1. NICE Guideline Synopsis

2. Definitions Stage 1 Hypertension Clinic BP 140/90 or higher And ABPM Daytime average/HBPM 135/85 or higher

3. Definitions Stage 2 Hypertension Clinic BP 160/100 or higher And ABPM Daytime average/HBPM 150/95 or higher

4. Definitions Severe Hypertension Clinic BP 180 systolic or higher or diastolic 110 or higher

5. Diagnosis If clinic BP >140/90 then offer ABPM ABPM should have at least 2 readings per hr in persons normal waking hours (usually 8-22.00) Average of at least 14 readings required Offer HBPM if ABPM is deemed unacceptable BP should be taken in both arms-if difference >20mmHg use highest reading arm for subsequent reading

6. HBPM BP taken BD for minimum of 4 days but ideally 7 days Ideally morning and evening 2 BP readings done each time with patient seated and 1 minute apart Discard readings done on day 1 and average remaining readings

8. Treatment Stage 1 Hypertension (=/>140/90 or 135/85) <80 Target organ damage (urine dip, ecg, fundi, U&E, chol, BG) Renal disease CVD Diabetes 10y CVD risk of 20% or higher Stage 2 Hypertension (=/> 160/100 or 150/95) Any age

9. Severe Hypertension Consider starting medication same day Specialist Ix If secondary causes suspected Same day referral if concerns re accelerated htn- BP >180/110 with papilloedema/retinal haemorrhage or suspected phaeochromocytoma (headache, labile/postural hypotension, pallor, palpitations and diaphoresis)

10. Young People <40 with Stage 1 Hypertension but no signs of end organ damage/CVD/renal disease/diabetes consider specialist referral for further investigation of secondary causes as 10y CVD risk assessment underestimates risk in these people

12. Treatments <55y >55y or black Afro Carribean 1. ACEi/ARB 2. CCB 3. Thiazide like diuretic 4. Low dose spironolactone (25mg bd)if K 4.5 consider higher dose thiazide diuretic 5. B blocker may be considered alternative to ACEi in young people/women of childbearing age 1. CCB (Thiazide like diuretic if heart failure/risk of/oedema/intolerance) 2. ACEi (ARB for black afrocaribean) 3. Thiazide like diuretic 4. Low dose spironolactone (25mg bd)if K 4.5 consider higher dose thiazide diuretic

13. If treatment with a thiazide like diuretic is started or changed then use indapamide (1.25mg MR od or 2.5mg od) or chlortalidone (12.5-25mg od)

14. What About Lifestyle Advice? Smoking/alcohol Exercise Keeping salt low Discourage excess caffeine Relaxation techniques if pt interested Advice re local initiatives for lifestyle help

15. Targets Clinic Readings ABPM/HBPM <80 y <140/90 >80y <150/90 <80 y <135/85 >80y <145/85