Test Co-morbidity = Heart Failure without T2 Diabeteswithout T2 DiabetesStage 1 HypertensionStage 1 Hypertensionwith T2 Diabeteswith T2 Diabeteswithout T2 Diabeteswithout T2 Diabeteswith T2 Diabeteswith T2 DiabetesDiagnosing HypertensionDiagnosing HypertensionManagementManagementMeasuring BPMeasuring BPCCBCCBDiureticDiureticACEI or ARBACEI or ARBCCBCCBDiureticDiureticSTEP 2STEP 2STEP 3STEP 3STEP 1STEP 1Black African or African–Caribbean family origin?Black African or African–Caribbean family origin?NONOAGE ≥ 55?AGE ≥ 55?NONOACEI or ARBACEI or ARBCCBCCBDiureticDiureticSTEP 1STEP 1YESYESYESYESDiureticDiureticACEI or ARBACEI or ARBSTEP 3STEP 3STEP 2STEP 2Clinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgStage 2 HypertensionStage 2 HypertensionSTEP 4STEP 4SpironolactoneSpironolactoneAlpha-blockerAlpha-blockerBeta-blockerBeta-blockerPOTASSIUM levelPOTASSIUM level≤ 4.5 mmol/l≤ 4.5 mmol/l> 4.5 mmol/l> 4.5 mmol/lConfirm resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypotension and discuss adherenceConfirm resistant hypertension:...ORORSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4 drugsSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4...Text is not SVG - cannot display Co-morbidity = without T2 Diabeteswithout T2 DiabetesStage 1 HypertensionStage 1 Hypertensionwith T2 Diabeteswith T2 Diabeteswithout T2 Diabeteswithout T2 Diabeteswith T2 Diabeteswith T2 DiabetesDiagnosing HypertensionDiagnosing HypertensionManagementManagementMeasuring BPMeasuring BPCCBCCBDiureticDiureticACEI or ARBACEI or ARBCCBCCBDiureticDiureticSTEP 2STEP 2STEP 3STEP 3STEP 1STEP 1Black African or African–Caribbean family origin?Black African or African–Caribbean family origin?NONOAGE ≥ 55?AGE ≥ 55?NONOACEI or ARBACEI or ARBCCBCCBDiureticDiureticSTEP 1STEP 1YESYESYESYESDiureticDiureticACEI or ARBACEI or ARBSTEP 3STEP 3STEP 2STEP 2Clinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgStage 2 HypertensionStage 2 HypertensionSTEP 4STEP 4SpironolactoneSpironolactoneAlpha-blockerAlpha-blockerBeta-blockerBeta-blockerPOTASSIUM levelPOTASSIUM level≤ 4.5 mmol/l≤ 4.5 mmol/l> 4.5 mmol/l> 4.5 mmol/lConfirm resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypotension and discuss adherenceConfirm resistant hypertension:...ORORSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4 drugsSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4...Text is not SVG - cannot display Co-morbidity = without T2 Diabeteswithout T2 DiabetesStage 1 HypertensionStage 1 Hypertensionwith T2 Diabeteswith T2 Diabeteswithout T2 Diabeteswithout T2 Diabeteswith T2 Diabeteswith T2 DiabetesDiagnosing HypertensionDiagnosing HypertensionManagementManagementMeasuring BPMeasuring BPCCBCCBDiureticDiureticACEI or ARBACEI or ARBCCBCCBDiureticDiureticSTEP 2STEP 2STEP 3STEP 3STEP 1STEP 1Black African or African–Caribbean family origin?Black African or African–Caribbean family origin?NONOAGE ≥ 55?AGE ≥ 55?NONOACEI or ARBACEI or ARBCCBCCBDiureticDiureticSTEP 1STEP 1YESYESYESYESDiureticDiureticACEI or ARBACEI or ARBSTEP 3STEP 3STEP 2STEP 2Clinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgStage 2 HypertensionStage 2 HypertensionSTEP 4STEP 4SpironolactoneSpironolactoneAlpha-blockerAlpha-blockerBeta-blockerBeta-blockerPOTASSIUM levelPOTASSIUM level≤ 4.5 mmol/l≤ 4.5 mmol/l> 4.5 mmol/l> 4.5 mmol/lConfirm resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypotension and discuss adherenceConfirm resistant hypertension:...ORORSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4 drugsSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4...Text is not SVG - cannot display Classification of Hypertension Stage 1 Hypertension Clinic blood pressure (BP) between 140/90 mmHg and 159/99 mmHg. Average daytime ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) between 135/85 mmHg and 149/94 mmHg. Stage 2 Hypertension Clinic BP of 160/100 mmHg or higher but less than 180/120 mmHg. Subsequent ABPM daytime average or HBPM average BP of 150/95 mmHg or higher. Stage 3 or Severe Hypertension Clinic systolic BP of 180 mmHg or higher, or clinic diastolic BP of 120 mmHg or higher. Accelerated (Malignant) Hypertension Severe increase in BP to 180/120 mmHg or higher (often over 220/120 mmHg). Signs of retinal hemorrhage and/or papilloedema (swelling of the optic nerve). Usually associated with new or progressive target organ damage.