NG136

  1. Overview
  2. Diabetes
  3. NG136

1.1 Measuring blood pressure

1.1.1Ensure that healthcare professionals taking blood pressure measurements have adequate initial training and periodic review of their performance. [2004]

1.1.2Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. [2011]

1.1.3Healthcare providers must ensure that devices for measuring blood pressure are properly validated, maintained and regularly recalibrated according to manufacturers' instructions. See the British and Irish Hypertension Society's website for a list of validated blood pressure monitoring devices. [2004]

1.1.4When measuring blood pressure in the clinic or in the home, standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. Use an appropriate cuff size for the person's arm. [2011, amended 2019]

1.1.5In people with symptoms of postural hypotension (falls or postural dizziness):

  • measure blood pressure with the person either supine or seated

  • measure blood pressure again with the person standing for at least 1 minute before measurement. [2004, amended 2011]

1.1.6If the systolic blood pressure falls by 20 mmHg or more when the person is standing:

  • review medication

  • measure subsequent blood pressures with the person standing

  • consider referral to specialist care if symptoms of postural hypotension persist. [2004, amended 2011]

1.2 Diagnosing hypertension

1.2.1When considering a diagnosis of hypertension, measure blood pressure in both arms:

  • If the difference in readings between arms is more than 15 mmHg, repeat the measurements.

  • If the difference in readings between arms remains more than 15 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading. [2019]

1.2.2If blood pressure measured in the clinic is 140/90 mmHg or higher:

  • Take a second measurement during the consultation.

  • If the second measurement is substantially different from the first, take a third measurement.

    Record the lower of the last 2 measurements as the clinic blood pressure. [2019]

1.2.3If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. See the section on identifying who to refer for people with a clinic blood pressure 180/120 mmHg or higher. [2019]

1.2.4If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. [2019]

1.2.5While waiting for confirmation of a diagnosis of hypertension, carry out:

1.2.6When using ABPM to confirm a diagnosis of hypertension, ensure that at least 2 measurements per hour are taken during the person's usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person's usual waking hours to confirm a diagnosis of hypertension. [2011]

1.2.7When using HBPM to confirm a diagnosis of hypertension, ensure that:

  • for each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute apart and with the person seated and

  • blood pressure is recorded twice daily, ideally in the morning and evening and

  • blood pressure recording continues for at least 4 days, ideally for 7 days.

    Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. [2011]

1.2.8Confirm diagnosis of hypertension in people with a:

  • clinic blood pressure of 140/90 mmHg or higher and

  • ABPM daytime average or HBPM average of 135/85 mmHg or higher. [2019]

1.2.9If hypertension is not diagnosed but there is evidence of target organ damage, consider carrying out investigations for alternative causes of the target organ damage (for information on investigations, see NICE's guidelines on chronic kidney disease and chronic heart failure). [2011]

1.2.10If 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. [2011]

Annual blood pressure measurement for people with type 2 diabetes

1.2.11Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice. [2009]

Specialist investigations for possible secondary causes of hypertension

1.2.12Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. [2004, amended 2011]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review A: diagnosis.

1.3 Assessing cardiovascular risk and target organ damage

For guidance on the early identification and management of chronic kidney disease, see NICE's guideline on chronic kidney disease.

1.3.1Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension, both for raised blood pressure and other modifiable risk factors. [2004]

1.3.2Estimate cardiovascular risk in line with the recommendations on identifying and assessing cardiovascular disease risk in NICE's guideline on cardiovascular disease. Use clinic blood pressure measurements to calculate cardiovascular risk. [2008]

1.3.3For all people with hypertension offer to:

  • test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip

  • take a blood sample to measure glycated haemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol

  • examine the fundi for the presence of hypertensive retinopathy

  • arrange for a 12‑lead electrocardiograph to be performed. [2011, amended 2019]

1.4 Treating and monitoring hypertension

Lifestyle interventions

For guidance on the prevention of obesity and cardiovascular disease, see NICE's guidelines on obesity prevention and cardiovascular disease prevention.

