🩺
Protocol Β· Already diagnosed Confirmed Hypertension β€” ongoing management Everything to be done in primary care for a patient with a confirmed diagnosis β€” non-drug measures, the stepwise drug ladder, monitoring, follow-up and safety-netting β€” up to the point of referral to secondary care. Re-enter at the ladder on any follow-up where BP is not at target. NICE NG136 Β· CKS 2026.
Target <80y<140/90ABPM/HBPM <135/85
Target β‰₯80y<150/90ABPM/HBPM <145/85
T2DM / high ACR<130/80Tighter target
Drug ladderA β†’ C β†’ Dthen spironolactone
Step-up intervalEvery 4 wkadherence first
Step 4 pivotK⁺ 4.5spiro vs α/β-blocker
Foundation Non-drug Medication Monitoring Follow-up Safety-net Refer
1 Foundation

Set the blood-pressure target for this patient

Diagnosis is already confirmed (ABPM/HBPM β‰₯135/85, or clinic β‰₯140/90 with end-organ damage). Before anything else, agree the number you are treating to β€” it drives every step-up decision below.

Patient groupClinic targetABPM / HBPM
Age <80 years<140/90<135/85
Age β‰₯80 years<150/90<145/85
Type 2 diabetes<130/80<125/75
CKD + ACR β‰₯70<120–129 / <80<115–124 / <75
Postural drop / frailty / multimorbidityCheck lyingβ†’standing BP if β‰₯80y, T2DM or postural symptoms β€” significant drop = systolic β‰₯20 or diastolic β‰₯10 mmHg; then aim for the target on the standing BP. Clinical judgement over a strict number
A target makes the plan testable: at each review you either are or are not there, which removes ambiguity about whether to step up. Tighter targets in diabetes/CKD reflect their higher absolute cardiovascular and renal risk. In the very elderly or frail, over-treatment causes falls β€” the standing BP and the patient's function matter more than the headline figure.
2 Non-drug Β· every patient, continuously

Lifestyle prescription β€” a real treatment, not a delay tactic

Offer to every patient at every stage β€” before, alongside and after drugs. Each measure has a mechanism, a measurable target and a quantified BP effect. Agree one specific change today rather than reciting five.

πŸ§‚ Salt <6 g/day↓ plasma volume β†’ ↓ cardiac output. Works in everyone (renin-independent). Avoid processed food; caution K⁺ salt-substitutes if on ACEi/ARB or CKD.<6 g/day↓4–5 mmHg
πŸ₯— DASH diet↑ K⁺/Mg²⁺/Ca²⁺ β†’ vasodilation + natriuresis. Veg, fruit, whole grains, low-fat dairy; ↓ red meat & sugar.5+ portions/day↓8–14 mmHg
πŸƒ Exercise↓ peripheral resistance via endothelial NO; ↓ sympathetic tone. Even 10-min daily walks help β€” start where they are.150 min/wk↓4–9 mmHg
βš–οΈ Weight↓ insulin resistance β†’ ↓ RAAS. Frame: "losing 5 kg is like one BP tablet."BMI <25~1 mmHg / kg
🍺 AlcoholChronic intake β†’ ↑ cortisol/RAAS; binges spike BP. AUDIT-C brief intervention.≀14 u/wk↓2–4 mmHg
🚭 SmokingDoesn't lower BP directly but is the biggest modifiable CV risk. Refer stop-smoking + NRT/varenicline.Cessation↓CVD 50%/yr
β˜• CaffeineLimit excess (>4 strong coffees/day) β€” modest transient pressor effect.Moderate
😴 Sleep / OSAScreen for obstructive sleep apnoea if snoring + daytime somnolence β€” a treatable secondary contributor.STOP-BANG
Lifestyle changes alone can drop your blood pressure by as much as a tablet would. Let's pick just one to start with β€” which feels most doable for you?
Lifestyle is treatment, not a holding pattern: the DASH diet alone lowers systolic BP 8–14 mmHg β€” equivalent to a first-line drug. One specific, achievable, measurable target massively outperforms a generic list the patient will ignore. It continues after drugs start because it reduces the number of tablets ultimately needed.
Does this patient need drug treatment now?
Stage & risk decide. Lifestyle continues either way.
NO β€” lifestyle trial

Stage 1, <80y, QRISK <10%, no end-organ damage

NICE permits deferring drugs. 3-month structured lifestyle trial, then repeat BP + QRISK. If still above target or new indication appears β†’ cross into the drug ladder.

YES β€” start the ladder

Stage 2, OR Stage 1 with any indication

Treat now if: Stage 2 (any age), or Stage 1 plus end-organ damage, established CVD, renal disease, diabetes, or QRISK β‰₯10%. Begin at Step 1 below.