[NG136; CKS] Target Organ Damage Damage to organs such as the heart, brain, kidneys, and eyes. Examples include left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy, or increased urine albumin:creatinine ratio.[NG136] Established Cardiovascular Disease History of ischemic heart disease, cerebrovascular disease, peripheral vascular disease, aortic aneurysm, or heart failure. Generally associated with a build-up of fatty deposits inside the arteries (atherosclerosis) and an increased risk of blood clots.[NG136] Masked Hypertension Normal clinic BP measurements (less than 140/90 mmHg). Higher BP measurements outside the clinic using average daytime ABPM or average HBPM.[NG136; CKS] White-Coat Effect A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM BP measurements at the time of diagnosis. Primary and Secondary Hypertension Primary hypertension occurs in about 90% of people with no identifiable cause. Secondary hypertension occurs in about 10% of people with a known underlying cause, such as renal, endocrine, or vascular disorder, or the use of certain drugs. Measuring Blood Pressure Training in Blood Pressure Measurement: Ensure proper initial training and regular performance reviews for professionals measuring blood pressure. Training in Blood Pressure Measurement Ensure proper initial training and regular performance reviews for professionals measuring blood pressure. Pulse Check Before Blood Pressure Measurement: Palpate the radial or brachial pulse before using automated devices to measure blood pressure, especially in the presence of pulse irregularities like atrial fibrillation. If irregularity is detected, measure blood pressure manually using direct auscultation over the brachial artery. Blood Pressure Device Maintenance: Validate, maintain, and recalibrate blood pressure measuring devices as recommended, consulting the BIHS for validated device listings. Measurement Environment: Standardise the environment for blood pressure measurements, ensuring the person is relaxed, seated, and using an appropriately sized cuff. Postural Hypotension Measurements: In people with symptoms of postural hypotension (e.g., falls, postural dizziness), measure blood pressure while they are supine (or seated), and again after standing for at least 1 minute. Managing Significant Blood Pressure Drops: If systolic blood pressure falls by 20 mmHg or more upon standing, review medication, measure subsequent blood pressures with the person standing, and consider specialist referral if postural hypotension symptoms persist. DIAGNOSIS Diagnosing Hypertension: BP < 140/90 Measure blood pressure in both arms for hypertension diagnosis. Repeat measurements if the difference between arms is over 15 mmHg. If the difference remains over 15 mmHg, use the arm with the higher reading for future measurements. No CKD or Type 2 Diabetes If clinic blood pressure is < 140/90 mmHg Check BP at least every 5 years and more often if close to 140/90 mmHg Type 2 Diabetes Measure blood pressure at least annually Provide and emphasise preventive lifestyle advice. CKD Manage as per the NICE CKD guideline [NG203] Diagnosing Hypertension: BP 140/90 - 179/119 Measuring blood pressure Measure blood pressure in both arms for hypertension diagnosis. Repeat measurements if the difference between arms is over 15 mmHg. If the difference remains over 15 mmHg, use the arm with the higher reading for future measurements. If clinic blood pressure is 140/90 mmHg or higher, take a second measurement. If the first and second measurements differ significantly, take a third measurement. Record the lower of the last two measurements as the clinic blood pressure. Offer ABPM Offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. While waiting for confirmation of a diagnosis of hypertension, carry