Essential (primary) hypertension

• Essential (primary) hypertension is high blood pressure without an identifiable secondary cause: most adults with raised blood pressure (roughly 85 to 90%) have it.
• It is the single largest contributor to the global burden of disease: about 1.4 billion adults aged 30–79 years worldwide had hypertension in 2024.
• Diagnosis and treatment thresholds differ by guideline, but they agree that sustained elevation outside the clinic matters more than one high reading.
• Blood pressure (BP) is a continuous risk, so management combines lifestyle advice for everyone with drugs for most patients, aiming for a BP in the 120–139/70–89 (elevated) range treated in selected high-risk adults and below standard targets for diagnosed hypertension.
• A high BP that is ≥180/120 mmHg with symptoms, retinal haemorrhage or acute organ injury is a hypertensive emergency and needs same-day specialist care.

By the end of this page you should be able to:

1. Define essential hypertension and explain how the major guidelines classify BP.
2. Describe measurement technique, out-of-office confirmation, and white-coat and masked hypertension.
3. Take a focussed assessment for target organ damage and secondary causes.
4. Estimate cardiovascular risk and state drug treatment thresholds.
5. Choose and titrate first-line drugs, combination therapy and resistant-hypertension add-ons with doses.
6. State follow-up targets for standard, older, diabetic and renal groups, including low-resource practice.

Essential (primary) hypertension is persistently raised arterial blood pressure (BP) without a single identifiable cause. It arises from the combined effect of genetic susceptibility and lifestyle (salt, adiposity, alcohol, inactivity) on the systems that regulate pressure, mainly the kidney–renin–angiotensin axis, the sympathetic nervous system and vascular tone. The term “primary” distinguishes it from secondary hypertension, where a specific cause (renal, endocrine, drug-related) is found.

BP is best thought of as a continuous cardiovascular risk rather than a disease that switches on at a number. Different guidelines therefore draw different “hypertension” lines in the sand. The 2024 European Society of Cardiology (ESC) guideline calls BP non-elevated below 120/70 mmHg, elevated from 120–139/70–89 mmHg, and hypertension at ≥140/90 mmHg, and treats the elevated band risk-dependently. ^[1] The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline lowered the diagnostic threshold to ≥130/80 mmHg, with stage 1 from 130–139/80–89 and stage 2 at ≥140/90. ^[3][1] The 2025 AHA/ACC multisociety guideline, which replaces the 2017 document, keeps hypertension at ≥130/80 mmHg and stage 2 at ≥140/90, and calls a systolic pressure of 120–129 mmHg “elevated”. ^[13][12] Its main changes concern what happens next: a new risk calculator, earlier drug treatment for some stage 1 adults, a lower preferred target and an explicit single-pill, two-drug start for stage 2 (all set out below). ^[12] Both the ESC and AHA/ACC now raise the question “who actually needs drugs?” using 10-year cardiovascular risk.

The first table below gives the American categories and what each prompts; the second lines the main guidelines up against each other.

The 2024 ESC guideline keeps the traditional 140/90 mmHg line because, on its reading, treating most adults becomes clearly net-beneficial above it, while introducing an “elevated” band (120–139/70–89) in which treatment is triggered by overall cardiovascular risk. ^[1] The 2017 ACC/AHA guideline instead moved the line down to 130/80, so that many more people are classified as stage 1 hypertension, and the 2025 AHA/ACC guideline keeps that line. ^[3][13] The 2025 document is described as recommending drug treatment earlier, and aiming for lower pressures, than the ESC and ESH guidelines. ^[13] At least 96% of national hypertension guidelines in one global comparison still use ≥140/90 mmHg. ^[3] The two positions genuinely differ, and a clinician should follow the guideline adopted locally.

