Hypertension — Protocol

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Protocol · Already diagnosed Confirmed Hypertension — ongoing management Everything to be done in primary care for a patient with a confirmed diagnosis — non-drug measures, the stepwise drug ladder, monitoring, follow-up and safety-netting — 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 · CKS 2026.

Target <80y<140/90ABPM/HBPM <135/85

Target ≥80y<150/90ABPM/HBPM <145/85

CKD + DM / ACR ≥70<130/80T2DM alone: <140/90

Drug ladderA → C → 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 ≥135/85, or clinic ≥140/90 with end-organ damage). Before anything else, agree the number you are treating to — it drives every step-up decision below.

Patient group	Clinic target	ABPM / HBPM
Age <80 years	<140/90	<135/85
Age ≥80 years	<150/90	<145/85
Type 2 diabetes (no CKD)	<140/90 (<80y — NG136 unified in 2019)	<135/85
CKD + diabetes, or CKD + ACR ≥70	<130/80 (NG203)	systolic 120–129
Postural drop / frailty / multimorbidity	Check lying→standing BP if ≥80y, T2DM or postural symptoms — significant drop = systolic ≥20 or diastolic ≥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 — the standing BP and the patient's function matter more than the headline figure.

2 Non-drug · every patient

Lifestyle prescription — a real treatment, not a delay tactic

Offer to every patient at every stage — 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.

🧂 Salt <6 g/day↓ plasma volume → ↓ 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

🥗 DASH diet↑ K⁺/Mg²⁺/Ca²⁺ → vasodilation + natriuresis. Veg, fruit, whole grains, low-fat dairy; ↓ red meat & sugar.5+ portions/day↓8–14 mmHg

🏃 Exercise↓ peripheral resistance via endothelial NO; ↓ sympathetic tone. Even 10-min daily walks help — start where they are.150 min/wk↓4–9 mmHg

⚖️ Weight↓ insulin resistance → ↓ RAAS. Frame: "losing 5 kg is like one BP tablet."BMI <25~1 mmHg / kg

🍺 AlcoholChronic intake → ↑ 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

☕ CaffeineLimit excess (>4 strong coffees/day) — modest transient pressor effect.Moderate

😴 Sleep / OSAScreen for obstructive sleep apnoea if snoring + daytime somnolence — 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 — which feels most doable for you?

Lifestyle is treatment, not a holding pattern: the DASH diet alone lowers systolic BP 8–14 mmHg — 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 — 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 → cross into the drug ladder.

YES — 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 ≥10%. Begin at Step 1 below.

3 Medication · stepwise

The A → C → 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 — 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 — choice depends on profile titrate to max tolerated

<55y · not African / Afro-Caribbean

ACEi A

Ramipril 1.25–2.5 → 10 mg OD (or perindopril erbumine 4 → 8 mg, or lisinopril 10 → 20 mg). Switch to ARB — candesartan 8 → 32 mg (more effective & safer than losartan) — if dry cough.

≥55y · OR African / Afro-Caribbean (no DM)

CCB C

Amlodipine 5 → 10 mg OD. Troublesome ankle oedema → switch to lercanidipine 10 mg or felodipine. (Black + DM → ARB first.)

Type 2 diabetes · or CKD with ACR >3 (any age)

ACEi / ARB A

Renoprotective regardless of age/ethnicity. ARB first-line in Black patients.

BP ≥ target after 4 wk → check adherence, then ↓

Step 2 Dual therapy — 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 ≥ target after 4 wk → check adherence, then ↓

Step 3 Triple therapy — A + C + D thiazide-like diuretic

Add D — indapamide 1.5 mg MR OD (preferred over bendroflumethiazide; better CV outcomes).

Check U&Es + eGFR before starting and at 4–6 weeks — 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 — don't double up diuretics.

Still ≥ target on optimal A+C+D = resistant HTN → ↓

Step 4 Resistant hypertension — 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 — esp. with ACEi/ARB.

K⁺ > 4.5 mmol/L

α-blocker (doxazosin) or β-blocker (bisoprolol)

Doxazosin IR 2–4 mg OD, or bisoprolol 2.5 mg OD (β-blocker if other indication — AF, IHD, HF). Doxazosin: ask about PDE5 inhibitors first.

⚠ Hyperkalaemia: ACEi/ARB + spironolactone needs close K⁺ monitoring — K⁺ >5.5 = stop + recheck. Still uncontrolled on 4 drugs → 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. β-blockers are not first-line for uncomplicated HTN — 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 — the "1-2-1" rule

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

Drug	Test	When	Action threshold
ACEi / ARB	U&E + K⁺ + eGFR	1 week	K⁺ rise >0.5 or creatinine ↑ >30% → stop + seek advice
Thiazide-like	Na⁺ + K⁺ + eGFR	2 weeks	K⁺ <3.5 → supplement/switch · Na⁺ <130 → stop urgently
Spironolactone	K⁺ + eGFR + Na⁺	1 month	K⁺ >5.5 → stop + recheck in 1 week
All antihypertensives	BP · U&E · ACR · QRISK	Annually	Above target → titrate or add the next step

Most adverse events from a new antihypertensive happen in the first 1–4 weeks — 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

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.

Every 4 weeks while titrating

Step-up reviews

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

3 months

Lifestyle-only Stage 1 patients

Repeat BP, reassess QRISK, reinforce lifestyle. Target not met → start the drug ladder.

