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New presentation of high blood pressure Clinic BP ≥140/90 mmHg in an adult, no prior diagnosis. Use this pathway through a single 12-minute consultation.
Progress 0 / 9
The full reasoning pathway — confirm with ABPM/HBPM (not one clinic reading), exclude the accelerated/secondary emergency, stage and risk-stratify, treat by NG136 stepwise drugs to a target, prescribe lifestyle, and monitor.StartDecisionInvestigateActionReferStop / Admit
Presentation · clinic BP bandsRaised blood pressure
<140/90 normotensive (recheck ≥5-yearly) · 140–179 / 90–119 → confirm with ABPM/HBPM · ≥180/120 = severe. Repeat if clinic ≥140/90; if 2nd reading differs, take a 3rd and record the lowest. Measure both arms (use higher if difference >15 mmHg).
Step 1 · Safety — exclude the emergencyBP ≥180/120 with red flags?
  • Accelerated (malignant) hypertension — papilloedema or retinal haemorrhages
  • Phaeochromocytoma — labile BP, headache, palpitations, pallor, sweating
  • Target-organ emergency — new confusion/neurology, chest pain, heart failure, AKI
  • Pregnancy ≥20 wk + BP ≥140/90 → ?pre-eclampsia
YES — red flag
Stop · same-daySame-day assessment
Accelerated HTN / phaeochromocytoma → same-day specialist; pre-eclampsia → obstetric emergency. If ≥180/120 but asymptomatic with no red flags: assess for target-organ damage ASAP — present → treat immediately without waiting for ABPM; absent → repeat clinic BP within 7 days.
NO — 140–179/90–119
Step 2 · InvestigateABPM/HBPM + risk + end-organ
ABPM (≥14 daytime readings) or HBPM (2 readings twice daily, ≥4 days, discard day 1). ECG, urine ACR + dip (haematuria), U&E, HbA1c, lipids, fundoscopy; QRISK3. Check a postural drop if ≥80, T2DM or postural symptoms.
Step 3 · stage by ABPM/HBPM average
Stage 1 · ABPM ≥135/85
Treat by age & risk
Offer drugs if <80 with target-organ damage, established CVD, renal disease, diabetes, or QRISK ≥10%. Discuss drugs if QRISK <10% (esp. <60). Lifestyle for all.
Stage 2 · ABPM ≥150/95
Offer drugs at any age
Offer antihypertensive treatment regardless of age (account for frailty and multimorbidity).
Step 7 · NG136 stepwise drug ladder
Step 7 · Action — drug ladder & targetsStep up every 4 weeks until target reached
  • Step 1 by profile: <55 & not African/Caribbean, or any-age T2DM → A (ACEi e.g. ramipril; ARB if cough/African-Caribbean). ≥55 or African/Caribbean (no T2DM) → C (amlodipine).
  • Step 2: A + C. Step 3: A + C + D (thiazide-like diuretic, indapamide). Check U&E 1–2 weeks after starting/up-titrating A or spironolactone.
  • Step 4 (resistant): confirm adherence; if K⁺ ≤4.5 add spironolactone, if >4.5 add alpha- or beta-blocker → specialist.
  • Targets: clinic <140/90 (ABPM/HBPM <135/85) if <80; clinic <150/90 (HBPM <145/85) if ≥80. Add a statin for primary prevention if QRISK ≥10%.
Step 6 · escalation thresholds
Step 6 · ReferEscalation thresholds
  • Same-day accelerated hypertension (papilloedema), phaeochromocytoma, pregnancy ≥20 wk + ≥140/90, BP ≥180/120 with target-organ symptoms.
  • Specialist resistant hypertension on ≥3 drugs, suspected secondary cause (Conn's, renal artery stenosis, Cushing's), or age <40 with stage 2 (risk tools underestimate lifetime risk).
  • Primary care stable, no red flags → manage and monitor per below.
Step 8 · lifestyle prescription
Step 8 · Lifestyle — measurable targets (≈10–15 mmHg)Lifestyle is treatment, not a delay
Salt <6 g/day · DASH/Mediterranean diet · weight loss to BMI <25 · alcohol ≤14 u/wk · 150 min/wk aerobic activity · stop smoking · reduce caffeine. Set one specific target, not five — combined effect rivals a single drug.
Step 9 · monitor & safety-net
Step 9 · Monitoring & safety-netWhat to recheck, when to return
Recheck: U&E 1–2 wks after ACEi/ARB or spironolactone (stop if K⁺ >5.5 or creatinine ↑>30%); HBPM at 4 wks and step up if not at target; annual BP, U&E, ACR, QRISK and lifestyle review. Call 999 if sudden severe headache, focal weakness, vision loss or chest pain.
⚠️ Diagnose with ABPM/HBPM, not a single clinic reading (clinic readings are for screening & assessing response). Stage 1 ABPM ≥135/85; stage 2 ≥150/95. Always check a postural drop in the elderly/diabetic to avoid over-treatment and falls.
1
Safety

