High and Low blood pressure


High and low blood pressure

Hypotension (under 90/60)

  • fludrocortisone 100–400 micrograms daily
  • Midrodine - for severe orthostatic hypotension due to autonomic dysfunction when corrective factors have been ruled out and other forms of treatment are inadequate Initially 2.5 mg 3 times a day, increased if necessary up to 10 mg 3 times a day, dose to be increased at weekly intervals, according to blood pressure measurements; usual maintenance 10 mg 3 times a day, avoid administration at night; the last daily dose should be taken at least 4 hours before bedtime


Stage 1 hypertension

Clinic BP 140/90 mmHg - 159/99 mmHg and subsequent ABPM daytime average or HBPM average BP ranging from 135/85 mmHg - 149/94 mmHg

Stage 2 hypertension

Clinic BP 160/100 mmHg - 180/120 mmHg and subsequent ABPM daytime average or HBPM average BP > 150/95 mmHg

Stage 3 or severe hypertension

Clinic systolic BP > 180 mmHg or clinic diastolic BP >120 mmHg

Chronic Kidney Disease

If ACR > 70 mg/mmol aim for BP < 130/80 mmHg

Offer lifestyle advice 

  • exercise patterns
  • healthy diet
  • alcohol consumption
  • discourage excessive consumption of coffee and other caffeine-rich products
  • sodium intake
  • smoking.
Continue to offer lifestyle advice and support them to make lifestyle changes whether or not they choose to start antihypertensive drug treatment.

Assess risk 

Stage 1 hypertension 

Age > 80
  • treat if their clinic blood pressure is over 150/90 mmHg
  • Use clinical judgement for people with frailty or multimorbidity 
Age 60-80 

Treat if 1 or more of the following: 

  • Q Risk > 10%
  • renal disease
  • diabetes
  • target organ damage
  • established cardiovascular disease
  • Use clinical judgement for people with frailty or multimorbidity 
Age 40- 60 

Treat even if Q Risk < 10% as it may underestimate the lifetime probability of developing cardiovascular disease

Age < 40 

seek specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks

Stage 2 hypertension

  • offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension
  • use clinical judgement for people of any age with frailty or multimorbidity  
 Postural hypertension

Measure standing as well as seated blood pressure in people with hypertension and:

  • with type 2 diabetes or
  • with symptoms of postural hypotension or
  • aged 80 and over.
  • In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure.
  • Advise people with hypertension who choose to self-monitor their blood pressure to use HBPM
  • Be aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurements
  • Good for white-coat syndrome
  • Masked hypertension (in which clinic and non-clinic blood pressure results are conflicting)
  • When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person's usual waking hours 4]


Co-morbidity with hyoertension and preferred ACE Inhibitor

Co-morbidity enalapril lisinoril perindopril ramipril trandopril
heart failure a a   a a
diabetes a a a a a
myocardial infarction (without heart failure)   a a a  


Calcium Channel blocker (CCB)

Thiazide-like diuretics


Step 1

For patients who

  • have type 2 diabetes and are of any age or family origin or
  • are aged under 55 but not of black African or African–Caribbean family origin
    • Offer an ACE inhibitor or an ARB 
    • If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB to treat hypertension.
    • Do not combine an ACE inhibitor with an ARB to treat hypertension. 

 For patients who

  • are aged 55 or over and do not have type 2 diabetes or
  • are of black African or African–Caribbean family origin and do not have type 2 diabetes (of any age)
    • Offer a CCB
    • If a CCB is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension such as indapamid
    • For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment. 
 Step 2 


  • a CCB

  • a thiazide-like diuretic

  • an ACE inhibitor

  • an ARB

Black African or African–Caribbean family origin who do not have diabetes: avoid ACE

Step 3  
  • an ACE inhibitor or ARB  and

  • a CCB and

  • a thiazide-like diuretic. 

Step 4 Resistant hypertension
  • if serum K+ level < 4.5 mmol/l & eGFR >60
    • spironolactone then BT
  • if serum K+ level > 4.5 mmol/l
    • alpha-blocker or beta-blocker 
Step 5 seek specialist advice

BP > 180/120 mmHg or higher

Assess for target organ dammage

  • signs of retinal haemorrhage or papilloedema (accelarated hypertension) or

  • life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury

  • If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

  • If no target organ damage is identified, repeat clinic blood pressure measurement within 7 days

 Refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

Chronic Kidney Disease 

  • ACE inhibitors have renoprotective properties and may also prevent and control diabetic nephropathy & retinopathy
  • ARBs have not been shown to be as protecting as  ACE inhibitors
  •  Do not offer a combination of renin–angiotensin system antagonists to people with CKD
  • Do not start if serum K+ > 5.0 mmol/litre
  • Concurrent prescription of drugs known to promote hyperkalaemia is not a contraindication to the use of renin–angiotensin system antagonists, but be aware that more frequent monitoring of serum potassium concentration may be required.
  • Stop if K+ > 6.0 mmol/litre 

Pre-pregnancy advice

Increased risks of congenital malformation are associated with

  • ACE inhibitors
  • ARBs
  • thiazide or thiazide-like diuretics

Switch hypertensive medication to:

  • labetalol (firstline) 
    • 100 mg bd, increased at intervals of 14 days; usual dose 200 mg BD, increased if necessary up to 400 mg BD, Max dose 2.4g to be given in 3–4 divided doses; 
    • to be taken with food
    • avoid in asthmatics & type 1 diabetic (part of the warning system for hypo’s is palpitations, labetalol will stop this happening)
    • side effects: oedema/scalp tingling/ headaches/weakness/liver damage/GI disturbances
  • nifedipine (secondline) 
    • 10mg SR bd, max dosage 80mgs
    • Avoid: Grapefruit juice increases blood levels
    • Side effects: May inhibit labour/ headaches/ flushing/ dizziness/ palpitations/fluid retention
  • methyldopa (thirdline)
    • 250mgs TDS as starting dose, max dosage 3g daily
    • C/I: severe depressives, post natal due to risk of PN depression (stop within 2 days of delivery)
    • Side effects: depression and tiredness/dry mouth/GI disturbances 

Pregnancy and pre-eclampsia risk

Pregnant women are at high risk of pre-eclampsia if they have any of the following:

  • chronic hypertension
  • hypertensive disease during a previous pregnancy
  • chronic kidney disease
  • autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome
  • type 1 or type 2 diabetes

For these women prescribe aspirin 75–150 mg daily from 12 weeks until the birth of the baby  



bendroflumethiazide hydrochlorothiazide indapamid spironolactone labetalol nifedipine methyldopa

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