An estimated 1.4 billion adults aged 30–79 years worldwide had hypertension in 2024, about one third (33%) of adults in that age range, and roughly two thirds of them live in low- and middle-income countries. ^[5] Prevalence varies by region (about 38% in the WHO Eastern Mediterranean Region, 29% in the Western Pacific). ^[5] The number of adults with hypertension has risen from 650 million in 1990 to 1.4 billion in 2024, mainly because of ageing populations in lower-income countries. ^[5]

Essential hypertension remains the dominant form. Among adults with hypertension, roughly 600 million (44%) are unaware of it, about 630 million (44%) are diagnosed and treated, and only about 320 million (23%) have it under control. ^[5] Hypertension contributes about 10.4 million premature deaths annually. ^[3]

Clinical pearl: a condition with no symptoms and a one-in-three prevalence in midlife is not rare; every clinic day is a hypertension clinic.

No single cause exists in essential hypertension. Genetic background sets the slope; environment determines how fast a patient walks up it. Risk factors cluster and summate:

• Non-modifiable: age (blood pressure rises with age in most populations), male sex until midlife, family history, some ethnicities.
• Modifiable lifestyle: excess dietary salt, overweight/obesity, physical inactivity, harmful alcohol, low potassium intake, tobacco.
• Cardiometabolic: diabetes, dyslipidaemia, chronic kidney disease, obstructive sleep apnoea.
• Environmental: high sodium, low potassium, air pollution.

The WHO model is useful here: unhealthy diet, inactivity, tobacco and alcohol, being overweight/obese are the modifiable drivers, while age over 65, family history and co-existing diabetes or kidney disease are major non-modifiable ones. ^[5]

Essential hypertension is not one disease mechanism; it is several overlapping faults in pressure regulation that converge on one number.

1. Renal sodium handling and volume: in susceptible people the kidney does not excrete a salt load efficiently (“salt sensitivity”). Retained sodium holds water, raises cardiac output and then peripheral resistance, fixing a higher pressure set-point.
2. Renin–angiotensin–aldosterone system (RAAS): angiotensin II (made from angiotensin I by angiotensin-converting enzyme, ACE) vasoconstricts and stimulates aldosterone, which promotes sodium retention. Aldosterone also causes vascular and cardiac remodelling. This axis stays inappropriately active for the prevailing pressure.
3. Sympathetic nervous system: chronic psychological and metabolic stress, obesity and sleep apnoea drive excess sympathetic activity, raising heart rate, contractility and renal sodium reabsorption.
4. Endothelial dysfunction: nitric-oxide-mediated vasodilation falls and endothelin-1/oxidative stress rises, so vessels are stiffer and less responsive.
5. Arterial stiffness and aortic pulse wave: with age and exposure, the large arteries stiffen; systolic pressure rises and the cushioning diastolic phase falls (isolated systolic hypertension in older adults).

Left long enough, the higher pressure thickens the left ventricle, stiffens arteries and accelerates atherosclerosis in the brain, heart and kidneys. The fact that BP lowering reduces these events is exactly what makes the 120–139 “elevated” band worth identifying.

Hypertension is usually silent. Most patients feel normal until complications appear—this is why systematic measurement matters.

History. Ask about:

• documented BP values, home or pharmacy readings, symptoms of orthostatic dizziness;
• cardiovascular risk: smoking, diabetes, dyslipidaemia, menopause, erectile dysfunction (a cardiovascular red flag);
• possible secondary causes: kidney disease, snoring/apnoea, extremes of age, episodes of sweating/palpitations/pallor, medications (NSAIDs, oral contraceptives, steroids, decongestants, erythropoietin, liquorice, cocaine);
• family history of hypertension, kidney disease or early cardiovascular death;
• target-organ symptoms: headache, angina, breathlessness, ankle swelling, transient visual loss, focal neurological deficits.

