GPAtlas🧭 When to suspect
Hypertension is usually asymptomatic – the “silent killer” – so it is most often found through opportunistic screening or as an incidental clinic reading, rather than because the patient feels unwell. Suspect it when a clinic blood pressure (BP) is ≥ 140/90 mmHg, or when there is evidence of hypertension-mediated organ damage (left ventricular hypertrophy, chronic kidney disease, retinopathy or raised urine albumin:creatinine ratio).
A single high clinic reading is not a diagnosis. Because a discrepancy of more than 20/10 mmHg between clinic and out-of-office readings (the white-coat effect) is common, confirm the diagnosis with ambulatory BP monitoring (ABPM) – or home BP monitoring (HBPM) if ABPM is unsuitable or not tolerated – unless the clinic BP is in the severe range (≥ 180/120 mmHg), which warrants more urgent action. Adults with a normal BP should be screened at least every 5 years.
| Category | Clinic BP | ABPM / HBPM average |
|---|---|---|
| Normal / not diagnosed | < 140/90 mmHg | – |
| Stage 1 | 140/90 – 159/99 mmHg | 135/85 – 149/94 mmHg |
| Stage 2 | ≥ 160/100 (and < 180/120) mmHg | ≥ 150/95 mmHg |
| Stage 3 / severe | Systolic ≥ 180 or diastolic ≥ 120 mmHg | Confirm urgently / same-day review if indicated |
Raise suspicion of a secondary cause in anyone aged under 40, in resistant hypertension, or where the history points to it: paroxysmal headache, palpitations, pallor and sweating (phaeochromocytoma); muscle weakness or hypokalaemia (primary hyperaldosteronism / Conn’s); snoring and daytime somnolence (obstructive sleep apnoea); or renal disease. Always review BP-raising agents – NSAIDs, corticosteroids, combined oral contraceptives, venlafaxine, decongestants and liquorice.
Source: NICE NG136
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