Hypertension Management in General Practice: A Complete 2025 Guide

Hypertension is the silent epidemic of modern medicine. With over 1.28 billion adults affected globally and fewer than half achieving adequate blood pressure control, it remains the single largest contributor to cardiovascular morbidity and mortality worldwide. For General Practitioners, hypertension management is one of the most common and consequential clinical tasks performed daily.

Understanding the 2023 NICE NG136 Updates

The updated NICE guideline NG136 brought several important changes to hypertension management in primary care. The most significant shift was the clarification of clinic versus ambulatory blood pressure monitoring (ABPM) thresholds, and the emphasis on cardiovascular risk stratification before initiating treatment.

Diagnostic Thresholds

The ABCD Drug Selection Algorithm

NICE recommends a structured step-wise approach to antihypertensive drug selection based on age, ethnicity, and comorbidities. The ABCD algorithm remains the cornerstone of initial drug selection in UK primary care.

• Step 1 (Age <55, non-Black): ACE inhibitor (A) or ARB — e.g., ramipril 2.5–10 mg OD, lisinopril 10–40 mg OD
• Step 1 (Age ≥55 or Black ethnicity): Calcium channel blocker (C) — e.g., amlodipine 5–10 mg OD
• Step 2: Combine A + C (e.g., ramipril + amlodipine)
• Step 3: Add thiazide-like diuretic (D) — indapamide 1.5 mg SR or chlortalidone 12.5–25 mg
• Step 4 (Resistant): Add spironolactone 25 mg if K+ <4.5 mmol/L, or alpha/beta-blocker if K+ ≥4.5 mmol/L

ACE Inhibitors vs ARBs: When to Switch

ACE inhibitors and ARBs are therapeutically equivalent for blood pressure reduction. The key practical difference is the ACE inhibitor cough, which affects 10–15% of patients (and up to 30–40% of East Asian patients). If a patient develops a persistent dry cough on an ACE inhibitor, switch to an ARB — do not add an ARB on top of an ACE inhibitor, as this combination increases the risk of hyperkalaemia and AKI without additional cardiovascular benefit.

Blood Pressure Targets

Resistant Hypertension: A Systematic Approach

Resistant hypertension is defined as BP remaining above target despite adherence to three antihypertensive drugs at optimal doses, including a diuretic. It affects approximately 10–15% of hypertensive patients. Before labelling a patient as having resistant hypertension, always exclude pseudo-resistance.

Causes of Pseudo-Resistance

• White coat hypertension (confirm with ABPM)
• Poor medication adherence (ask directly, check dispensing records)
• Suboptimal drug doses or inappropriate drug combinations
• Interfering substances: NSAIDs, oral contraceptives, decongestants, liquorice, cocaine
• Measurement error: wrong cuff size, arrhythmia, calcified arteries in elderly

Secondary Causes to Exclude

• Primary hyperaldosteronism (most common secondary cause — check aldosterone:renin ratio)
• Renal artery stenosis (renal bruit, flash pulmonary oedema, deteriorating renal function on ACEi)
• Obstructive sleep apnoea (morning headaches, daytime somnolence, partner reports apnoeas)
• Phaeochromocytoma (episodic headache, sweating, palpitations — check 24h urinary catecholamines)
• Cushing syndrome (central obesity, striae, proximal myopathy)

Special Populations

Hypertension in Pregnancy

Hypertension in pregnancy requires specialist input. Safe antihypertensives in pregnancy include labetalol (first-line), nifedipine (modified release), and methyldopa. ACE inhibitors, ARBs, and direct renin inhibitors are absolutely contraindicated in pregnancy due to teratogenicity. Refer urgently if BP ≥160/110 mmHg or if pre-eclampsia is suspected (proteinuria, headache, visual disturbance, epigastric pain).

Hypertension in CKD

In CKD, ACE inhibitors or ARBs are preferred as they reduce proteinuria and slow CKD progression. Monitor eGFR and potassium 1–2 weeks after initiation and after each dose increase. A rise in creatinine of up to 30% is acceptable and expected — do not stop the drug unless the rise exceeds 30% or hyperkalaemia develops (K+ >5.5 mmol/L).