out: investigations for target organ damage, followed by formal assessment of cardiovascular risk [QRISK] CONFIRM DIAGNOSIS If the clinic BP ≥ 140/90 mmHg and daytime ABPM (or HBPM) average ≥ 135/85 mmHg Stage 1 hypertension: Clinic BP - 140/90 mmHg to 159/99 mmHg. ABPM/HBPM - 135/85 mmHg to 149/94 mmHg. Stage 2 hypertension: Clinic BP - 160/100 mmHg to 179/119 mmHg. ABPM/HBPM ≥ 150/95 mmHg. Stage 3 or severe hypertension: Clinic BP ≥ 180/120 Accelerated (Malignant) hypertension: Clinic BP ≥ 180/120 with retinal haemorrhage and/or papilloedema If hypertension is not diagnosed but there is evidence of target organ damage, consider carrying out investigations for alternative causes If hypertension is not diagnosed, measure the person's clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person's clinic blood pressure is close to 140/90 mmHg. Diagnosing Hypertension: BP ≥ 180/120 Measuring blood pressure Measure blood pressure in both arms for hypertension diagnosis. Repeat measurements if the difference between arms is over 15 mmHg. If the difference remains over 15 mmHg, use the arm with the higher reading for future measurements. If clinic blood pressure is 140/90 mmHg or higher, take a second measurement. If the first and second measurements differ significantly, take a third measurement. Record the lower of the last two measurements as the clinic blood pressure. CONSIDER THE NEED FOR SAME-DAY REFERRAL Accelerated hypertension BP ≥ 180/120 mmHg (often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension. Life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury Suspected phaeochromocytoma labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis Stage 3 or severe hypertension: Clinic BP ≥ 180/120 Accelerated (Malignant) hypertension: Clinic BP ≥ 180/120 with retinal haemorrhage and/or papilloedema AETIOLOGY Training in Blood Pressure Measurement : Ensure proper initial training and regular performance reviews for professionals measuring blood pressure. Pulse Check Before Blood Pressure Measurement : Palpate the radial or brachial pulse before using automated devices to measure blood pressure, especially in the presence of pulse irregularities like atrial fibrillation. If irregularity is detected, measure blood pressure manually using direct auscultation over the brachial artery. Blood Pressure Device Maintenance : Validate, maintain, and recalibrate blood pressure measuring devices as recommended, consulting the BIHS for validated device listings. Test before summary Measurement Environment : Standardise the environment for blood pressure measurements, ensuring the person is relaxed, seated, and using an appropriately sized cuff. Postural Hypotension Measurements : In people with symptoms of postural hypotension (e.g., falls, postural dizziness), measure blood pressure while they are supine (or seated), and again after standing for at least 1 minute. Managing Significant Blood Pressure Drops : If systolic blood pressure falls by 20 mmHg or more upon standing, review medication, measure subsequent blood pressures with the person standing, and consider specialist referral if postural hypotension symptoms persist. CLINICAL FEATURES Training in Blood Pressure Measurement Ensure proper initial training and regular performance reviews for professionals measuring blood pressure. Pulse Check Before Blood Pressure Measurement Palpate the radial or brachial pulse before using automated devices to measure blood pressure, especially in the presence of pulse irregularities like atrial fibrillation. If irregularity is detected, measure blood pressure manually using direct auscultation over the brachial artery. Blood Pressure Device Maintenance Validate, maintain, and recalibrate blood pressure measuring devices as recommended, consulting the BIHS for validated device listings. Measurement Environment Provide periodic lifestyle advice for those with suspected or diagnosed hypertension. Encourage a healthy diet and regular exercise to reduce blood pressure. Recommend reducing excessive alcohol intake for lower