Rule out hypertensive emergency first

If any of the boxes below are present → same-day medical assessment / 999 if neurology, chest pain, or BP >180/120 with target-organ symptoms. Otherwise continue.
BP ≥180/120 + new headache, vision change, focal weakness, chest pain, breathlessness
Suspected phaeo sweating, tremor, paroxysms, palpitations
Pregnancy >20w BP ≥140/90 — same-day obstetric review (?pre-eclampsia)
Papilloedema / retinal haemorrhage on fundoscopy
Acute kidney injury rising creatinine, oliguria
Aortic dissection signs tearing chest pain, BP arm-to-arm difference
Severe HTN with target-organ symptoms is a medical emergency. Untreated, mortality at 1 year was historically >90%. The point of this step is to not start chronic-pathway thinking in someone who needs same-day specialist input.
2
Diagnose

Confirm with ABPM (or HBPM if declined)

Do not treat on a single clinic reading. Repeat BP in clinic. If still ≥140/90, arrange:
1st line
ABPM 24-hour, ≥14 daytime readings averaged.
If declined
HBPM 7 days, BD, discard day 1, average the rest.
Diagnostic ≥
135/85 mmHg average (= clinic 140/90).
White-coat effect overdiagnoses ~25% of clinic HTN. ABPM/HBPM removes that. NICE NG136 mandates confirmation before chronic treatment unless ≥180/120 with target-organ damage.
3
Diagnose

Stage the confirmed hypertension

Stage 1
Clinic 140/90 · ABPM/HBPM 135/85 – 149/94. Treat if <80y AND target-organ damage, CVD, renal disease, diabetes, or QRISK ≥10%.
Stage 2
Clinic ≥160/100 · ABPM/HBPM ≥150/95. Treat all adults regardless of age.
Stage 3 (severe)
Clinic ≥180/120. Same-day specialist if any target-organ symptoms; otherwise treat immediately + investigate.
Staging determines whether to treat at all. Many stage 1 patients under 60 with low QRISK do not need lifelong tablets — lifestyle alone is the right answer.
4
Diagnose

Targeted examination

BP both arms
Difference >15 mmHg → vascular disease / coarctation. Use the higher arm thereafter.
Standing BP
If ≥80y, frail, T2DM, postural symptoms. Drop ≥20/10 → postural hypotension.
Fundi
Look for hypertensive retinopathy, esp. if severe HTN. Papilloedema = same-day.
Cardiac
Apex displacement, S4, murmurs — LVH or aortic disease.
Renal bruits
Especially if young, resistant HTN, or rapid eGFR fall → renal artery stenosis.
BMI + waist
Quantify the modifiable target.
Examination here is not screening — it's looking for findings that change the plan: secondary cause triggers, target-organ damage, and orthostasis (which changes drug choice).
5
Diagnose

Baseline investigations (do them all)

Bloods
U&Es eGFR HbA1c Lipid profile (non-fast)
Urine
ACR Dipstick (blood)
ECG
LVH (Sokolow-Lyon), prior MI, AF.
QRISK3
10-year CVD risk — needed for stage 1 decision and for statin discussion.
Consider
Aldosterone:renin if <40y or resistant. TFTs if symptomatic. Renal US if abnormal U&Es.
U&Es are mandatory before ACEi/ARB (and within 1–2 weeks of starting). ACR proves microalbuminuria — itself a treatment indication. ECG + QRISK quantify the risk you are trying to reduce.
6
Refer