1.4.1Offer lifestyle advice to people with suspected or diagnosed hypertension, and continue to offer it periodically. [2004]

1.4.2Ask about people's diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes. [2004]

1.4.3Ask about people's alcohol consumption and encourage a reduced intake if they drink excessively, because this can reduce blood pressure and has broader health benefits. See the recommendations for practice in NICE's guideline on alcohol-use disorders. [2004, amended 2019]

1.4.4Discourage excessive consumption of coffee and other caffeine-rich products. [2004]

1.4.5Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. Note that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin II receptor blockers. Encourage salt reduction in these groups. [2004, amended 2019]

1.4.6Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. [2004]

1.4.7Offer advice and help to smokers to stop smoking. See NICE's guideline on tobacco. [2004]

1.4.8Inform people about local initiatives by, for example, healthcare teams or patient organisations that provide support and promote healthy lifestyle change, especially those that include group work for motivating lifestyle change. [2004]

For a short explanation of why the committee deleted the recommendation on relaxation therapies and how this might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review H: relaxation therapies.

Starting antihypertensive drug treatment

NICE has produced a patient decision aid on treatment options for hypertension to help people and their healthcare professionals discuss the different types of treatment and make a decision that is right for each person.

For advice on shared decision making for medicines, see the information on patient decision aids in NICE's guideline on medicines optimisation.

To support adherence and ensure that people with hypertension make the most effective use of their medicines, see NICE's guideline on medicines adherence.

1.4.9Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity (see also NICE's guideline on multimorbidity). [2019]

1.4.10Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:

1.4.11Discuss with the person their individual cardiovascular disease risk and their preferences for treatment, including no treatment, and explain the risks and benefits before starting antihypertensive drug treatment. Continue to offer lifestyle advice and support them to make lifestyle changes (see the section on lifestyle interventions), whether or not they choose to start antihypertensive drug treatment. [2019]

1.4.12Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10‑year risk below 10%. Bear in mind that 10‑year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease. [2019]

1.4.13Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with stage 1 hypertension if their clinic blood pressure is over 150/90 mmHg. Use clinical judgement for people with frailty or multimorbidity (see also NICE's guideline on multimorbidity). [2019]

1.4.14For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks. [2019]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review C: initiating treatment.

Monitoring treatment and blood pressure targets

For specific recommendations on blood pressure control in people with other conditions or who are pregnant, see also the NICE guidelines on chronic kidney disease, type 1 diabetes and hypertension in pregnancy.

1.4.15Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension. [2019]

1.4.16Measure standing as well as seated blood pressure (see recommendation 1.1.6) in people with hypertension and:

  • with type 2 diabetes or

  • with symptoms of postural hypotension or

  • aged 80 and over.

    In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure. [2019]

1.4.17Advise people with hypertension who choose to self-monitor their blood pressure to use HBPM. (NHS England is supporting the use of HBPM through the blood pressure@home scheme.) [2019]

1.4.18Consider ABPM or HBPM, in addition to clinic blood pressure measurements, for people with hypertension identified as having a white-coat effect or masked hypertension (in which clinic and non-clinic blood pressure results are conflicting). Be aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurements (see recommendation 1.2.8 for diagnostic thresholds). [2019]

1.4.19For people who choose to use HBPM, provide:

  • training and advice on using home blood pressure monitors

  • information about what to do if they are not achieving their target blood pressure.

    Be aware that the corresponding measurements for HBPM are 5 mmHg lower than for clinic measurements (see recommendation 1.2.8 for diagnostic thresholds). [2019]

1.4.20For adults with hypertension aged under 80, reduce clinic blood pressure to below 140/90 mmHg and ensure that it is maintained below that level. [2019, amended 2022]

1.4.21For adults with hypertension aged 80 and over, reduce clinic blood pressure to below 150/90 mmHg and ensure that it is maintained below that level. Use clinical judgement for people with frailty or multimorbidity (see also NICE's guideline on multimorbidity). [2019, amended 2022]

1.4.22When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person's usual waking hours (see recommendations 1.2.6 and 1.2.7). Reduce blood pressure and ensure that it is maintained:

  • below 135/85 mmHg for adults aged under 80

  • below 145/85 mmHg for adults aged 80 and over.