3 Medication Β· stepwise

The A β†’ C β†’ D drug ladder

Start at Step 1 and step up only when BP stays above target. Before every step-up: confirm adherence, re-check HBPM, and reinforce lifestyle β€” do not add a drug to compensate for one that isn't being taken. Recheck U&Es 1–2 weeks after any ACEi/ARB or spironolactone change.

Step 1 Monotherapy β€” choice depends on profile titrate to max tolerated
<55y Β· not African / Afro-Caribbean
ACEi A
Ramipril 1.25–2.5 β†’ 10 mg OD (or perindopril erbumine 4 β†’ 8 mg, or lisinopril 10 β†’ 20 mg). Switch to ARB β€” candesartan 8 β†’ 32 mg (more effective & safer than losartan) β€” if dry cough.
β‰₯55y Β· OR African / Afro-Caribbean (no DM)
CCB C
Amlodipine 5 β†’ 10 mg OD. Troublesome ankle oedema β†’ switch to lercanidipine 10 mg or felodipine. (Black + DM β†’ ARB first.)
Type 2 diabetes Β· or CKD with ACR >3 (any age)
ACEi / ARB A
Renoprotective regardless of age/ethnicity. ARB first-line in Black patients.
BP β‰₯ target after 4 wk β†’ check adherence, then ↓
Step 2 Dual therapy β€” A + C add the class not yet used
Add whichever of A or C is not already on board.
  • Combining two classes lowers BP more than doubling the dose of one.
  • ACEi + CCB has the strongest outcome evidence (ACCOMPLISH).
  • Consider a fixed-dose combination tablet (e.g. perindopril + amlodipine) to aid adherence.
BP β‰₯ target after 4 wk β†’ check adherence, then ↓
Step 3 Triple therapy β€” A + C + D thiazide-like diuretic
Add D β€” indapamide 1.5 mg MR OD (preferred over bendroflumethiazide; better CV outcomes).
  • Check U&Es + eGFR before starting and at 4–6 weeks β€” can drop K⁺/Na⁺ (stop if Na⁺ <130) and precipitate gout. Bendroflumethiazide 2.5 mg is an alternative.
  • If already on a thiazide for another reason, that counts as D β€” don't double up diuretics.
Still β‰₯ target on optimal A+C+D = resistant HTN β†’ ↓
Step 4 Resistant hypertension β€” add a 4th agent confirm true resistance first
First confirm it is real: adherence (consider urine drug screen), exclude white-coat (ABPM), exclude secondary cause. Then choose by serum potassium:
K⁺ ≀ 4.5 mmol/L
Spironolactone 25 mg OD
Most effective 4th agent (PATHWAY-2). Recheck U&Es/K⁺ at 1 month β€” esp. with ACEi/ARB.
K⁺ > 4.5 mmol/L
Ξ±-blocker (doxazosin) or Ξ²-blocker (bisoprolol)
Doxazosin IR 2–4 mg OD, or bisoprolol 2.5 mg OD (Ξ²-blocker if other indication β€” AF, IHD, HF). Doxazosin: ask about PDE5 inhibitors first.
⚠ Hyperkalaemia: ACEi/ARB + spironolactone needs close K⁺ monitoring β€” K⁺ >5.5 = stop + recheck. Still uncontrolled on 4 drugs β†’ refer (see step 7).
The age/ethnicity split reflects renin physiology: younger non-Black patients have high-renin HTN that responds to RAAS blockade (A); older and Black patients have low-renin, volume-dependent HTN best controlled by a CCB or diuretic. Ξ²-blockers are not first-line for uncomplicated HTN β€” they re-enter only at Step 4 or when separately indicated. Spironolactone is the highest-yield 4th agent because resistant HTN is frequently aldosterone-driven.
4 Monitoring

Bloods after each change β€” the "1-2-1" rule

ACEi / ARB / spironolactone β†’ U&Es within 1 week. Thiazide-like β†’ within 2 weeks. Spironolactone at Step 4 β†’ recheck at 1 month. Everyone β†’ structured review once a year.

DrugTestWhenAction threshold
ACEi / ARBU&E + K⁺ + eGFR1 weekK⁺ rise >0.5 or creatinine ↑ >30% β†’ stop + seek advice
Thiazide-likeNa⁺ + K⁺ + eGFR2 weeksK⁺ <3.5 β†’ supplement/switch Β· Na⁺ <130 β†’ stop urgently
SpironolactoneK⁺ + eGFR + Na⁺1 monthK⁺ >5.5 β†’ stop + recheck in 1 week
All antihypertensivesBP Β· U&E Β· ACR Β· QRISKAnnuallyAbove target β†’ titrate or add the next step
Most adverse events from a new antihypertensive happen in the first 1–4 weeks β€” a rising creatinine on an ACEi can signal undiagnosed renal artery stenosis, and hyperkalaemia is silent until dangerous. The blood test isn't a formality; it's how you catch harm before the patient feels it.
5 Follow-up

The review schedule

1
2–4 weeks after any change
Response & tolerability check

BP response + side effects. U&Es per the 1-2-1 rule. Titrate dose or step up if not at target and adherence is good.

