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Health condition · Clinically reviewed

High blood pressure, confirmed properly, treated by the ladder.

Around one in three UK adults - and half don\'t know it. This guide covers what the numbers mean, how it is confirmed, and the NICE step-based approach to bringing it under control. See also our clinical hub at hypertension.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE NG136, ESC/ESH and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK guidance including ABPM confirmation, step-based therapy and renal denervation.

Key facts

High blood pressure at a glance.

The essentials, in plain English - what counts as high, why it matters, and how modern UK practice brings it under control.

  • How common

    Around one in three UK adults has raised blood pressure. Half are unaware, half are untreated or inadequately controlled.

  • What counts as high

    Clinic BP of 140/90 mmHg or above, confirmed by ABPM or HBPM averaging 135/85 or more (NICE NG136).

  • Essential vs secondary

    Around 90 per cent is essential (no single cause). Around 10 per cent is secondary to renal, endocrine, drug or sleep-apnoea causes.

  • Why treat it

    It is the single largest modifiable risk factor for stroke, heart attack, heart failure, kidney disease and vascular dementia.

  • First-line drugs

    ACE inhibitor or ARB, calcium-channel blocker, and thiazide-like diuretic (indapamide). Choice depends on age and ethnicity.

  • Resistant hypertension

    When three drugs at optimal doses fail, spironolactone, further specialist drugs, or renal denervation may be considered.

Why this guide matters

Confirm it. Stage it. Treat it by the ladder.

Three ideas do most of the heavy lifting when it comes to modern hypertension care - and they anchor everything else on this page.

  • ABPM or HBPM confirms the diagnosis

    A single high clinic reading isn't a diagnosis. NICE requires ambulatory or home monitoring so we don't treat white-coat effect, and we don't miss masked hypertension.

  • The step ladder does most of the work

    ACE inhibitor or ARB, calcium-channel blocker, thiazide-like diuretic - in a defined order with clear escalation. Most people get to target on this pathway alone.

  • Resistant hypertension is a specialist question

    Three drugs at optimal doses and still not at target? That is resistant hypertension - spironolactone, further specialist drugs, or renal denervation come next.

How the diagnosis is made

From a raised clinic reading to a confirmed plan.

The pathway a UK GP or specialist will normally follow, in order, so you know what to expect and why. Cardiovascular risk is estimated using QRISK3 - see our coronary disease prevention guide.

  1. 01

    Assessing

    Clinic BP measurement

    Seated, rested, correct cuff, both arms first time. A reading of 140/90 mmHg or above triggers further assessment.

  2. 02

    Assessing

    Confirm with ABPM or HBPM

    NICE NG136 requires ambulatory or home monitoring - hypertension is confirmed when the daytime average is 135/85 mmHg or above.

  3. 03

    Assessing

    Stage the hypertension

    Stage 1 (clinic 140/90, ABPM 135/85). Stage 2 (clinic 160/100, ABPM 150/95). Stage 3 severe (clinic 180/120 or above).

  4. 04

    Confirming

    Screen for end-organ damage

    Fundoscopy, ECG, urine ACR, U&Es, HbA1c, lipids and, where indicated, an echocardiogram to look for left-ventricular hypertrophy.

  5. 05

    Confirming

    Estimate cardiovascular risk

    QRISK3 sets the 10-year risk of stroke or heart attack - see our guide to coronary disease prevention for how this shapes treatment thresholds.

  6. 06

    Confirming

    Consider secondary causes

    Younger patients, resistant hypertension, or clues on history and bloods trigger a workup for renal, endocrine or sleep-related causes.

  7. 07

    Preparing

    Shared decision on treatment

    Lifestyle for everyone. Drug therapy for stage 2, or stage 1 with target-organ damage, diabetes, established cardiovascular disease or QRISK3 above 10 per cent.

Typical timeline: a first raised reading to a confirmed diagnosis in one to four weeks.

Essential vs secondary

When there is a specific cause behind the numbers.

Around 90 per cent of high blood pressure is essential - no single cause we can point to. Around 10 per cent has an identifiable driver worth chasing, especially in younger patients or resistant disease.

  • Renal parenchymal disease

    Chronic kidney disease, glomerular disease and polycystic kidneys - a raised creatinine, protein on ACR or abnormal ultrasound points the way.

  • Renal artery stenosis

    Atherosclerotic (older, vascular) or fibromuscular (younger women) - a bruit, asymmetric kidneys or a jump in creatinine after ACE inhibition is a clue.

  • Primary aldosteronism (Conn's)

    Low or low-normal potassium and hypertension - screen with aldosterone-to-renin ratio. See our page on Conn's syndrome (/conditions/hyperaldosteronism-conns-syndrome/) for the workup.

  • Cushing's syndrome

    Central weight gain, thin skin, easy bruising and hypertension - 24-hour urinary free cortisol or overnight dexamethasone suppression are first-line.