Examination. Use the approach in cardiac physical examination and add:

• BP in both arms (a >15 mmHg inter-arm difference needs confirmation and, if persistent, future measurements in the higher arm). ^[2]
• Postural BP in symptomatic or older patients: lying then standing at 1 minute. A fall of ≥20 mmHg systolic or ≥10 mmHg diastolic defines postural (orthostatic) hypotension. ^[2]
• Heart sounds and apex for left ventricular hypertrophy; peripheral pulses, bruits and fundi for hypertensive changes; ankles for oedema.
• Abdomen for renal masses or bruits; neck for carotid bruits; listen for features of coarctation in young patients.

Red flag: BP ≥180/120 mmHg with retinal haemorrhage/papilloedema or life-threatening symptoms (new confusion, chest pain, heart failure signs, acute kidney injury) needs same-day specialist care. ^[2]

The main differential is secondary hypertension, because it changes management. Secondary clues include onset before 30 or after 55, severe or resistant hypertension, abrupt onset, no family history, renal or endocrine symptoms, and hypokalaemia. Common categories: renovascular and renal parenchymal disease; primary aldosteronism (ESC 2024 advises screening all confirmed hypertensive adults with renin/aldosterone); phaeochromocytoma; Cushing’s and thyroid disease; coarctation; obstructive sleep apnoea; drugs. Pregnancy-related and endocrine topics are covered elsewhere. Heart failure and hypertensive crises are looked at in their own pages.

White-coat and masked hypertension, rather than being “differential diagnoses”, are forms of measurement pattern that must be separated from true sustained hypertension (below).

Accurate measurement is the treatment. Use validated devices, recalibrated, with the right cuff size (a cuff that is too small over-reads). Standardise the setting: quiet, temperate, seated, arm supported at heart level, the patient rested 5 minutes and not talking. Palpate the pulse first—automated cuffs can be wrong with irregular rhythm (such as atrial fibrillation), in which case measure manually by auscultation. ^[2]

Office blood pressure. If clinic BP is ≥140/90 mmHg, take a second reading during the visit (and a third if they differ substantially), and record the lower of the last two. ^[2] A sustained clinic value of 140/90 mmHg or more leads to ABPM/HBPM confirmation when it is 140–179 systolic/90–119 diastolic; values ≥180/120 mmHg need an accelerated pathway (page above). ^[2]

Ambulatory blood pressure monitoring (ABPM). ABPM is the reference for out-of-office assessment: at least two readings per hour during waking hours, using the average of at least 14 daytime readings (for example 08:00–22:00). Hypertension is confirmed when clinic BP is ≥140/90 and daytime ABPM (or HBPM) average is ≥135/85 mmHg. ^[2]

Home blood pressure monitoring (HBPM). Two consecutive seated readings, 1 minute apart, twice daily (morning and evening), for at least 4 days and ideally 7, discarding the first day, then averaging the rest. ^[2] ABPM/HBPM values run about 5 mmHg lower than clinic equivalents; correspondingly, targets monitored at home are 135/85 mmHg rather than 140/90 in younger adults. ^[2]

White-coat hypertension is a clinic BP ≥140/90 with normal out-of-office BP (average <135/85), a discrepancy of more than 20/10 mmHg. ^[2] Masked hypertension is the reverse—normal clinic BP but elevated out-of-office BP. ^[2] The ESC 2024 and ACC/AHA 2017 guidelines rely heavily on out-of-office confirmation (ESC 2024 makes it class I, with repeat office measurements only when ABPM/HBPM are unavailable); the 2023 ESH guideline still makes repeated office BP its diagnostic anchor with out-of-office testing as adjunct. ^[1] Both white-coat and masked patterns matter: white-coat risks over-treatment; masked hypertension carries real cardiovascular risk and is often missed.