blood pressure and overall health. Discourage excessive caffeine consumption. Advise low sodium intake, with specific cautions for at-risk groups. Avoid suggesting calcium, magnesium, or potassium supplements for blood pressure control. Assist smokers in quitting. Inform about local support groups for promoting healthy lifestyle changes. Postural Hypotension Measurements In people with symptoms of postural hypotension (e.g., falls, postural dizziness), measure blood pressure while they are supine (or seated), and again after standing for at least 1 minute. Managing Significant Blood Pressure Drops If systolic blood pressure falls by 20 mmHg or more upon standing, review medication, measure subsequent blood pressures with the person standing, and consider specialist referral if postural hypotension symptoms persist. INVESTIGATIONS MANAGEMENT Lifestyle interventions Provide periodic lifestyle advice for those with suspected or diagnosed hypertension. Encourage a healthy diet and regular exercise to reduce blood pressure. Recommend reducing excessive alcohol intake for lower blood pressure and overall health. Discourage excessive caffeine consumption. Advise low sodium intake, with specific cautions for at-risk groups. Avoid suggesting calcium, magnesium, or potassium supplements for blood pressure control. Assist smokers in quitting. Inform about local support groups for promoting healthy lifestyle changes. Choosing anti-hypertensive drug treatment Target Population: Guidelines for hypertension treatment in individuals with or without type 2 diabetes. Pregnancy and Breastfeeding: Avoid ACE inhibitors and angiotensin II receptor antagonists. Consider risks and benefits in essential cases. Adhere to MHRA safety advice regarding these drugs during pregnancy and breastfeeding. Chronic Kidney Disease: Refer to NICE's guideline; prefer once-daily medication. Drug Prescriptions: Use non-proprietary drugs to reduce costs. Isolated Systolic Hypertension: Treat similarly to general hypertension. Women of Childbearing Age: Adhere to specific guidelines for hypertension management during pregnancy and breastfeeding. Black African or African–Caribbean Descent: Prefer ARBs over ACE inhibitors. Cardiovascular Disease Management: Adhere to NICE guidelines specific to each cardiovascular condition. Acute coronary syndrome Acute heart failure Chronic HFrEF Stable Angina Type 1 Diabetes Stage 1 Hypertension without Type 2 Diabetes Treatment Decision Making Use patient decision aid for discussing hypertension treatment options Stage 1 Hypertension in Under 80s: Discuss starting antihypertensive drugs, along with lifestyle advice, for adults under 80 with persistent stage 1 hypertension and any of the following: Target organ damage Established cardiovascular disease Renal disease Diabetes 10% or higher 10-year cardiovascular disease risk. Use clinical judgement for frail or multimorbid patients. Risk and Preferences Discussion: Discuss cardiovascular risks and treatment preferences, including non-treatment, before starting antihypertensive drugs. Maintain lifestyle advice regardless of treatment choice. Under-60s with Low Risk: Consider drug treatment for those under 60 with stage 1 hypertension and low 10-year cardiovascular risk. Over-80s with Stage 1 Hypertension: Consider treatment for those over 80 with stage 1 hypertension and blood pressure above 150/90 mmHg, taking into account frailty and multimorbidity. Hypertension in Under-40s: For adults under 40 with hypertension, consider specialist evaluation for secondary causes and assess long-term treatment benefits and risks. Black African/Caribbean origin or Aged ≥ 55 Aged ≥ 55 OR any age adult of Black African or African–Caribbean origin Step 1 Offer a calcium-channel blocker (CCB**) Step 2 Check adherence +/- Offer an ACE inhibitor*/ARB (ARB preferred if of Black African or African–Caribbean origin) or thiazide-like diuretic info Step 3 Check adherence +/- CCB + ACE inhibitor*/ARB + thiazide-like diuretic info * If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB - Do not combine an ACE inhibitor with an ARB to treat hypertension.