Annual — all confirmed HTN

Structured review

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

…at any review, if BP is still above target

🔁 Not responding? Work through this before adding the next drug

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

1 · AdherenceOpen, non-judgemental enquiry. Check pharmacy refill / prescription record. Consider once-daily / combination tablets.

2 · MeasurementCorrect cuff size, supported arm, both arms. Confirm with ABPM/HBPM to exclude white-coat effect.

3 · BP-raising drugsNSAIDs, oral steroids, COCP, venlafaxine, decongestants, liquorice, recreational stimulants, alcohol.

4 · Lifestyle driftSalt creep, weight gain, alcohol, reduced activity. Re-set one measurable target.

5 · Secondary causeYoung, abrupt, or truly resistant? Screen for Conn's, renal disease, phaeo, OSA (see refer).

6 · Optimise dosesAre existing drugs at maximum tolerated dose before a new one is added?

All excluded and adherent → return to the ladder and step up to the next rung

6 Safety-net

Safety-netting — say these out loud, document them

🔴 999 — all patients"Sudden severe headache unlike any before, weakness/numbness on one side, sudden vision change, chest pain, or confusion — call 999 immediately. Don't drive yourself; don't wait to ring us."

💊 Starting any drug"You may feel dizzy when standing, especially in week one — move slowly. If you feel faint, call us — but don't stop the tablet without speaking to us first."

🟠 On an ACEi"A dry tickly cough isn't dangerous — don't stop, ring us and we'll switch. But swelling of lips/tongue/throat is different — call 999."

⚖️ On a diuretic / spiro"If you get a vomiting-and-diarrhoea illness, pause these for 48h ('sick-day rules') and call us — 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 — 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

✚ Confirm · don't miss

Masked hypertension & the ≥180/120 rules

Situation	What it means / do
Masked hypertension	Normal clinic but high ABPM/HBPM — same risk as sustained HTN. Suspect in high-CV-risk patients with end-organ damage; don't be reassured by a good clinic reading.
≥180/120 + signs	Retinal haemorrhage/papilloedema or chest pain/HF/AKI/neuro → same-day admission (accelerated hypertension).
≥180/120, no signs	Urgent bloods + ACR + ECG, start/intensify treatment, repeat within 7 days — not 999, not routine.
Pregnancy ≥20wk, ≥140/90	Same-day obstetric assessment (pre-eclampsia).

✚ Medication · side effects

Fix the side effect — keep the class working

Side effect	Drug	Fix
Dry cough (~10–15%)	ACEi	Switch to ARB (candesartan); warn at initiation so they don't just stop
Angioedema	ACEi	STOP permanently; 999 if airway; ARB only with specialist advice
Ankle oedema	Amlodipine	Diuretic-resistant → switch to lercanidipine; adding the ACEi helps
Gout flare	Indapamide	Treat flare; consider swapping D; losartan is mildly uricosuric
Hyponatraemia	Thiazide-like	Na⁺ <130 → stop; use another class
Gynaecomastia	Spironolactone	Switch to eplerenone (specialist) or the K⁺>4.5 arm
Erectile dysfunction	Thiazides, β-blockers	Silent non-adherence cause; ACEi/ARB/CCB more neutral; PDE5i safe (not with doxazosin)

✚ Secondary causes

Screen with the right first-line test

Suspect when	Cause	First-line test
Low K⁺, resistant HTN	Primary aldosteronism (Conn's)	Aldosterone:renin ratio → endocrine
Creatinine ↑>30% on ACEi, bruit, flash oedema	Renal artery stenosis	Renal Doppler / MRA
Paroxysmal headache + sweating + palpitations	Phaeochromocytoma	Plasma metanephrines → endocrine
Snoring + somnolence + resistant	Obstructive sleep apnoea	STOP-BANG → sleep study
Central obesity, striae, proximal weakness	Cushing's	Overnight dexamethasone suppression
Young, radio-femoral delay, differential BP	Coarctation	Echo / CT aorta

Screen if: age <40 with confirmed HTN, abrupt onset, or truly resistant (uncontrolled on 4 drugs, adherence + white-coat excluded). Do the first-line test in primary care before referring.

✚ Special groups & CV risk

Populations that change the plan + treat the risk

Group	What changes
Statin / CV risk	QRISK3 ≥10% → atorvastatin 20mg (80mg if established CVD). No aspirin for primary prevention. Treating BP but not lipids is half a job.
Pregnancy / pre-conception	Stop ACEi/ARB/thiazide BEFORE conception → labetalol / nifedipine MR / methyldopa; aspirin 75–150mg from 12wk if risk factors.
Black African / Caribbean	CCB or ARB (not ACEi) first-line; ARB preferred over ACEi; DM → ARB.
CKD	ACEi/ARB to max if ACR≥3 + SGLT2i; target <130/80 if ACR≥70; stable creatinine rise ≤30% acceptable.
Elderly / frail	Treat to STANDING BP; deprescribe/relax if postural symptoms or falls — over-treatment harms here.

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 — 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 ≥180/120 with new chest pain, breathlessness, neuro signs or AKI; suspected phaeo crisis; pregnancy ≥20 wk with BP ≥140/90.

Resistant HTNAbove target on optimal A + C + D + 4th agent, once adherence and white-coat are excluded → 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 — 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 — 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.