Cardiology · NICE

Hypertension in adults

NICE

Source:NICE NG136 Hypertension in adults: diagnosis and management (last updated November 2023)

Verified Apr 2026

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Red Flags

BP ≥180/120 with retinal haemorrhages, papilloedema, or new acute end-organ damage — same-day specialist assessment^[1]
Suspected phaeochromocytoma (labile BP, headaches, sweating, palpitations) — endocrine workup before treatment escalation^[1]
Pregnancy with BP ≥140/90 — same-day obstetric medicine review^[1]
Resistant hypertension uncontrolled on optimal triple therapy — investigate secondary causes; consider spironolactone (PATHWAY-2)^[1]

First-line treatment

Interventions

Stepped therapy (A → A+C → A+C+D → resistant)^[1]
Step 1 (A or C per algorithm) → Step 2 (A+C) → Step 3 (A+C+D) → Step 4 add spironolactone or alpha-/beta-blocker
Lifestyle modification^[1]
Salt <6 g/day, healthy diet, regular activity, weight reduction, alcohol moderation, smoking cessation

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Amlodipine (CCB)^[1]	Calcium channel blocker	5–10 mg PO once daily	—	Step 1 if age ≥55 OR Black African / African-Caribbean origin (any age) without T2DM
Ramipril or losartan^[1]	ACE inhibitor or ARB	Ramipril 1.25–10 mg daily; losartan 50–100 mg daily	—	Step 1 if age <55 without Black African/Caribbean origin, OR T2DM at any age. ARB preferred over ACE-i in Black African/Caribbean origin patients with T2DM
Indapamide^[1]	Thiazide-like diuretic	1.5 mg sustained-release once daily OR 2.5 mg standard daily	—	Step 3 partner. Preferred over hydrochlorothiazide
Spironolactone (low-dose)^[1]	Aldosterone antagonist	12.5–50 mg PO once daily; monitor K+ and creatinine 4 weeks after initiation	—	Step 4 in resistant hypertension if K+ ≤4.5 mmol/L (per PATHWAY-2)

Amlodipine (CCB)^[1]

Calcium channel blocker

Adult: 5–10 mg PO once daily
Paediatric: —

Step 1 if age ≥55 OR Black African / African-Caribbean origin (any age) without T2DM

Ramipril or losartan^[1]

ACE inhibitor or ARB

Adult: Ramipril 1.25–10 mg daily; losartan 50–100 mg daily
Paediatric: —

Step 1 if age <55 without Black African/Caribbean origin, OR T2DM at any age. ARB preferred over ACE-i in Black African/Caribbean origin patients with T2DM

Indapamide^[1]

Thiazide-like diuretic

Adult: 1.5 mg sustained-release once daily OR 2.5 mg standard daily
Paediatric: —

Step 3 partner. Preferred over hydrochlorothiazide

Spironolactone (low-dose)^[1]

Aldosterone antagonist

Adult: 12.5–50 mg PO once daily; monitor K+ and creatinine 4 weeks after initiation
Paediatric: —

Step 4 in resistant hypertension if K+ ≤4.5 mmol/L (per PATHWAY-2)

Safety-net

Take medication every day even when feeling well — hypertension is silent until target organs are damaged^[1]
Sudden severe headache, chest pain, vision changes, slurred speech, or one-sided weakness — call emergency services immediately^[1]
Bring your home BP record to every visit; HBPM helps detect white-coat and masked hypertension^[1]

Referral criteria

BP ≥180/120 with retinal haemorrhages, papilloedema, or new acute end-organ damageSame-day specialist (acute medicine or hypertension clinic)^[1]
Resistant hypertension uncontrolled on triple therapyHypertension clinic for secondary cause workup^[1]
Pregnancy with BP ≥140/90Obstetric medicine same-day^[1]
Suspected secondary cause (young age, abrupt onset, hypokalaemia, abdominal bruit, paroxysmal symptoms)Endocrinology or nephrology^[1]

Clinical summary

Diagnosis and management of hypertension in adults via stepped pharmacotherapy with primary-care emphasis.

References

1.NICE NG136 Hypertension in adults: diagnosis and management (last updated November 2023) (2023)

Drug

Class

Adult

Paediatric

Notes