Hypertension Management

Hypertension Classification

Stage and Criteria

Stage 1Clinic BP ≥ 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP ≥ 135/85 mmHg
Stage 2Clinic BP ≥ 160/100 mmHg and subsequent ABPM daytime or HBPM average BP ≥ 150/95 mmHg
Stage 3Clinic BP ≥ 180 mmHg, or clinic diastolic BP ≥ 110 mmHg


  • ABPM: Ambulatory Blood Pressure Monitoring
  • HBPM: Home Blood Pressure Monitoring

Note: Clinic BP is usually higher than ABPM and HBPM because some people get stressed or anxious while at a clinic, causing a slight increase in BP.

Management of Hypertension

Lifestyle Advice

  • Low salt diet
  • Reduce caffeine intake
  • Stop smoking
  • Drink less alcohol
  • Eat a balanced diet rich in fruits and vegetables
  • Exercise more
  • Lose weight

When to Treat Stage 1 Hypertension

  • Treat if the patient’s age is < 80 years and has any of the following:
  • Target organ damage
  • Established cardiovascular disease
  • Renal disease
  • Diabetes
  • A 10-year cardiovascular risk equivalent to 20% or more

Note: If a patient has stage 1 hypertension but is otherwise healthy, recommend lifestyle and diet modifications with regular follow-up.
When to Treat Stage 2 Hypertension

  • Always treat if ABPM or HBPM confirms hypertension with BP ≥ 150/95 mmHg
  • For patients < 40 years with stage 2 hypertension or higher, consider specialist referral to exclude secondary causes of hypertension

Initial Treatment Steps Based on Age and Ethnicity

Patient GroupStep 1 Management
Patients < 55 yearsStart with ACE inhibitor (ACEi) or ARB
Patients ≥ 55 years or Afro-Caribbean origin (any age)Start with Calcium channel blocker (CCB)
White < 55 yearsStart with ACEi or ARB
White ≥ 55 yearsStart with CCB
Afro-Caribbean (any age)Start with CCB

Stepwise Management

  • Step 1:
  • Patients < 55 years: Start with ACEi or ARB
  • Patients ≥ 55 years or Afro-Caribbean: Start with CCB
  • Step 2:
  • If still hypertensive after step 1, combine ACEi or ARB with CCB (A + C)
  • Step 3:
  • If still hypertensive after step 2, add a thiazide diuretic (A + C + D)
  • Examples:
  • ACEi: Enalapril
  • CCB: Amlodipine
  • Thiazide diuretics: Chlorthalidone, Indapamide
  • Step 4 (Resistant Hypertension):
  • Consider further diuretic treatment
  • If potassium < 4.5 mmol/L, add spironolactone (25 mg once daily)
  • If potassium > 4.5 mmol/L, add a higher-dose thiazide-like diuretic
  • If further diuretic therapy is not tolerated, consider alpha- or beta-blockers
  • Refer to a specialist if hypertension remains uncontrolled with four drugs

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