AKT · Cardiovascular/Vessels, aorta & venous

Hypertension (essential & secondary)

Sustained elevated arterial pressure — primary (essential) or secondary to a defined cause

Overview

Persistently raised arterial blood pressure, confirmed with ambulatory/home monitoring. Most is essential (primary); secondary causes (renal, endocrine, drugs, coarctation) matter in the young or treatment-resistant. It is a major modifiable cardiovascular risk factor, and the NICE staged drug algorithm depends on age and ethnicity. Malignant hypertension and the emergencies are the acute danger.

Recognise

Usually asymptomatic — found on screening; end-organ effects: LVH, retinopathy, renal impairment, stroke risk
Clinic BP ≥140/90 → confirm with ABPM/HBPM (stage 1 ≥135/85 ambulatory; stage 2 ≥150/95 ambulatory)
Secondary clues: young age, resistant hypertension, hypokalaemia (Conn's), paroxysms (phaeo), renal bruit/disease, radio-femoral delay (coarctation)

Red flags

Severe hypertension ≥180/120 with retinal haemorrhages/papilloedema, or new confusion/chest pain/AKI/heart failure → hypertensive emergency → same-day specialist care
Accelerated (malignant) hypertension → controlled BP reduction; pre-eclampsia in pregnancy (cross-ref O&G)

Differentials & how to tell them apart

White-coat hypertensionraised clinic BP, normal ambulatory readings — confirm before treating

Secondary hypertensionrenal/endocrine cause; young, resistant, or biochemical clues

Pre-eclampsiahypertension + proteinuria after 20 weeks' gestation

Investigations

Confirm with ABPM/HBPM; assess end-organ damage and total CV risk: U&Es, urine ACR + dipstick (haematuria), HbA1c, lipids, ECG (LVH), fundoscopy; QRISK; investigate for secondary causes in the young/resistant (renin:aldosterone, plasma metanephrines, renal imaging).

Management

Lifestyle + staged drugs: <55/non-Black → ACEi/ARB; ≥55 or Black → CCB (NICE NG136)

1Confirm with ABPM/HBPM, assess end-organ damage and 10-year CV risk (QRISK). Offer lifestyle measures and treat per threshold (all stage 2; stage 1 if <80 with risk factors/organ damage).Gate: Severe hypertension ≥180/120 with retinal haemorrhages/papilloedema or acute end-organ damage → hypertensive emergency, same-day specialist assessment — don't just start oral therapy and send home.
2Step the drugs: Step 1 by age/ethnicity (ACEi/ARB vs CCB), Step 2 combine, Step 3 add thiazide-like diuretic, Step 4 spironolactone (or alpha/beta-blocker) for resistant disease.Gate: Resistant hypertension or a young patient → look for a secondary cause (renal artery stenosis, Conn's, phaeochromocytoma, coarctation) before escalating blindly.
3Targets: clinic <140/90 (<150/90 if ≥80); tighter in diabetes/CKD with albuminuria. Treat overall CV risk (statin per QRISK).

Step 1: <55 and not Black African/Caribbean → ACE inhibitor/ARB; ≥55 or Black African/Caribbean → calcium-channel blocker — the age/ethnicity rule; ARB preferred over ACEi in Black patients if a RAS drug is needed; type 2 diabetes → ACEi/ARB regardless of age

Step 2: add the other (ACEi/ARB + CCB), or a thiazide-like diuretic (indapamide) — combine across classes

Step 3: ACEi/ARB + CCB + thiazide-like diuretic — triple therapy

Step 4 (resistant): add spironolactone if K ≤4.5, or an alpha-/beta-blocker if K >4.5 — check adherence and exclude secondary causes first

Key points

Confirm with ambulatory/home BP before labelling. NICE Step 1: ACEi/ARB if <55 and not of Black African/Caribbean origin; CCB if ≥55 or Black. Young/resistant → hunt a secondary cause. ≥180/120 with papilloedema/organ damage = emergency.

Monitor & prognosis

BP control, U&Es after ACEi/ARB/diuretic, annual review of CV risk and organ damage.

Excellent risk reduction (stroke/MI) with control; uncontrolled hypertension damages brain, heart, kidney, eye.

Source: NICE NG136 (hypertension); NG238 (CVD risk)