Protocol · WHO HEARTS

Hypertension in adults

Most people with high blood pressure feel well, so the clinic has to find them. Measure carefully, confirm the diagnosis, start treatment from a simple drug- and dose-specific protocol, and step up every month until the target is reached. Then keep people on treatment.

  • Based on WHO HEARTS
  • For doctors, clinical officers and nurses
  • Reviewed October 2026
One-page print (A4)Short course with CPD

1Who / 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.

This protocol does not cover hypertensive emergencies, secondary or resistant hypertension: refer those.

2Red 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.

Refer the same day. Hypertensive emergencies are outside this protocol.

3Assess

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.

4Classify

Diagnosis needs raised readings on two different days, unless BP is very high or there is organ damage.
Reading (mmHg)What it meansAction
180/110 or higher with symptomsPossible emergencyRefer the same day
160/100 or higherHypertension, highStart treatment today
140 to 159 or 90 to 99RaisedRecheck 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 riskHigh riskTreat: WHO recommends treatment with existing CVD and suggests it in the other groups
Below 140/90Not hypertensionLifestyle advice; recheck every 1 to 5 years

5Treat

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 doseFull doseWatch for
Amlodipine (calcium channel blocker)5 mg once daily10 mg once dailyAnkle swelling. Safe to start without blood tests. Use in pregnancy-possible women.
Lisinopril (ACE inhibitor)20 mg once daily40 mg once dailyDry cough in about 1 in 10; check creatinine and potassium. Not in pregnancy.
Losartan or telmisartan (ARB)50 mg or 40 mg100 mg or 80 mgUse if ACE inhibitor cough. Check creatinine and potassium. Not in pregnancy.
Chlorthalidone (thiazide-like)12.5 mg once daily25 mg once dailyLow potassium, more at full dose. If unavailable: hydrochlorothiazide 25 mg, then 50 mg.

A typical HEARTS sequence (WHO example protocol)

  1. Start an ACE inhibitor or ARB plus amlodipine at starting doses (two pills or one combination pill).
  2. At the next monthly visit, if still 140/90 or higher: move both to full doses.
  3. Next month, if still raised: add chlorthalidone.
  4. 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.

Beta-blockers are not first line: add one after a heart attack in the last 3 years, or for atrial fibrillation, heart failure or angina. Start a statin with BP treatment after a heart attack or stroke, or at high CVD risk (not in pregnancy). Low-dose aspirin only after heart attack or ischaemic stroke.

6Follow-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.

If systolic BP is under 110 on treatment, or the person feels faint on standing, check standing BP and reduce the dose or number of medicines. If someone is controlled on an affordable regimen already, do not switch it.

7Counsel

  • 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.

8When 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.

9Sources

  1. World Health Organization. Guideline for the pharmacological treatment of hypertension in adults. 2021.
  2. World Health Organization. HEARTS technical package for cardiovascular disease management in primary health care: evidence-based treatment protocols. 2018 (WHO/NMH/NVI/18.2).
  3. World Health Organization. Diagnosis and management of type 2 diabetes (HEARTS-D). 2020 (WHO/UCN/NCD/20.1). Used for the same-day referral signs.
  4. World Health Organization. Guideline: sodium intake for adults and children. 2012.
  5. World Health Organization. WHO Model List of Essential Medicines. 2025.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.