2
Every 4 weeks while titrating
Step-up reviews

Continue 4-weekly until at target. Each visit: adherence β†’ HBPM β†’ lifestyle β†’ then escalate. Use HBPM diaries between visits.

3
3 months
Lifestyle-only Stage 1 patients

Repeat BP, reassess QRISK, reinforce lifestyle. Target not met β†’ start the drug ladder.

4
Annual β€” all confirmed HTN
Structured review

BP + pulse Β· U&E + ACR + eGFR Β· HbA1c Β· QRISK Β· medication & adherence review Β· complication screen Β· lifestyle & psychosocial check-in.

…at any review, if BP is still above target
πŸ” Not responding? Work through this before adding the next drug

"Apparent" resistance is usually adherence, technique or white-coat β€” not true pharmacological failure. Exclude each before escalating.

1 Β· AdherenceOpen, non-judgemental enquiry. Check pharmacy refill / prescription record. Consider once-daily / combination tablets.
2 Β· MeasurementCorrect cuff size, supported arm, both arms. Confirm with ABPM/HBPM to exclude white-coat effect.
3 Β· BP-raising drugsNSAIDs, oral steroids, COCP, venlafaxine, decongestants, liquorice, recreational stimulants, alcohol.
4 Β· Lifestyle driftSalt creep, weight gain, alcohol, reduced activity. Re-set one measurable target.
5 Β· Secondary causeYoung, abrupt, or truly resistant? Screen for Conn's, renal disease, phaeo, OSA (see refer).
6 Β· Optimise dosesAre existing drugs at maximum tolerated dose before a new one is added?
All excluded and adherent β†’ return to the ladder and step up to the next rung
6 Safety-net

Safety-netting β€” say these out loud, document them

πŸ”΄ 999 β€” all patients"Sudden severe headache unlike any before, weakness/numbness on one side, sudden vision change, chest pain, or confusion β€” call 999 immediately. Don't drive yourself; don't wait to ring us."
πŸ’Š Starting any drug"You may feel dizzy when standing, especially in week one β€” move slowly. If you feel faint, call us β€” but don't stop the tablet without speaking to us first."
🟠 On an ACEi"A dry tickly cough isn't dangerous β€” don't stop, ring us and we'll switch. But swelling of lips/tongue/throat is different β€” call 999."
βš–οΈ On a diuretic / spiro"If you get a vomiting-and-diarrhoea illness, pause these for 48h ('sick-day rules') and call us β€” they can affect your kidneys when you're dehydrated."
Naming the exact symptom and the exact action ("call 999", not "seek help") produces faster patient-activated escalation and is medico-legally protective β€” documented specific advice is a defence if the patient later deteriorates. Pre-warning about the ACEi cough prevents needless off-class switching; angioedema counselling is potentially life-saving.
when primary-care management is exhausted or a red flag appears
7 Refer to secondary care

When to step beyond primary care

Manage everything above in primary care first. Refer when you hit a ceiling or a red flag β€” keep treating in the interim unless instructed otherwise, and tell the patient the reason and what to expect.

Same-day / emergencyAccelerated HTN (papilloedema / retinal haemorrhage); BP β‰₯180/120 with new chest pain, breathlessness, neuro signs or AKI; suspected phaeo crisis; pregnancy β‰₯20 wk with BP β‰₯140/90.
Resistant HTNAbove target on optimal A + C + D + 4th agent, once adherence and white-coat are excluded β†’ specialist hypertension clinic.
Suspected secondary causeHypokalaemia + HTN (Conn's); abdominal bruit / rapid eGFR fall (renal artery stenosis); paroxysmal sweating/palpitations (phaeo); resistant OSA.
Young patientAge <40 with confirmed hypertension β€” secondary screen and specialist assessment.
Specialist input neededIntolerance to multiple classes; eGFR <30 needing RAAS drugs; pregnancy / pre-conception planning; HTN with significant end-organ disease.
I've taken your treatment as far as we safely can here, so I'm referring you to a specialist who can run some extra tests and fine-tune things. We'll keep your current tablets going while you wait.
Educational use only. Management pathway anchored to NICE NG136 and NICE CKS (2026). This is a static reference for an already-confirmed diagnosis β€” it does not replace clinical judgement, the patient's individual context, or your local prescribing formulary. Always verify drugs and doses against the current BNF.