Hypertension in adults: diagnosis and management

Context

High blood pressure (hypertension) is one of the most important, treatable causes of premature morbidity and mortality in the world. It is a major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. In 2015, it was reported that high blood pressure affected more than 1 in 4 adults in England (31% of men; 26% of women) – around 13.5 million people – and contributed to 75,000 deaths. The clinical management of hypertension accounts for 12% of visits to primary care and up to £2.1 billion of healthcare expenditure. Managing the cardiovascular events caused by hypertension also consumes considerable resources.

The guideline covers adults (over 18 years) with suspected or diagnosed hypertension, including those with type 2 diabetes.

2019 update

Between 2010 and 2020, progress has been made to improve the diagnosis and management of hypertension: the population average blood pressure in England has fallen by about 3 mmHg systolic and the proportion of adults with untreated high blood pressure has decreased. However, the Public Health England Blood Pressure Action Plan called for further action to reduce the population average blood pressure by 5 mmHg through improved prevention, detection and management (Public Health England's Tackling high blood pressure: from evidence into action, 2015 and Tackling high blood pressure: an update, 2018).

Since the publication of the 2011 NICE guideline on hypertension, new studies have been published in key areas of management; in particular, the optimal method and threshold for diagnosis of hypertension, managing blood pressure in lower risk populations and reducing blood pressure to lower targets in people with hypertension (including those with type 2 diabetes). The updated guideline makes new recommendations in these areas, based on the evidence, that aim to improve care and reduce variation in current practice.

Treating resistant hypertension (when more than 3 drugs are needed to treat hypertension) remains challenging. New data was also reviewed in this area and the recommendations updated.

There is uncertainty in current practice about which people with symptomatic very high blood pressure (accelerated hypertension) to refer for immediate assessment. The available evidence was reviewed and new recommendations made to provide guidance for primary care on when to refer.