1. Managing hypertension in primary care
Clinical Knowledge Summaries CKS Hypertension (not people with diabetes)
Managing hypertension in primary care
Educational slides based on the CKS topic; Hypertension – not diabetic (April 2012), and NICE guidance (2011); Hypertension: clinical management of primary hypertension in adults.

2. Key learning points and objectives
To be able to:
Describe the benefits of lowering blood pressure.
Outline which antihypertensives should be prescribed initially.
Describe when to continue or stop a beta-blocker.
Describe how to adjust treatment.
Recognise when referral or admission is required.

3. If BP is very high in clinic?
Arrange same-day admission if:
BP is 220/120 mmHg or higher.
BP is 180/110 mmHg or higher with signs of accelerated (malignant) hypertension (papilloedema and/or retinal haemorrhage).
Start antihypertensives immediately if no signs of accelerated hypertension and:
Systolic BP is 180 mmHg or higher, or 
Diastolic BP is 110 mmHg or higher.

4. Management following ABPM and HBPM
Offer antihypertensive treatment if the person is:
Younger than 80 years with stage 1 hypertension and has one or more of the following:
Target organ damage, established cardiovascular disease, renal disease, diabetes, and/or a 10 year cardiovascular risk of 20% or more.
Any age with stage 2 hypertension.

5. Initial management For all people with hypertension:
Assess and manage cardiovascular risk.
Reinforce lifestyle advice such as:
Stopping smoking.
Moderation in alcohol, salt, and caffeine consumption.
Give advice on weight loss (if appropriate).

6. Life style and non-drug measures
Advise:
Moderation in alcohol consumption.
Moderation in consumption of coffee and other caffeine-rich products.
Reducing salt consumption, or using a salt substitute.
Stopping smoking — offer referral to smoking cessation services.
About local initiatives that provide support and promote lifestyle change (e.g. run by healthcare teams or patient organizations).

7. Life style and non-drug measures
Advise that:
Sustained relaxation therapies may reduce BP (e.g. stress management, meditation).
Information on self-care can be obtained from the Blood Pressure Association (
Consider offering referral for:
Smoking cessation.
Exercise and physical activity programmes.
Weight loss programmes.
Dietary advice.

8. Benefits of antihypertensives in general
People using antihypertensives can expect:
To extend their life by between 8 and 11 months if they are 50 years of age.
To extend their life by between 3 and 5 months if they are 70 years of age.
Greater absolute risk reductions if they have higher baseline risks for coronary heart disease or stroke.
Greater risk reduction for stroke than for coronary heart disease.

9. Target clinic blood pressures
Target clinic blood pressures (BP):
Aim for a BP lower than 140/90 mmHg for people under 80 years.
Aim for a BP lower than 150/90 mmHg for people 80 years and older.

10. Starting antihypertensives
If younger than 55 years of age (not of black African or Caribbean ethnic origin) start:
An angiotensin-converting enzyme (ACE) inhibitor, or
A low-cost angiotensin II receptor antagonist (AIIRA).
If ACE inhibitors or AIIRAs are not suitable:
Start a low-dose thiazide-type diuretic or a calcium channel blocker (CCB).
A beta-blocker can be considered as initial treatment for:
Younger people who cannot use or tolerate ACE inhibitors and AIIRAs.
Women who might become pregnant or are planning a pregnancy.
People with evidence of increased sympathetic drive (e.g. sweating).

11. Starting antihypertensives
If 55 years of age or older and of black African or Caribbean ethnic origin (any age):
Offer a CCB, or
A low-dose thiazide-type diuretic, if:
A CCB is not suitable (e.g. oedema or intolerant),
There is heart failure, or
A high risk of heart failure.
If aged 80 years and older:
Offer the same treatment as people aged 55 years and older.
Take into account any co-morbidities and other drugs being taken.
For people with isolated systolic hypertension:
Offer the same treatment as people with both raised systolic and diastolic blood pressure (BP).

12. On a beta-blocker for another indication
If BP is well controlled and:
There is a compelling indication for a beta-blocker (e.g. symptomatic angina), continue the beta-blocker.
There is no compelling indication for a beta-blocker, discuss and consider adding or switching to another antihypertensive drug, according to the stepwise approach.
Always gradually step the dose down if stopping a beta-blocker.

13. On a beta-blocker for another indication
If BP is not controlled:
Consider continuing the beta-blocker and adding a new antihypertensive drug according to the stepwise approach.
If a beta-blocker is being considered for long-term use with a thiazide diuretic:
Discuss with the person the benefits of treatment versus the risk of developing diabetes.

14. Which antihypertensive?
NICE recommend using an ACE inhibitor, an AIIRA, a calcium channel blocker, or a beta blocker that can be taken once a day, is generic, and minimizes cost.