Target organ damage (TOD). For all adults with hypertension, NICE recommends testing urine albumin:creatinine ratio (and haematuria), blood tests (HbA1c, electrolytes, creatinine, eGFR, total and HDL cholesterol), fundoscopy and a 12-lead electrocardiogram; the fundoscopic and renal findings are what “target organ damage” means (left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy, raised albumin:creatinine ratio). ^[2] ESC 2024 additionally asks for echocardiography when the ECG is abnormal or there are cardiac symptoms, fundoscopy for suspected hypertensive emergency/diabetes, and consideration of renal ultrasound in CKD. ^[1] ACC/AHA 2017 made the ECG standard and other tests optional; the 2025 AHA/ACC guideline adds urine albumin-to-creatinine ratio (and protein-to-creatinine ratio) for everyone newly diagnosed, a step the 2017 guideline treated as optional. ^[1][13] An echocardiogram (or ECG) also helps spot co-existing heart failure; an abnormal rhythm would need ECG interpretation and, if symptomatic, consideration of tachyarrhythmias.

Secondary causes. Adults under 40 should be considered for specialist evaluation of secondary causes. ^[2] ESC 2024 advises comprehensive screening for the main secondary causes in adults <40, with OSA evaluation first in obese young adults, and (a major change) considering renin/aldosterone screening in all adults with confirmed hypertension, given primary aldosteronism prevalence of roughly 5–20% and frequent absence of hypokalaemia. ^[1] ACC/AHA 2017 limited primary-aldosteronism screening to high-probability groups (resistant hypertension, hypokalaemia, adrenal mass, family history of young hypertension, young stroke). ^[1] The 2025 AHA/ACC guideline widens screening to everyone with stage 2 or resistant hypertension. ^[12] Test for secondary causes promptly in the classic red-flag picture: resistant hypertension, onset <30 years, sudden change in control, disproportionate TOD, malignant hypertension, unprovoked hypokalaemia. ^[1][2]

Cardiovascular risk. Use a formal risk assessment rather than guessing. ACC/AHA 2017 used the pooled cohort equations with a 10% cut-off (and treated all stage 2). ^[1] The 2025 AHA/ACC guideline replaces them with the PREVENT equations, which estimate 10-year and 30-year total cardiovascular risk (including heart failure) in adults aged 30–79 years, and uses a 10-year risk of 7.5% or more as the high-risk line. ^[12][15] ESC 2024 uses SCORE2/SCORE2-OP and treats raised BP when predicted 10-year CVD risk is ≥10% in the elevated band (5–10% with additional modifiers). ^[1] NICE assesses risk per its CVD prevention guideline and offers treatment for stage 1 under 80 when risk ≥10%, as well as for stage 2 at any age. ^[2] A 12-lead ECG is cheap, local and still worthwhile.

Hypertension is not one threshold. Essential point: confirm, stage, and risk-stratify.

• NICE stages: stage 1 (clinic 140–159/90–99 with out-of-office 135–149/85–94), stage 2 (160/100 to 179/119 with out-of-office ≥150/95), stage 3 (≥180/120). ^[2]
• ISH grades: high-normal 130–139/85–89, grade 1: 140–159/90–99, grade 2: ≥160/100. ^[4]
• WHO 2021 does not restate the diagnostic definition; it focuses on pharmacological treatment once hypertension is confirmed. ^[4]
• Never treat a number in isolation: confirm with ABPM/HBPM, look at TOD and risk, and treat to target.

Most essential hypertension is managed in the clinic. BP ≥180/120 mmHg with life-threatening features or retinal haemorrhage/papilloedema changes is a same-day specialist problem (accelerated/malignant hypertension); without those features, repeat and investigate target-organ damage within 7 days and start treatment if found. ^[2] A dedicated hypertensive crises topic covers emergency care.

The only cure is a sustained reduction in effective pressure over years. Effective management is a package: accurate diagnosis, lifestyle advice, pharmacological treatment based on BP and risk, combination therapy, and uninterrupted follow-up. Single-drug monotherapy controls BP adequately in a minority; most patients need a combination.

