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
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.