  • Phaeochromocytoma

    Paroxysmal severe hypertension with sweating, palpitations and headache - plasma or urinary metanephrines are the screening tests.

  • Hyperthyroidism

    Systolic hypertension with tachycardia, weight loss and heat intolerance - a suppressed TSH confirms the picture.

  • Acromegaly

    Enlarging hands and feet, coarse features and sweating - IGF-1 is the initial screen, with pituitary imaging if raised.

  • Hyperparathyroidism

    Raised calcium with a raised or inappropriately normal PTH - hypertension is common though rarely the main issue.

  • Drug-induced

    NSAIDs, oral contraceptives, decongestants, corticosteroids, ciclosporin, tacrolimus, VEGF inhibitors, licorice, cocaine and stimulants.

  • Obstructive sleep apnoea

    Snoring, witnessed apnoeas, unrefreshing sleep and daytime somnolence - STOP-BANG plus a sleep study, then CPAP where appropriate.

  • Coarctation of the aorta

    Radio-femoral delay, blood-pressure difference between arms and legs, and rib notching on chest X-ray - imaging confirms.

  • Pregnancy-related

    Gestational hypertension and pre-eclampsia - always managed on obstetric pathways, never as routine primary-care hypertension.

Symptoms

What high blood pressure feels like - and doesn\'t.

Most people feel entirely normal. The features below are worth knowing precisely because everyday hypertension is silent - and because a handful of red flags aren\'t.

  • Often silent

    Most people feel entirely well - which is why case-finding at pharmacies, workplace checks and NHS Health Checks matters.

  • Morning headache

    Occasional dull morning headache in severe hypertension - not a reliable everyday sign, and easily attributed to other causes.

  • Nosebleeds and visual blurring

    Uncommon, and mostly with severe or accelerated hypertension. Any new visual loss needs urgent assessment.

  • Palpitations or breathlessness

    Especially on exertion - may reflect left-ventricular hypertrophy or early heart failure from long-standing high pressure.

  • Peripheral oedema

    Ankle swelling from calcium-channel blockers, or from heart failure. Both deserve a proper look, not just a dose change.

  • Snoring and daytime sleepiness

    Obstructive sleep apnoea is a common, treatable driver of resistant hypertension - ask about it and screen with STOP-BANG.

  • Episodic sweating and palpitations

    Paroxysmal symptoms with severe surges in blood pressure raise the possibility of phaeochromocytoma - rare, but worth catching.

  • Red flag - accelerated hypertension

    BP 180/120 mmHg or above with new retinal haemorrhages, papilloedema or acute organ damage is a same-day emergency.

Treatment

How high blood pressure is treated in the UK.

Lifestyle first for everyone. Then a defined step-based drug ladder per NICE NG136, escalating until the target is reached or resistant hypertension is confirmed.

  • Lifestyle foundations

    DASH-style eating, salt below 6 g/day, weight loss where relevant, 150 minutes of moderate activity a week, alcohol within 14 units, no smoking, and caffeine review.

  • Step 1 - ACE inhibitor or ARB

    For patients under 55 not of Black African or Caribbean family origin, and for anyone with type 2 diabetes at any age. ARB if ACE cough is a problem.

  • Step 1 - calcium-channel blocker

    For patients aged 55 or over, and for those of Black African or Caribbean family origin at any age. Amlodipine is the usual choice.

  • Step 2 - add the other agent

    Combine an ACE inhibitor or ARB with a calcium-channel blocker (or a thiazide-like diuretic if CCB is not tolerated).

  • Step 3 - triple therapy

    ACE inhibitor or ARB plus calcium-channel blocker plus a thiazide-like diuretic such as indapamide - the standard NICE combination.

  • Step 4 - resistant hypertension

    If potassium is 4.5 mmol/L or below, add low-dose spironolactone. Otherwise consider an alpha- or beta-blocker, with specialist input.

  • Renal denervation

    A commissioned specialist option for truly resistant hypertension - catheter-based ablation of renal sympathetic nerves to lower blood pressure.

  • Baroreflex activation therapy

    An emerging device-based therapy for selected patients with resistant hypertension - available only in specialist tertiary centres.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or cardiologist knows your history and comorbidities and can tell you which parts apply to you. If in doubt, get seen.

  • NICE. Hypertension in adults: diagnosis and management (NG136).

  • European Society of Cardiology and European Society of Hypertension. Guidelines for the management of arterial hypertension.

  • British and Irish Hypertension Society. Standards and position statements.

  • MHRA. Safety updates on antihypertensive medicines.

  • NHS England. Clinical commissioning policy on renal denervation for resistant hypertension.

Red flags

When high blood pressure needs urgent attention.

Most hypertension is a slow, silent condition managed in primary care. These are the situations that aren\'t - and where same-day or specialist review is needed.

  • Accelerated (malignant) hypertension

    BP 180/120 mmHg or above with new fundal changes, papilloedema or acute organ damage - a same-day emergency admission.