Offer repeatedly, not once. ^[2]

• Salt: aim to reduce dietary sodium to below about 2 g/day in all guidelines—ESC 2024 and ESH recommend 2 g sodium (class I), while ACC/AHA 2017 did not set a single numeric target but still advised salt reduction. ^[1][5] The 2025 AHA/ACC guideline advises below 2300 mg of sodium a day, ideally below 1500 mg. ^[13] The WHO factsheet target is also under 2 g/day. ^[5] NICE advises against potassium-chloride salt substitutes for older adults, for people with diabetes or kidney disease and for those on ACE inhibitors or ARBs (they can raise potassium); use plain salt reduction instead. ^[2]
• Weight: aim for a normal BMI; ESC/EHS 2024, ESH and ACC/AHA all recommend weight loss when overweight. ^[1]
• Alcohol: advise reduced intake (WHO suggests at most about 1 drink/day for women and 2 for men); excess raises BP and treatment response falls. ^[5]
• Exercise: at least 150 minutes/week moderate or 75 minutes/week vigorous aerobic activity, plus dynamic/isometric resistance training 2–3 times per week (ESC 2024 wording), which has evidence for BP reduction. ^[1][5]
• Diet: a DASH-style pattern (vegetables, fruits, lower saturated/trans fat, reduced salt) plus smoking-cessation support; excessive coffee/caffeine discouraged. ^[2][5]
• Potassium: raising potassium intake (diet or potassium-enriched salt, if safe) lowers BP; ESC 2024 recommends this with caution class IIa, while ESH/ACC/AHA give class I. ^[1] The 2025 AHA/ACC guideline gives potassium-based salt substitutes class 2a (reasonable), except in CKD or another condition that raises the risk of high potassium. ^[13] Do not prescribe calcium, magnesium or potassium supplements as BP-lowering therapy. ^[2]
• CVD risk management: treat lipids and diabetes, advise on air-pollution avoidance where relevant.

When to start. Everyone with ≥140/90 mmHg should have prompt lifestyle and drug therapy regardless of age/risk in ESC 2024. ^[1] ACC/AHA 2017 did the same at ≥140/90 (stage 2), and so does 2025 AHA/ACC, which starts two drugs together. ^[1][12] ESH 2023 starts drugs at ≥140/90 for those aged 18–79 but ≥160 systolic in those ≥80 (lifestyle can precede in low-risk grade 1). ^[1] NICE offers drugs to adults of any age with stage 2, and to under-80s with stage 1 plus target-organ damage, CVD, renal disease, diabetes or 10-year CVD risk ≥10%. ^[2] For BP 130–139/80–89 (elevated/stage 1), all three of ESC, ACC/AHA and ESH recommend drugs in high-risk people: established CVD, HMOD, diabetes, moderate/severe CKD, familial hypercholesterolaemia, or 10-year risk ≥10% (ESC); established CVD, heart failure, CKD, diabetes or risk ≥10% (ACC/AHA 2017); history of CVD (ESH). ^[1] The 2025 AHA/ACC guideline recommends drugs from 130/80 for adults with previous CVD, diabetes, CKD or a PREVENT 10-year risk of 7.5% or more; lower-risk adults with stage 1 hypertension start a drug only if blood pressure is still 130/80 or higher after 3–6 months of lifestyle change. ^[12] This is the clearest difference from ESC 2024, where drugs in the 130–139 band are limited to the high-risk groups above.

First-line drug classes. ESC 2024 and ACC/AHA 2017 recommend angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), dihydropyridine calcium channel blockers (CCB) and thiazide/thiazide-like diuretics, and the 2025 AHA/ACC guideline lists the same three groups (ACEi or ARB, long-acting dihydropyridine CCB, thiazide-type diuretic). ^[1][13] WHO 2021 lists the same four as first-line. ^[5] ESH 2023 (and ISH 2020) also include beta blockers as first-line; ESC 2024 does not, because beta blockers were inferior for stroke prevention compared with the other classes and are reserved for compelling indications such as heart failure, ischaemic heart disease or arrhythmia. ^[1][4] Alpha blockers and other agents (MRA, centrally acting, direct vasodilators) are used later or for compelling reasons. ^[2]

Choosing a class for the individual patient. First-line classes are only the starting point: a second condition often decides which drug goes first, and which to avoid. The table below summarises the preferred drugs for the common situations and says which guideline each statement comes from. UK names are given first, with US names in brackets where they differ.