    Use clinical judgement for people with frailty or multimorbidity (see also NICE's guideline on multimorbidity). [2019, amended 2022]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review B: monitoring the response to treatment.

1.4.23Use the same blood pressure targets for people with and without cardiovascular disease. [2022]

For a short explanation of why the committee made the recommendation on blood pressure targets for people with cardiovascular disease and how this might affect practice, see the .

Full details of the evidence and the committee's discussion are in the evidence review J: blood pressure targets.

1.4.24Provide an annual review of care for adults with hypertension to monitor blood pressure, provide people with support, and discuss their lifestyle, symptoms and medication. [2004]

Treatment review when type 2 diabetes is diagnosed

1.4.25For an adult with type 2 diabetes on antihypertensive drug treatment when diabetes is diagnosed, review blood pressure control and medications used. Make changes only if there is poor control or if current drug treatment is not appropriate because of microvascular complications or metabolic problems. [2009]

Choosing antihypertensive drug treatment (for people with or without type 2 diabetes)

The recommendations in this section apply to people with hypertension with or without type 2 diabetes. They replace the recommendations on diagnosing and managing hypertension in NICE's guideline on type 2 diabetes in adults. For guidance on choosing antihypertensive drug treatment in people with type 1 diabetes, see also the section on control of cardiovascular risk in NICE's guideline on type 1 diabetes.

Note that ACE inhibitors and angiotensin II receptor antagonists should not be used in pregnant or breastfeeding women or women planning pregnancy unless absolutely necessary, in which case the potential risks and benefits should be discussed. Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, recommendations on how to use for breastfeeding and the related clarification on breastfeeding.

1.4.26For guidance on choice of hypertensive agent in people with chronic kidney disease, see NICE's guideline on chronic kidney disease. If possible, offer treatment with drugs taken only once a day. [2004]

1.4.27Prescribe non-proprietary drugs if these are appropriate and minimise cost. [2004]

1.4.28Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure. [2004]

1.4.29Offer antihypertensive drug treatment to women of childbearing potential with diagnosed hypertension in line with the recommendations in this guideline. For women considering pregnancy or who are pregnant or breastfeeding, manage hypertension in line with the recommendations on management of pregnancy with chronic hypertension, and on antihypertensive treatment while breastfeeding in NICE's guideline on hypertension in pregnancy. [2010, amended 2019]

1.4.30When choosing antihypertensive drug treatment for adults of Black African or African–Caribbean family origin, consider an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor. [2019]

Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, how to use for breastfeeding and clarification on breastfeeding.

1.4.31For people with cardiovascular disease:

For a short explanation of why the committee made the recommendation on choosing antihypertensive drug treatment for people with cardiovascular disease and how this might affect practice, see the .

Full details of the evidence and the committee's discussion are in the evidence review K: pharmacological treatment in cardiovascular disease.

Step 1 treatment

1.4.32Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:

1.4.33If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB to treat hypertension. [2019]

Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, how to use for breastfeeding and clarification on breastfeeding.

1.4.34Do not combine an ACE inhibitor with an ARB to treat hypertension. [2019]

1.4.35Offer a calcium-channel blocker (CCB) to adults starting step 1 antihypertensive treatment who:

  • are aged 55 or over and do not have type 2 diabetes or

  • are of Black African or African–Caribbean family origin and do not have type 2 diabetes (of any age). [2019]

1.4.36If a CCB is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension. [2019]

1.4.37If there is evidence of heart failure, offer a thiazide-like diuretic and follow NICE's guideline on chronic heart failure. [2019]

1.4.38If starting or changing diuretic treatment for hypertension, offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [2019]

1.4.39For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment. [2019]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review E: step 1 treatment.