  • Acute pulmonary oedema

    Breathlessness, pink frothy sputum and orthopnoea at high blood pressure - blue-light emergency and immediate IV therapy.

  • Suspected phaeochromocytoma

    Paroxysmal severe surges with sweating, palpitations and headache - urgent plasma metanephrines and endocrine referral.

  • Hypertension in pregnancy

    New BP 140/90 mmHg or above with proteinuria, headache or visual disturbance - pre-eclampsia pathway and same-day obstetric review.

  • Aortic dissection warning

    Sudden severe tearing chest or interscapular pain with a very high blood pressure - blue-light emergency and CT aortogram.

  • Stroke or TIA

    Facial droop, arm weakness or speech disturbance - immediate FAST assessment and hyperacute stroke pathway, not a routine BP review.

  • Refractory hypokalaemia

    Low potassium that won't stay corrected raises the possibility of primary aldosteronism - see Conn's syndrome for the workup.

  • Snoring with witnessed apnoeas

    Untreated obstructive sleep apnoea drives resistant hypertension - a sleep-study referral is often the fastest route to control.

  • Renal bruit or asymmetric kidneys

    Suggests renal artery stenosis - imaging with Doppler, CT or MR angiography and vascular referral where appropriate.

Living with it

A lifelong condition, controlled by daily choices.

Four things that make the biggest day-to-day difference - measure well, keep salt low, move regularly and take the tablets you\'ve been prescribed.

A quiet reminder

Consistency beats intensity, every time.

Small, steady habits kept up for years lower blood pressure more reliably than any six-week programme ever will.

  1. 01 Measure

    Own the numbers

    Validated home monitor, seated after five minutes' rest, two readings a minute apart, morning and evening for a week. Averages beat single readings.

  2. 02 Salt

    Below 6 g a day, honestly

    Most salt hides in bread, cereals, sauces and processed meat. Reading labels shifts blood pressure more than the salt cellar ever will.

  3. 03 Move

    150 minutes, split however suits

    Brisk walking, cycling, swimming, gardening - anything that raises the pulse. Even 10-minute blocks count towards the total.

  4. 04 Adhere

    Take the tablets - all of them

    Missed doses are the commonest reason for uncontrolled blood pressure. Fixed-dose combinations, pillboxes and phone reminders help.

Frequently asked

Everything we get asked about high blood pressure.

Quick answers on diagnosis, drug choice, resistant hypertension and renal denervation.

  • What counts as high blood pressure in the UK?

    A clinic reading of 140/90 mmHg or above, confirmed by ambulatory monitoring (ABPM) or home monitoring (HBPM) with a daytime average of 135/85 mmHg or above. This is the threshold NICE NG136 uses to diagnose hypertension and to consider treatment. This page covers the same condition as our clinical hub at /conditions/hypertension/.

  • Why is it called the silent killer?

    Because most people with high blood pressure feel entirely well. The damage - to arteries, heart, brain, kidneys and eyes - happens invisibly over years. It is the single largest modifiable risk factor for stroke and heart disease worldwide, which is why case-finding matters even when you feel fine.

  • What are the secondary causes I should know about?

    Around one in ten cases are secondary. The main groups are renal (chronic kidney disease, renal artery stenosis, glomerular disease), endocrine (primary aldosteronism or Conn's syndrome, Cushing's syndrome, phaeochromocytoma, hyperthyroidism, acromegaly, hyperparathyroidism), drug-induced (NSAIDs, oral contraceptives, decongestants, corticosteroids, ciclosporin, VEGF inhibitors), obstructive sleep apnoea and, rarely, coarctation of the aorta.

  • What is the NICE step-based drug approach?

    Step 1 is a single agent - ACE inhibitor or ARB if you are under 55 and not of Black African or Caribbean family origin, or if you have type 2 diabetes; calcium-channel blocker (usually amlodipine) if you are 55 or over, or of Black African or Caribbean family origin. Step 2 adds the other class. Step 3 is triple therapy with a thiazide-like diuretic such as indapamide. Step 4, for resistant hypertension, adds spironolactone if potassium is 4.5 mmol/L or below, or an alpha- or beta-blocker with specialist input.

  • What is renal denervation, and who is it for?

    A catheter-based procedure that ablates the sympathetic nerves running to the kidneys, reducing the neural drive to raise blood pressure. It is a commissioned NHS option for selected patients with true resistant hypertension after optimal medical therapy. Baroreflex activation therapy is a newer device-based approach available in specialist tertiary centres.

  • How is this page different from your hypertension guide?

    They cover the same medical condition - "high blood pressure" is simply the everyday name for hypertension. This page is written for people searching for the plain-English term, with more emphasis on what the numbers mean and what to do next. Our clinical hub at /conditions/hypertension/ is the fuller reference, and both pages link to the same treatments, tests and related conditions.

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