**If a CCB is not tolerated, for example because of oedema (or evidence of heart failure), offer a thiazide-like diuretic Resistant Hypertension Diagnosis: Define as uncontrolled despite optimal doses of an ACE inhibitor or ARB, a CCB, and a thiazide-like diuretic. Step 4 Treatment: Pre-Treatment Checks: Confirm elevated blood pressure ABPM or HBPM. Assess for postural hypotension. Review medication adherence. Add a fourth antihypertensive drug or consult a specialist. Adhere to MHRA guidelines for ACE inhibitors and ARBs. Potassium ≤ 4.5 mmol/L: Consider Spironolactone for resistant hypertension, with caution in reduced eGFR. Monitoring with Additional Diuretics: Check blood sodium, potassium, and renal function within 1 month, and monitor regularly. Potassium Levels > 4.5 mmol/L: Use an alpha-blocker or beta-blocker. Seek Specialist Advice: If hypertension persists despite four medications. Aged < 55 Aged < 55 AND NOT of Black African or African–Caribbean origin Step 1 Offer an ACE inhibitor* or an ARB Step 2 Check adherence +/- Offer a calcium-channel blocker (CCB**) or thiazide-like diuretic info Step 3 Check adherence +/- ACE inhibitor*/ARB + CCB + thiazide-like diuretic info * If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB - Do not combine an ACE inhibitor with an ARB to treat hypertension.**If a CCB is not tolerated, for example because of oedema (or evidence of heart failure), offer a thiazide-like diuretic Resistant Hypertension Diagnosis: Define as uncontrolled despite optimal doses of an ACE inhibitor or ARB, a CCB, and a thiazide-like diuretic. Step 4 Treatment: Pre-Treatment Checks: Confirm elevated blood pressure ABPM or HBPM. Assess for postural hypotension. Review medication adherence. Add a fourth antihypertensive drug or consult a specialist. Adhere to MHRA guidelines for ACE inhibitors and ARBs. Potassium ≤ 4.5 mmol/L: Consider Spironolactone for resistant hypertension, with caution in reduced eGFR. Monitoring with Additional Diuretics: Check blood sodium, potassium, and renal function within 1 month, and monitor regularly. Potassium Levels > 4.5 mmol/L: Use an alpha-blocker or beta-blocker. Seek Specialist Advice: If hypertension persists despite four medications. Stage 1 Hypertension with Type 2 Diabetes Treatment Decision Making Treatment Decision Making: Use NICE's patient decision aid for discussing hypertension treatment options. Refer to NICE guidelines for shared decision-making and medicines adherence. Stage 1 Hypertension in Under 80s: Discuss starting antihypertensive drugs, along with lifestyle advice, for adults under 80 with persistent stage 1 hypertension and any of the following: Target organ damage Established cardiovascular disease Renal disease Diabetes 10% or higher 10-year cardiovascular disease risk. Use clinical judgement for frail or multimorbid patients. Risk and Preferences Discussion: Discuss cardiovascular risks and treatment preferences, including non-treatment, before starting antihypertensive drugs. Maintain lifestyle advice regardless of treatment choice. Under-60s with Low Risk: Consider drug treatment for those under 60 with stage 1 hypertension and low 10-year cardiovascular risk. Over-80s with Stage 1 Hypertension: Consider treatment for those over 80 with stage 1 hypertension and blood pressure above 150/90 mmHg, taking into account frailty and multimorbidity. Hypertension in Under-40s: For adults under 40 with hypertension, consider specialist evaluation for secondary causes and assess long-term treatment benefits and risks. Hypertension with Type 2 Diabetes Step 1 Offer an ACE inhibitor* or an ARB (ARB preferred if of Black African or African–Caribbean origin) Step 2 Check adherence +/- Offer a calcium-channel blocker (CCB**) or thiazide-like diuretic info Step 3 Check adherence +/- ACE inhibitor*/ARB + CCB + thiazide-like diuretic info * If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB - Do not combine an ACE inhibitor with an ARB to treat hypertension.