Screen for secondary hypertension — refer when

Refer specialist
Age <40 with stage 2 Resistant on ≥3 drugs Hypokalaemia + HTN Abdominal bruit Paroxysmal symptoms
Same-day
Accelerated HTN (papilloedema) Pregnancy ≥20w + ≥140/90 BP ≥180/120 with target-organ symptoms
Routine
Stable, no red flags → manage in primary care, follow steps 7–9.
~10% of HTN has a secondary cause. Missing Conn's, phaeochromocytoma, or renal artery stenosis means treating the wrong target. Resistant or young HTN is the highest-yield trigger.
7
Treat

Drug ladder — Step 1 splits by profile, Steps 2–4 are linear

Start at Step 1. Step up every 4 weeks until target reached. Check U&Es within 1–2 weeks of any ACEi/ARB or spironolactone change.
Step 1 · <55 yrs, not African / Afro-Caribbean
ACEi A
Ramipril 2.5–10 mg od. Switch to ARB if cough.
Step 1 · ≥55 yrs, OR African / Afro-Caribbean (any age, no DM)
CCB C
Amlodipine 5–10 mg od. Switch to thiazide-like (indapamide) if oedema or HF.
Step 1 · Type 2 diabetes (any age, any ethnicity)
ACEi or ARB A
Renoprotective. Choose ARB first-line in African / Afro-Caribbean.
Step 2A + C   or   A + D (thiazide-like diuretic — indapamide).
Step 3A + C + D   — confirm adherence and HBPM before progressing.
Step 4 · K⁺ ≤ 4.5Add spironolactone 25 mg od. Recheck U&Es at 1 month. Specialist if still uncontrolled.
Step 4 · K⁺ > 4.5Add alpha-blocker (doxazosin) or beta-blocker (bisoprolol). Refer if uncontrolled.
Renin physiology drives the age/ethnicity split: younger non-Black patients have high-renin HTN responsive to RAAS blockade; older / Black patients have low-renin HTN best controlled with volume reduction (CCB or thiazide). Beta-blockers are not first-line for uncomplicated HTN.
8
Lifestyle

Lifestyle prescription — measurable targets

Lifestyle alone can drop systolic BP 10–15 mmHg — equivalent to one drug. Set one target, not five.
Salt < 6 g / day. Avoid processed food, check labels.
Activity 150 min / week moderate. Brisk walking counts.
Alcohol ≤ 14 units / week, spread, with alcohol-free days.
Weight Aim BMI < 25; 5–10% loss = meaningful BP fall.
Diet DASH-style: vegetables, fruit, low-fat dairy, lean protein.
Caffeine Limit excess (> 4 strong coffees / day).
Smoking Refer to local stop-smoking service.
Sleep Screen for OSA if snoring + daytime somnolence.
Lifestyle is not a delay tactic — it is treatment. The DASH diet alone reduces SBP ~8–14 mmHg. One specific, achievable target outperforms a list of platitudes.
9
Safety

Follow-up + safety-net

1–2 weeks
U&Es after ACEi/ARB or spironolactone. K⁺ > 5.5 or Cr ↑ >30 % → stop, recheck, specialist.
4 weeks
Review HBPM. If not at target < 135/85, step up.
Annually
BP, U&Es, ACR, QRISK, lifestyle reinforcement.
Safety-net 999
Sudden severe headache Focal weakness Vision loss Chest pain Breathlessness
Safety-net same-day GP
Postural dizziness, persistent cough on ACEi, swollen ankles on CCB.
Most adverse events from new HTN drugs happen in the first 2–4 weeks. Naming what to watch for protects the patient and documents your safety-netting in the notes.
Educational use. Pathway anchored to NICE NG136 and NICE CKS (2026). Always verify against current local guidance and the patient's individual context — this is a reference tool, not a substitute for clinical judgement.