Drug dosing (typical adult doses). Adjust for renal/hepatic function and check a local formulary; renal dosing is drug-specific.

(These are representative, not universal; other INNs in each class have their own label ranges.)

Combination and single-pill strategy. Most patients need two drugs; single-pill (fixed-dose) combinations improve adherence and control and lower therapeutic inertia. ^[1][4] ESC 2024 and ESH 2023 recommend initial two-drug combination therapy in most patients, stepping to three if needed, with single-pill combinations when ≥2 drugs are used. ^[1] ACC/AHA 2017 recommended starting two agents when BP was more than 20/10 above target, as separate or fixed-dose pills. ^[1] The 2025 AHA/ACC guideline recommends two first-line drugs of different classes for stage 2, preferably as a single pill, and allows a single first-line once-daily drug with close follow-up for stage 1. ^[12][13] Do not combine two RAAS blockers (ACEi + ARB, or ACEi/ARB + direct renin inhibitor): no added benefit and more harm. ^[2] NICE uses a step strategy: step 1 (ACEi/ARB if <55/non-black; CCB if ≥55 or Black African/African-Caribbean; thiazide-like if CCB not tolerated), step 2 (add CCB or thiazide-like), step 3 (ACEi/ARB + CCB + thiazide-like), step 4 (add low-dose spironolactone if potassium ≤4.5 mmol/L, otherwise alpha/beta blocker). ^[2]

Dose and monitor. Check renal function, electrolytes and BP shortly after starting or raising an ACEi/ARB or diuretic; monitor at appropriate intervals; check for postural symptoms in older, frail or diabetic patients. ^[2]

Blood-pressure targets.

• ESC 2024: SBP 120–129 mmHg in most adults, DBP 70–79 mmHg, if tolerated; use BP “as low as reasonably achievable” if the standard target is not tolerated; consider <140/90 if symptomatic orthostatic hypotension or age ≥85, and for moderate–severe frailty/limited life expectancy. ^[1]
• ACC/AHA 2017: <130/80 mmHg for adults with known CVD or estimated 10-year risk ≥10%; <130/80 may be reasonable for lower-risk adults. ^[1]
• 2025 AHA/ACC: a target of at least below 130 systolic for all groups, with encouragement to reach below 120/80 where feasible; shared decision-making is advised for frailty or limited life expectancy. ^[13][14]
• NICE: clinic <140/90 (<150/90 if age ≥80, with lower targets in some CKD/T1D) and ABPM/HBPM <135/85 (<145/85 in those ≥80). ^[2]
• ISH: <140/90 without comorbidities (optimal 121–129/71–79 if <65, <140/90 if ≥65); for high-risk <130 systolic. ^[4]
• WHO 2021: <140/90 without comorbidities and <130 systolic with known CVD or high-risk. ^[4]

ESC 2024 aims for 120–129/70–79 and advises against deliberately aiming lower in routine practice, whereas the 2025 AHA/ACC guideline encourages below 120/80 where feasible. ^[1][13] These targets genuinely disagree in some groups; the local guideline and the patient’s tolerance decide.