15. Calcium channel blockers
If a rate-limiting calcium-channel blocker is being considered:
Once-daily formulations of diltiazem or verapamil are recommended.
Do not prescribe verapamil with a beta-blocker
Risk of reduced cardiac output and heart failure.
Diltiazem can be used with caution with a beta-blocker:
It has a smaller negative inotropic effect than verapamil.
Monitor the person's pulse and blood pressure carefully due to the risk of bradycardia.

16. Which thiazide diuretic?
If already taking bendroflumethiazide and BP is well controlled, continue treatment with this.
If starting a thiazide-type diuretic:
Indapamide or chlortalidone are preferred because there is most trial data to support their use.
NICE found a lack of trial data to support bendroflumethazide, but could not confirm that it was ineffective.

17. Follow up If being treated with lifestyle measures only, follow up:
Every 3 or 4 months, until blood pressure is well controlled, or antihypertensive drug treatment is started.
Annually, when the blood pressure is well controlled.

18. Follow up When starting drug treatment:
Recheck BP every 4 weeks.
If starting a thiazide diuretic:
Check urea and electrolytes, and the eGFR at baseline and every 4-6 weeks.
If starting an ACE inhibitor or an AIIRA:
Check urea and electrolytes, and the eGFR at baseline and 1-2 weeks after starting treatment.
If starting a CCB no specific blood tests are required.

19. Adjusting drug treatment
Use clinic BP to monitor response:
If the person has a 'white coat effect', consider ambulatory or home blood pressure monitoring.
If BP is not adequately controlled on the maximum licensed or tolerated doses of one antihypertensive drug:
Check concordance.
Ensure that the person is taking the maximum licensed or highest tolerated dose of antihypertensive medication.
Consider secondary causes for hypertension and whether specialist advice may be helpful.
Consider adding additional drugs in a stepwise manner.

20. Adjusting drug treatment
If on monotherapy, add a second drug.
If on an ACE inhibitor or an AIIRA:
Add a CCB.
If the person cannot take a CCB, add a thiazide diuretic.
If on a CCB or a thiazide diuretic:
Add an ACE inhibitor or an AIIRA.
If the person cannot take an ACE inhibitor or an AIIRA consider combining a CCB with a thiazide diuretic.
If on dual therapy prescribe a third antihypertensive such as:
An ACE inhibitor or an AIIRA
A calcium-channel blocker, and
A thiazide-type diuretic.

21. Adding a third drug?
NICE acknowledged that little evidence was available to guide clinical practice.
The Guideline Development Group concluded that the most straightforward choice was to recommend:
Combining an ACE inhibitor or an AIIRA plus calcium-channel blocker plus thiazide type-diuretic.

22. Adding a fourth drug? If BP is not controlled on 3 drugs:
If serum potassium is:
> 4.5 mmol/L, consider increasing the dose of a thiazide diuretic.
4.5 mmol/L or lower, consider adding another diuretic such as low-dose spironolactone (off-label).
If further diuretic treatment is not tolerated, contraindicated, or ineffective add an alpha-blocker or a beta-blocker.
Again evidence is lacking to guide treatment choice.

23. Adjusting drug treatment
If BP is not controlled on 4 drugs:
Seek specialist advice (may not be possible to reach target BP).

24. When to refer? Consider referral if:
BP is not adequately controlled on optimal primary care treatment, or
Secondary hypertension is suspected which cannot be managed in primary care, or
Postural hypotension is symptomatic, or systolic blood pressure decreases by 20 mmHg or more on standing up, or
There is a consistent difference in blood pressure readings between arms of more than 20/10 mmHg, or
'White coat' hypertension is suspected and ambulatory blood pressure monitoring or home monitoring is not available.

25. When to admit? Admit, or refer immediately, those people with:
Accelerated (malignant) hypertension.
BP is 180/110 mmHg or higher with signs of papilloedema and/or retinal haemorrhage.
Hypertensive encephalopathy.
Suspected phaeochromocytoma and severe hypertension.
Severe hypertension and impending vascular complication.

26. Summary Target clinic BP is: Offer lifestyle advice:
Lower than 140/90 mmHg if less than 80 years.
Lower than 150/90 mmHg if older than 80 years.
Offer lifestyle advice:
Initially, and then periodically, to people being assessed or treated for hypertension.
If younger than 55 years of age (not of black African or Caribbean ethnic origin) start:
An angiotensin-converting enzyme (ACE) inhibitor, or
A low-cost angiotensin II receptor antagonist (AIIRA).

27. Summary If aged 80 years and older:
If 55 years of age or older and of black African or Caribbean ethnic origin (any age):
Offer a CCB, or
A low-dose thiazide diuretic (indapamide or chlortalidone preferred).
If aged 80 years and older:
Offer the same treatment as people aged 55 years and older.
A beta-blocker can be considered as initial treatment for:
Younger people who cannot use or tolerate ACE inhibitors and AIIRAs.
Women who might become pregnant or are planning a pregnancy.
People with evidence of increased sympathetic drive (e.g. sweating).