Step 2 treatment

1.4.40Before considering next step treatment for hypertension discuss with the person if they are taking their medicine as prescribed and support adherence in line with NICE's guideline on medicines adherence. [2019]

1.4.41If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step 1 treatment:

  • a CCB or

  • a thiazide-like diuretic. [2019]

1.4.42If hypertension is not controlled in adults taking step 1 treatment of a CCB, offer the choice of 1 of the following drugs in addition to step 1 treatment:

  • an ACE inhibitor or

  • an ARB or

  • a thiazide-like diuretic. [2019]

1.4.43If hypertension is not controlled in adults of Black African or African–Caribbean family origin who do not have type 2 diabetes taking step 1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step 1 treatment. [2019]

Step 3 treatment

1.4.44Before considering next step treatment for hypertension:

  • review the person's medications to ensure they are being taken at the optimal tolerated doses and

  • discuss adherence (see recommendation 1.4.40). [2019]

1.4.45If hypertension is not controlled in adults taking step 2 treatment, offer a combination of:

  • an ACE inhibitor or ARB (see also recommendation 1.4.30 for people of Black African or African–Caribbean family origin) and

  • a CCB and

  • a thiazide-like diuretic. [2019]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review F: step 2 and step 3 treatment.

Step 4 treatment

1.4.46If hypertension is not controlled in adults taking the optimal tolerated doses of an ACE inhibitor or an ARB plus a CCB and a thiazide-like diuretic, regard them as having resistant hypertension. [2019]

1.4.47Before considering further treatment for a person with resistant hypertension:

  • Confirm elevated clinic blood pressure measurements using ambulatory or home blood pressure recordings.

  • Assess for postural hypotension.

  • Discuss adherence (see recommendation 1.4.40). [2019]

1.4.48For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice. [2019]

Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, how to use for breastfeeding and clarification on breastfeeding.

1.4.49Consider further diuretic therapy with low-dose spironolactone for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of 4.5 mmol/l or less. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia. [2019]

In March 2019, this was an off-label use of some preparations of spironolactone. See NICE's information on prescribing medicines.

1.4.50When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium and potassium and renal function within 1 month of starting treatment and repeat as needed thereafter. [2019]

1.4.51Consider an alpha-blocker or beta-blocker for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4.5 mmol/l. [2019]

1.4.52If blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4 drugs, seek specialist advice. [2019]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review G: step 4 treatment.

1.5 Identifying who to refer for same-day specialist review

1.5.1If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral (see recommendation 1.5.2), carry out investigations for target organ damage (see recommendation 1.3.3) as soon as possible:

  • If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

  • If no target organ damage is identified, confirm diagnosis by:

     

    • repeating clinic blood pressure measurement within 7 days, or

    • considering monitoring using ABPM (or HBPM if ABPM is not suitable or not tolerated), following recommendations 1.2.6 and 1.2.7, and ensuring a clinical review within 7 days. [2019]

     

1.5.2Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

  • signs of retinal haemorrhage or papilloedema (accelerated hypertension) or

  • life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. [2019]

1.5.3Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). [2019]

For a short explanation of why the committee made the 2019 recommendations and how they might affect practice, see the .

Full details of the evidence and the committee's discussion are in evidence review I: same-day specialist review.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary.

Accelerated hypertension

A severe increase in blood pressure to 180/120 mmHg or higher (and 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.

Established cardiovascular disease

Medical history of ischaemic heart disease, cerebrovascular disease, peripheral vascular disease, aortic aneurysm or heart failure. Cardiovascular disease is a general term for conditions affecting the heart or blood vessels. It is usually associated with a build-up of fatty deposits inside the arteries (atherosclerosis) and an increased risk of blood clots. It can also be associated with damage to arteries in organs such as the brain, heart, kidneys and eyes through deposition of glassy material within the artery walls (arteriosclerosis). Cardiovascular disease is 1 of the main causes of death and disability in the UK, but it can often largely be prevented by leading a healthy lifestyle.

Masked hypertension

Clinic blood pressure measurements are normal (less than 140/90 mmHg), but blood pressure measurements are higher when taken outside the clinic using average daytime ambulatory blood pressure monitoring (ABPM) or average home blood pressure monitoring (HBPM) blood pressure measurements.

Persistent hypertension

High blood pressure at repeated clinical encounters.

Stage 1 hypertension

Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg.

Stage 2 hypertension

Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.

Stage 3 or severe hypertension

Clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.

Target organ damage

Damage to organs such as the heart, brain, kidneys and eyes. Examples are left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy or increased urine albumin:creatinine ratio.

White-coat effect

A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.