means | Action |
|---|
| 180/110 or higher with symptoms | Possible emergency | Refer the same day |
| 160/100 or higher | Hypertension, high | Start treatment today |
| 140 to 159 or 90 to 99 | Raised | Recheck on another day (usually within 1 to 4 weeks). If still raised, diagnose and start treatment within 4 weeks |
| 130 to 139 systolic, with heart disease, previous stroke, diabetes, kidney disease or high CVD risk | High risk | Treat: WHO recommends treatment with existing CVD and suggests it in the other groups |
| Below 140/90 | Not hypertension | Lifestyle advice; recheck every 1 to 5 years |
Treat
Use your national drug- and dose-specific protocol. WHO first-line classes are a thiazide or thiazide-like diuretic, an ACE inhibitor or ARB, and a long-acting dihydropyridine calcium channel blocker. WHO suggests starting with two medicines, ideally as a single-pill combination.
Example doses from the WHO HEARTS protocols (2018). Your national protocol and formulary take precedence.| Medicine (EML class) | Starting dose | Full dose | Watch for |
|---|
| Amlodipine (calcium channel blocker) | 5 mg once daily | 10 mg once daily | Ankle swelling. Safe to start without blood tests. Use in pregnancy-possible women. |
| Lisinopril (ACE inhibitor) | 20 mg once daily | 40 mg once daily | Dry cough in about 1 in 10; check creatinine and potassium. Not in pregnancy. |
| Losartan or telmisartan (ARB) | 50 mg or 40 mg | 100 mg or 80 mg | Use if ACE inhibitor cough. Check creatinine and potassium. Not in pregnancy. |
| Chlorthalidone (thiazide-like) | 12.5 mg once daily | 25 mg once daily | Low potassium, more at full dose. If unavailable: hydrochlorothiazide 25 mg, then 50 mg. |
A typical HEARTS sequence (WHO example protocol)
- Start an ACE inhibitor or ARB plus amlodipine at starting doses (two pills or one combination pill).
- At the next monthly visit, if still 140/90 or higher: move both to full doses.
- Next month, if still raised: add chlorthalidone.
- Still raised: check the tablets are being taken correctly and regularly; if they are, refer.
PregnancyWomen who could become pregnant and are not using effective contraception: avoid ACE inhibitors, ARBs and thiazides; use amlodipine and refer if not controlled at full dose (HEARTS). If she is pregnant: stop ACE inhibitors, ARBs and thiazides and follow your antenatal protocol; for non-severe hypertension in pregnancy WHO (2020) favours methyldopa or a beta-blocker and advises avoiding calcium channel blockers.
Follow-up
- Every month after starting or changing treatment, until at target.
- Then every 3 to 6 months once controlled.
- Targets: below 140/90 for most people; systolic below 130 with heart disease or previous stroke (WHO also suggests this with diabetes, kidney disease or high CVD risk).
- Each visit: BP, adherence, side effects, supply of medicines.
- Check creatinine and potassium before and some weeks after starting an ACE inhibitor, ARB or diuretic, where available.
Counsel
- High BP usually has no symptoms: take the tablets every day, even when you feel well.
- Tablets for BP are long-term; they are not for headaches.
- Less salt: under 5 g a day (just under one teaspoon), including salt in food.
- Stop tobacco and avoid others' smoke; avoid harmful alcohol.
- Move more: about 150 minutes of brisk walking a week. Lose weight if overweight.
- Eat at least 5 portions of fruit and vegetables a day.
- Keep a supply of tablets at home; come back before they run out.
Your blood pressure is high. You will not feel it, but over years it damages the heart, brain and kidneys. These tablets protect you, so take them every day, even when you feel well.
When to refer
- Same day: any red flag above.
- Not at target on the full protocol, with tablets taken correctly.
- Serious side effects, or a major new medical problem.
- Suspected secondary or resistant hypertension.
- Any pregnant woman with raised BP (see the pre-eclampsia protocol), or a woman who may become pregnant not controlled on full-dose amlodipine.
Sources
World Health Organization. Guideline for the pharmacological treatment of hypertension in adults. 2021. World Health Organization. HEARTS technical package for cardiovascular disease management in primary health care: evidence-based treatment protocols. 2018. World Health Organization. Diagnosis and management of type 2 diabetes (HEARTS-D). 2020. World Health Organization. Guideline: sodium intake for adults and children. 2012. World Health Organization. WHO Model List of Essential Medicines. 2025.