**If a CCB is not tolerated, for example because of oedema (or evidence of heart failure), offer a thiazide-like diuretic Resistant Hypertension Diagnosis: Define as uncontrolled despite optimal doses of an ACE inhibitor or ARB, a CCB, and a thiazide-like diuretic. Step 4 Treatment: Pre-Treatment Checks: Confirm elevated blood pressure ABPM or HBPM. Assess for postural hypotension. Review medication adherence. Add a fourth antihypertensive drug or consult a specialist. Adhere to MHRA guidelines for ACE inhibitors and ARBs. Potassium ≤ 4.5 mmol/L: Consider Spironolactone for resistant hypertension, with caution in reduced eGFR. Monitoring with Additional Diuretics: Check blood sodium, potassium, and renal function within 1 month, and monitor regularly. Potassium Levels > 4.5 mmol/L: Use an alpha-blocker or beta-blocker. Seek Specialist Advice: If hypertension persists despite four medications. Stage 2 Hypertension without Type 2 Diabetes Treatment Decision Making Treatment Decision Making: Use NICE's patient decision aid for discussing hypertension treatment options. Refer to NICE guidelines for shared decision-making and medicines adherence. Stage 2 Hypertension: Offer drugs and lifestyle advice to adults with persistent stage 2 hypertension, adapting to frailty or multimorbidity. Risk and Preferences Discussion: Discuss cardiovascular risks and treatment preferences, including non-treatment, before starting antihypertensive drugs. Maintain lifestyle advice regardless of treatment choice. Under-60s with Low Risk: Consider drug treatment for those under 60 with stage 1 hypertension and low 10-year cardiovascular risk. Hypertension in Under-40s: For adults under 40 with hypertension, consider specialist evaluation for secondary causes and assess long-term treatment benefits and risks. Black African/Caribbean origin or Aged ≥ 55 Aged ≥ 55 OR any age adult of Black African or African–Caribbean origin Step 1 Offer a calcium-channel blocker (CCB**) Step 2 Check adherence +/- Offer an ACE inhibitor*/ARB (ARB preferred if of Black African or African–Caribbean origin) or thiazide-like diuretic info Step 3 Check adherence +/- CCB + ACE inhibitor*/ARB + thiazide-like diuretic info * If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB - Do not combine an ACE inhibitor with an ARB to treat hypertension.**If a CCB is not tolerated, for example because of oedema (or evidence of heart failure), offer a thiazide-like diuretic Resistant Hypertension Diagnosis: Define as uncontrolled despite optimal doses of an ACE inhibitor or ARB, a CCB, and a thiazide-like diuretic. Step 4 Treatment: Pre-Treatment Checks: Confirm elevated blood pressure ABPM or HBPM. Assess for postural hypotension. Review medication adherence. Add a fourth antihypertensive drug or consult a specialist. Adhere to MHRA guidelines for ACE inhibitors and ARBs. Potassium ≤ 4.5 mmol/L: Consider Spironolactone for resistant hypertension, with caution in reduced eGFR. Monitoring with Additional Diuretics: Check blood sodium, potassium, and renal function within 1 month, and monitor regularly. Potassium Levels > 4.5 mmol/L: Use an alpha-blocker or beta-blocker. Seek Specialist Advice: If hypertension persists despite four medications. Aged < 55 Aged < 55 AND NOT of Black African or African–Caribbean origin Step 1 Offer an ACE inhibitor* or an ARB Step 2 Check adherence +/- Offer a calcium-channel blocker (CCB**) or thiazide-like diuretic info Step 3 Check adherence +/- ACE inhibitor*/ARB + CCB + thiazide-like diuretic info * If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB - Do not combine an ACE inhibitor with an ARB to treat hypertension.