Step 1: Salt and Satiety 

• Educate people about the salt content of processed foods.
• Swap domestic table salt to a potassium enriched product.
• Support people to achieve and maintain a healthy weight.

Step 2: Sensible Drugs, Sensible Doses

• Follow BIHS-endorsed NICE therapeutic algorithm (A + C + D + 4th line agent).
• Select drugs based on clinical efficacy, long duration of action, simple dosing schedule.
• Use single pill combinations where available.
• Blood pressure target < 130/80 mmHg in most people.

Step 3: pSeudo Resistant Hypertension?

• Confirm blood pressure is elevated on ABPM or HBPM.
• Confirm medication adherence using Direct Observed Therapy or urine drug screen.
• Review concurrent medications, over-the-counter remedies and substances of abuse.

Step 4: Secondary Hypertension

• Rare in the general hypertensive population.
• Higher prevalence among people with renal disease, pregnancy, hyperaldosteronism.
• Request screening blood tests, urine analysis, renal imaging.
• Refer to a hypertension specialist based on results and clinical suspicion.

Step 1: Prepare the Environment

• Quiet and calm room with comfortable ambient temperature.
• Explain the procedure to the person and receive informed consent.
• Use a validated automated device with the correct cuff size.
• Exclude abnormal heart rhythms (automatic devices are unreliable in AF).

Step 2: Prepare the Person

• No exercise, smoking or caffeine for 30 minutes.
• Empty urinary bladder.
• Seated comfortably and relaxed for 5 minutes.
• Bare upper arm supported at heart level.
• Back supported, legs uncrossed, feet flat on the floor.

Step 3: Record the Blood Pressure Measurement

• Place centre of cuff bladder over brachial artery.
• Ensure lower edge of the cuff 2cm above the antecubital fossa.
• Do not talk during or between measurements.
• Measure blood pressure three times (1 minute apart).
• Record the average of the last 2 readings.

Young-onset hypertension defined as hypertension diagnosed before age 40, carries a high lifetime risk of cardiovascular disease. Early identification and management are essential to reduce long-term complications.

The BIHS recommends the following structured approach to the investigation and management of young-onset hypertension

• Confirm diagnosis with ambulatory or home BP monitoring.
• Investigate for secondary causes as these are more prevalent among younger people.
• Assess for hypertension-mediated organ damage.
• Support lifestyle modification including reduced dietary salt, weight management and exercise and moderation of alcohol.
• Initiate pharmacological therapy if BP ≥160/100 mmHg, or hypertension-mediated organ damage or high lifetime risk or if lifestyle measures are insufficient after 3–6 months among lower-risk people.
• Follow-up and BP targets should be tailored to the individual. The BIHS recommend a BP target of <130/80 mmHg to be achieved within 6 months, in most people.

Primary hyperaldosteronism is a condition in which the adrenal glands produce too much aldosterone. It affects between 2% and 10% of people with high blood pressure. It is more common among those with severe and resistant hypertension. It is associated with a higher risk of stroke, heart disease, atrial fibrillation, heart failure, diabetes, and metabolic syndrome. Almost all people living with primary hyperaldosteronism are asymptomatic.

General Management Principles

• The screening test for primary hyperaldosteronism is the plasma aldosterone to renin ratio (ARR). This test is most accurate before antihypertensive drugs are initiated.
• If ARR is suggestive of primary hyperaldosteronism, further tests are required to confirm the diagnosis. For example: oral sodium loading test, saline infusion test, captopril challenge test.
• Treatment options include surgery for confirmed unilateral primary hyperaldosteronism or medical treatment with Mineralocorticoid Receptor Antagonists (MRAs).
• Spironolactone is the first line drug for the management of primary hyperaldosteronism.
• Eplerenone is a weaker MRA compared with spironolactone, but is more selective and thus may be better tolerated.
• There are currently no randomised controlled trials directly comparing outcomes between adrenalectomy and the medical management of unilateral primary hyperaldosteronism.

Resistant hypertension is defined as uncontrolled blood pressure despite optimal treatment with three antihypertensive agents including a diuretic. People in whom blood pressure is controlled on more than 3 antihypertensive drugs may also be considered to have resistant hypertension. Resistant hypertension is associated with increased risk of adverse cardiovascular and renal outcomes.

The BIHS recommends the following structured approach to the investigation and management of resistant hypertension

1. Identify people with potential resistant hypertension by systematic screening of health records and opportunistic encounters.
2. Exclude pseudo-resistant hypertension including inaccurate blood pressure measurement, white-coat hypertension, non-adherence to therapy, sub-optimal treatment regimens, drug-induced hypertension.
3. Exclude secondary causes of hypertension.
4. Support lifestyle modification including reduced dietary salt, weight management, exercise and moderation of alcohol.
5. Optimise antihypertensive therapy and consider the addition of spironolactone as a fourth-line agent.
6. Consider referral to a hypertension specialist for management advice.

