Red Flags
- BP ≥180/120 mmHg with new neurological deficit, dyspnoea, chest pain, or AKI — hypertensive emergency, immediate IV therapy[1]
- Severe hypertension in pregnancy ≥20 weeks gestation — preeclampsia or eclampsia[2]
- BP elevation with hypokalaemia and metabolic alkalosis — screen for primary aldosteronism[1]
- Resistant hypertension — uncontrolled despite three agents at maximally tolerated doses including a diuretic[1]
First-line treatment
Interventions
- Lifestyle modification[1]Sodium <2 g/day, plant-based diet, ≥150 min/week moderate aerobic activity, weight reduction if BMI ≥25, alcohol limitation, smoking cessation
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Amlodipine + perindopril (single-pill combination)[1] | CCB + ACE inhibitor SPC | 5/4 mg once daily, up-titrate to 10/8 mg as needed | — | ESC 2024 strongly recommends starting with single-pill combinations to improve adherence |
| Telmisartan + amlodipine[1] | ARB + CCB SPC | 40/5 mg once daily, up-titrate to 80/10 mg | — | Alternative SPC, especially with diabetes or microalbuminuria |
| Indapamide[1] | Thiazide-like diuretic | 1.5 mg sustained-release once daily | — | Add as third agent if dual SPC inadequate; preferred over hydrochlorothiazide for cardiovascular outcomes |
| Empagliflozin[1] | SGLT2 inhibitor | 10–25 mg once daily | — | ESC 2024 recommends in hypertension with diabetes, heart failure, or CKD — modest BP reduction plus organ protection |
Amlodipine + perindopril (single-pill combination)[1]
CCB + ACE inhibitor SPC
- Adult
- 5/4 mg once daily, up-titrate to 10/8 mg as needed
- Paediatric
- —
ESC 2024 strongly recommends starting with single-pill combinations to improve adherence
Telmisartan + amlodipine[1]
ARB + CCB SPC
- Adult
- 40/5 mg once daily, up-titrate to 80/10 mg
- Paediatric
- —
Alternative SPC, especially with diabetes or microalbuminuria
Indapamide[1]
Thiazide-like diuretic
- Adult
- 1.5 mg sustained-release once daily
- Paediatric
- —
Add as third agent if dual SPC inadequate; preferred over hydrochlorothiazide for cardiovascular outcomes
Empagliflozin[1]
SGLT2 inhibitor
- Adult
- 10–25 mg once daily
- Paediatric
- —
ESC 2024 recommends in hypertension with diabetes, heart failure, or CKD — modest BP reduction plus organ protection
Safety-net
- Take medication daily even when feeling well — hypertension causes no symptoms until target organs are damaged[1]
- Sudden severe headache, chest pain, vision changes, slurred speech, or one-sided weakness — call emergency services immediately[1]
- Avoid NSAIDs (ibuprofen, diclofenac, naproxen) — they raise BP and worsen kidney function. Use paracetamol for pain[1]
Referral criteria
- BP ≥180/120 with neurological deficit, chest pain, dyspnoea, or AKIEmergency department for IV antihypertensive and end-organ workup[1]
- Resistant hypertension despite three agents including diuretic at maximum tolerated dosesHypertension clinic; consider renal denervation evaluation[1]
- Stage 2 hypertension with positive primary aldosteronism screen (high ARR)Endocrinology for confirmatory testing and adrenal imaging[1]
- Pregnancy with BP ≥140/90 mmHgObstetric medicine same-day[2]
Clinical summary
Diagnosis and management of elevated blood pressure and hypertension in adults, including a new 'elevated BP' category for SBP 120–139 or DBP 70–89 mmHg.