**If a CCB is not tolerated, for example because of oedema (or evidence of heart failure), offer a thiazide-like diuretic Resistant Hypertension Diagnosis: Define as uncontrolled despite optimal doses of an ACE inhibitor or ARB, a CCB, and a thiazide-like diuretic. Step 4 Treatment: Pre-Treatment Checks: Confirm elevated blood pressure ABPM or HBPM. Assess for postural hypotension. Review medication adherence. Add a fourth antihypertensive drug or consult a specialist. Adhere to MHRA guidelines for ACE inhibitors and ARBs. Potassium ≤ 4.5 mmol/L: Consider Spironolactone for resistant hypertension, with caution in reduced eGFR. Monitoring with Additional Diuretics: Check blood sodium, potassium, and renal function within 1 month, and monitor regularly. Potassium Levels > 4.5 mmol/L: Use an alpha-blocker or beta-blocker. Seek Specialist Advice: If hypertension persists despite four medications. Stage 2 Hypertension with Type 2 Diabetes Treatment Decision Making Treatment Decision Making: Use NICE's patient decision aid for discussing hypertension treatment options. Refer to NICE guidelines for shared decision-making and medicines adherence. Stage 2 Hypertension: Offer drugs and lifestyle advice to adults with persistent stage 2 hypertension, adapting to frailty or multimorbidity. Risk and Preferences Discussion: Discuss cardiovascular risks and treatment preferences, including non-treatment, before starting antihypertensive drugs. Maintain lifestyle advice regardless of treatment choice. Under-60s with Low Risk: Consider drug treatment for those under 60 with stage 1 hypertension and low 10-year cardiovascular risk. Hypertension in Under-40s: For adults under 40 with hypertension, consider specialist evaluation for secondary causes and assess long-term treatment benefits and risks. Hypertension with Type 2 Diabetes Step 1 Offer an ACE inhibitor* or an ARB (ARB preferred if of Black African or African–Caribbean origin) Step 2 Check adherence +/- Offer a calcium-channel blocker (CCB**) or thiazide-like diuretic info Step 3 Check adherence +/- ACE inhibitor*/ARB + CCB + thiazide-like diuretic info * If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB - Do not combine an ACE inhibitor with an ARB to treat hypertension.**If a CCB is not tolerated, for example because of oedema (or evidence of heart failure), offer a thiazide-like diuretic Resistant Hypertension Diagnosis: Define as uncontrolled despite optimal doses of an ACE inhibitor or ARB, a CCB, and a thiazide-like diuretic. Step 4 Treatment: Pre-Treatment Checks: Confirm elevated blood pressure ABPM or HBPM. Assess for postural hypotension. Review medication adherence. Add a fourth antihypertensive drug or consult a specialist. Adhere to MHRA guidelines for ACE inhibitors and ARBs. Potassium ≤ 4.5 mmol/L: Consider Spironolactone for resistant hypertension, with caution in reduced eGFR. Monitoring with Additional Diuretics: Check blood sodium, potassium, and renal function within 1 month, and monitor regularly. Potassium Levels > 4.5 mmol/L: Use an alpha-blocker or beta-blocker. Seek Specialist Advice: If hypertension persists despite four medications. MEDICATIONS Hypertension without Type 2 Diabetes Hypertension without Type 2 Diabetes Hypertension with Type 2 Diabetes COMPLICATIONS Co-morbidities Heart Failure Pancreatitis DKA Pathway First Choice Second Choice Third Choice Diagnosing HypertensionDiagnosing HypertensionManagementManagementMeasuring BPMeasuring BPuACR ≥ 70 mg/mmol uACR ≥ 70 mg/mmol Target BP of < 130/80 mmHgTarget BP of < 130/80 mmHg140/90 - 179/119 mmHg140/90 - 179/119 mmHgUnder 140/90 mmHgUnder 140/90 mmHg≥ 180/120 mmHg≥ 180/120 mmHgCheck BP at least every 5 years and more often if close to 140/90 mmHg Check BP at least every 5 years...Type 2 DiabetesType 2 DiabetesAND / ORAND / ORChronic Kidney DiseaseChronic Kidney DiseaseAt least Annual BP MonitoringAt least Annual BP MonitoringNICE BP TargetsNICE BP Targets ABPM/HBPM < 145/85 mmHgABPM/HBPM < 145/85 mmHgABPM/HBPM < 135/85 mmHgABPM/HBPM < 135/85 mmHgClinic BP < 140/90 mmHgClinic BP < 140/90 mmHgClinic BP < 150/90 mmHgClinic BP < 150/90 mmHgAge < 80Age < 80Age > 80Age > 80Use the same BP targets in CVDUse the same BP targets in CVDNICE BP Targets in CKDNICE BP Targets in CKD ABPM/HBPM < 125/75 mmHgABPM/HBPM < 125/75 mmHgABPM/HBPM < 135/85 mmHgABPM/HBPM < 135/85 mmHgClinic BP < 140/90 mmHgClinic BP < 140/90 mmHgClinic BP < 130/80 mmHgClinic BP < 130/80 mmHguACR < 70uACR < 70uACR ≥ 70uACR ≥ 70SELECT Clinic Blood PressureSELECT