Hypertensive crisis is a rare but acute severe elevation in blood pressure. Although only 1% of all people with a diagnosis of hypertension develop an episode of hypertensive crisis in their lifetime, it can cause rapid organ damage and death.

Presentations of Hypertensive Crisis

• Acute severe hypertension: Typically blood pressure ≥180/120 mmHg without acute end‑organ damage.
• Hypertensive emergency: Acute severe elevation in blood pressure associated with life-threatening end organ damage.
• Malignant hypertension: Severe hypertension (typically, diastolic blood pressure ≥120 mmHg) with bilateral grade 3 or grade 4 hypertensive retinopathy.

General Management Principles

• Acute severe hypertension AND acute end organ damage refer to the Emergency Department for same-day assessment and management.
• Acute severe hypertension WITHOUT end organ damage, initiate and/or up-titrate antihypertensive medication. Review blood pressure within 1 week.
• In general, aim for controlled and gradual blood pressure reductions. Sudden blood pressure reductions may cause hypoperfusion and organ injury from impaired autoregulation.

What is Systolic Blood Pressure Variability ?

• Fluctuations in systolic blood pressure over time (known as blood pressure variability) increase the risk of stroke, heart disease, kidney disease, dementia.
• Even in people with well controlled average blood pressure, high systolic blood pressure variability is associated with poorer health outcomes.
• Standard deviation is most often used to describe how much individual blood pressure readings vary from the average.
• A standard deviation above 12 indicates high systolic blood pressure variability.

Practical Strategies to Reduce Blood Pressure Variability

• Support people to take their antihypertensive medication consistently and at the same time each day.
• Non-pharmacological therapies, including achieving and maintaining a healthy weight, have been shown to reduce blood pressure variability.
• Use of long-acting calcium channel blockers (for example, amlodipine) and to a lesser extent thiazide-like diuretics (for example, chorthalidone) have been shown to reduce systolic blood pressure variability and improve health outcomes in post-hoc analyses of large clinical trials.

The goal of antihypertensive treatment is to achieve good blood pressure control with low systolic blood pressure variability

Hypertension affects 10% of all pregnancies and is a major cause of maternal and fetal morbidity and mortality worldwide. There are three main presentations:

• Chronic hypertension: Hypertension occurring before 20 weeks of pregnancy.
• Gestational hypertension: New-onset hypertension occurring after 20 weeks of pregnancy without proteinuria.
• Pre-eclampsia: Either new-onset hypertension occuring after 20 weeks of pregnancy with proteinuria OR new-onset hypertension occuring after 20 weeks of pregnancy with proteinuria and/or other organ involvement.

General Management Principles

• Advise women and their partners about the signs and symptoms of pre-eclampsia and encourage them to seek prompt medical attention.
• For women at risk of pre-eclampsia, offer 150 mg of aspirin nightly from 12 weeks of pregnancy until birth.
• First-line antihypertensive treatment for the management of mild to moderate hypertension in pregnancy include labetalol, modified release nifedipine, amlodipine, methyldopa.
• Management of severe hypertension in pregnancy should be considered an emergency due to the risk of developing pre-eclampsia. Expert advice should be sort. Delivery is the only definitive treatment for pre-eclampsia.
• Women who have experienced hypertension during pregnancy have an increased lifetime risk of cardiovascular disease. Long-term follow-up and management of modifable risk factors is important.

• Dr Luca Faconti, BIHS Education Committee Chair, Kings College London
• Dr Sally Brett,  BIHS Education Committee Member, Kings College London 
• Dr Tehreem Butt, BIHS Education Committee Member, Mid and South Essex NHS Foundation Trust 
• Dr Samuel Duffy, BIHS Education Committee Member, South Tyneside and Sunderland NHS Foundation Trust 
• Dr Emily Haseler,  BIHS Education Committee Member, Kings College London 
• Dr Roser Icart, BIHS Education Committee Member, Barts Health NHS Trust 
• Dr Bernadette Jenner, BIHS Member, Cambridge University Hospitals NHS Foundation Trust
• Dr Philip Lewis, BIHS Education Committee Member, Stockport NHS Foundation Trust (BIHS Education Committee Member)
• Dr Carmen Maniero, BIHS Education Committee Member, Barts Health NHS Trust 
• Dr Carmel McEniery, BIHS Education Committee Member, Cambridge University
• Dr Sarah Partridge, BIHS Member, Brighton & Sussex Medical School
• Dr Kalpana Sabapathy, BIHS Education Committee Member, The London School of Hygiene and Tropical Medicine
• Dr Abilash Sathyanarayanan, BIHS Education Committee Member, Nottingham University Hospitals
• Professor Peter Sever, BIHS Policy and Guidelines Committee Member, Imperial College London
• Professor Manish Sinha, BIHS Education Committee Member, Guy's & St Thomas's Foundation Hospitals NHS Trust
• Professor Ian Wilkinson, BIHS President and Chair of the Policy and Guidelines Committee, Cambridge University