Clinic Blood PressureText is not SVG - cannot displayParent First Choice Second Choice Third Choice Child 1 Choice 1 Choice 2 Choice 3 Child 2Choice TwoChoice OneChoice ThreeUntitled < 140/90 mmHg< 140/90 mmHg140/90 - 179/119 mmHg140/90 - 179/119 mmHg≥ 180/120 mmHg≥ 180/120 mmHgClinic BPClinic BPText is not SVG - cannot display without T2 Diabeteswithout T2 DiabetesStage 1 HypertensionStage 1 Hypertensionwith T2 Diabeteswith T2 Diabeteswithout T2 Diabeteswithout T2 Diabeteswith T2 Diabeteswith T2 DiabetesDiagnosing HypertensionDiagnosing HypertensionManagementManagementMeasuring BPMeasuring BPCCBCCBDiureticDiureticACEI or ARBACEI or ARBCCBCCBDiureticDiureticSTEP 2STEP 2STEP 3STEP 3STEP 1STEP 1Black African or African–Caribbean family origin?Black African or African–Caribbean family origin?NONOAGE ≥ 55?AGE ≥ 55?NONOACEI or ARBACEI or ARBCCBCCBDiureticDiureticSTEP 1STEP 1YESYESYESYESDiureticDiureticACEI or ARBACEI or ARBSTEP 3STEP 3STEP 2STEP 2Clinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgStage 2 HypertensionStage 2 HypertensionSTEP 4STEP 4SpironolactoneSpironolactoneAlpha-blockerAlpha-blockerBeta-blockerBeta-blockerPOTASSIUM levelPOTASSIUM level≤ 4.5 mmol/l≤ 4.5 mmol/l> 4.5 mmol/l> 4.5 mmol/lConfirm resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypotension and discuss adherenceConfirm resistant hypertension:...ORORSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4 drugsSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4...Text is not SVG - cannot display without T2 Diabeteswithout T2 DiabetesStage 1 HypertensionStage 1 Hypertensionwith T2 Diabeteswith T2 Diabeteswithout T2 Diabeteswithout T2 Diabeteswith T2 Diabeteswith T2 DiabetesDiagnosing HypertensionDiagnosing HypertensionManagementManagementMeasuring BPMeasuring BPCCBCCBDiureticDiureticACEI or ARBACEI or ARBCCBCCBDiureticDiureticSTEP 2STEP 2STEP 3STEP 3STEP 1STEP 1Clinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgStage 2 HypertensionStage 2 HypertensionSTEP 4STEP 4SpironolactoneSpironolactoneAlpha-blockerAlpha-blockerBeta-blockerBeta-blockerPOTASSIUM levelPOTASSIUM level≤ 4.5 mmol/l≤ 4.5 mmol/l> 4.5 mmol/l> 4.5 mmol/lConfirm resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypotension and discuss adherenceConfirm resistant hypertension:...ORORSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4 drugsSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4...Text is not SVG - cannot display without T2 Diabeteswithout T2 DiabetesStage 1 HypertensionStage 1 Hypertensionwith T2 Diabeteswith T2 Diabeteswithout T2 Diabeteswithout T2 Diabeteswith T2 Diabeteswith T2 DiabetesDiagnosing HypertensionDiagnosing HypertensionManagementManagementMeasuring BPMeasuring BPCCBCCBDiureticDiureticACEI or ARBACEI or ARBCCBCCBDiureticDiureticSTEP 2STEP 2STEP 3STEP 3STEP 1STEP 1Black African or African–Caribbean family origin?Black African or African–Caribbean family origin?NONOAGE ≥ 55?AGE ≥ 55?NONOACEI or ARBACEI or ARBCCBCCBDiureticDiureticSTEP 1STEP 1YESYESYESYESDiureticDiureticACEI or ARBACEI or ARBSTEP 3STEP 3STEP 2STEP 2Clinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP ≥ 160/100 mmHg || ABPM/HBPM ≥ 150/95 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgClinic BP: 140/90 - 159/99 mmHg || ABPM/HBPM: 135/85 - 149/94 mmHgStage 2 HypertensionStage 2 HypertensionSTEP 4STEP 4SpironolactoneSpironolactoneAlpha-blockerAlpha-blockerBeta-blockerBeta-blockerPOTASSIUM levelPOTASSIUM level≤ 4.5 mmol/l≤ 4.5 mmol/l> 4.5 mmol/l> 4.5 mmol/lConfirm resistant hypertension: confirm elevated BP with ABPM or HBPM, check for postural hypotension and discuss adherenceConfirm resistant hypertension:...ORORSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4 drugsSeek expert advice if BP is uncontrolled on optimal tolerated doses of 4...Text is not SVG - cannot display HiddenList Add RemoveProduct Name A Quantity Price: $0.00 Quantity Product Name B Quantity Price: $0.00 Quantity Product Name C Quantity Price: $0.00 Quantity Product Name A x Maecenas blandit in nisl vel accumsan. 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