Resistant hypertension. Defined as uncontrolled BP on the best tolerated doses of an ACEi/ARB plus a CCB plus a thiazide-like diuretic. ^[2] First, confirm it: repeat/ABPM, consider adherence (ESC recommends adherence testing; direct observation or drug-level), exclude secondary causes, check for “pseudoresistance” (poor measurement, white-coat, volume overload, NSAIDs). ^[1] Then add a fourth agent: ESC, the 2025 AHA/ACC guideline (a mineralocorticoid receptor antagonist if not contraindicated) and the WHO review favour spironolactone 12.5–50 mg daily if potassium ≤4.5 mmol/L and eGFR >45 mL/min/1.73 m²; amiloride, doxazosin, clonidine, beta blockers or others if MRA is unsuitable. ^[4][2] Renal denervation may be considered in uncontrolled hypertension in selected high-risk patients, but it is not first-line (class IIb, “may be considered”, in the 2025 AHA/ACC guideline). ^[1][12] Refer when ≥4 optimal drugs fail. ^[2] Resistant patients also need a heart-failure review where that is relevant (aldosterone antagonists help both).

Untreated or poorly controlled essential hypertension causes hypertensive vascular injury wherever high pressure acts:

• Heart: left ventricular hypertrophy, diastolic dysfunction, heart failure, coronary disease, atrial fibrillation.
• Brain: stroke (ischaemic and haemorrhagic), vascular cognitive impairment.
• Kidneys: nephrosclerosis, chronic kidney disease, proteinuria.
• Eyes: hypertensive retinopathy.
• Aorta and periphery: aortic disease, arrhythmia burden, peripheral vascular disease.

Atrial arrhythmia and hypertension interact: hypertension is a leading cause of atrial fibrillation; dramatic pressure swings can aggravate supraventricular tachycardias. Stroke and its cerebral consequences are the complications to discuss when motivating adherence.

For individual patients, risk rises continuously with BP; for populations, hypertension is the leading single risk driver of cardiovascular death. BP reduction works—meta-analyses show ~10 mmHg systolic reduction significantly cuts major CV events, coronary disease, stroke, heart failure and all-cause mortality by roughly 13%. ^[3] Even high-risk patients treated to ~120 mmHg have fewer events, though severe hypotension (<120/70) can harm; targets must be individualised. ^[4] Complications are preventable: only about a quarter of adults with hypertension globally are controlled, which is a system failure, not a biological one. ^[5]

BP should be checked in all adults; NICE advises at least every 5 years (more often if clinic BP is not hypertensive but still raised), and annual measurement in adults with type 2 diabetes without known hypertension. ^[2] Prevention is the lifestyle section above; add tobacco cessation and weight management. ^[2][5]

• Older adults: postural measurement is essential; many have isolated systolic hypertension. ESC targets a gentle <140/90 if symptomatic orthostatic hypotension or age ≥85 and considers <140/90 for frailty; NICE treats ≥80 to <150/90 but individualises; ESH steps systolic to 140–150 at ≥80. ^[1][2]
• Diabetes (type 2): NICE treats at any stage if other risk factors; BP target is usually <140/90, with tighter control in significant albuminuria/CKD; an ACEi or ARB first line for nephroprotection in type 2 if tolerated. ^[2] WHO and ISH view <130 systolic as appropriate in high risk. ^[4] Screen for hyperkalaemia after RAAS blockade.
• Chronic kidney disease: choose ACEi/ARB for renal protection in albuminuric CKD, monitor creatinine/eGFR and potassium closely after starting; adjust doses to renal function; BP targets are tighter when ACR ≥70 mg/mmol (clinic <130/80). ^[2] ESC 2024 considers renal denervation in uncontrolled hypertension only in selected patients with eGFR >40. ^[1]
• Black patients of African or African–Caribbean origin: NICE advises considering an ARB rather than an ACEi, and using a CCB or thiazide-like diuretic as first line. ^[2] WHO/ISH comparison confirms CCBs are especially effective in Black patients. ^[4]
• Women and pregnancy: ACE inhibitors and ARBs must not be used during pregnancy or breastfeeding unless absolutely necessary—manage according to NICE NG133 hypertension in pregnancy. ^[2] NICE aims for 135/85 mmHg in pregnancy, whereas the 2025 AHA/ACC guideline aims for below 140/90 and also avoids atenolol, direct renin inhibitors and mineralocorticoid antagonists. ^[17][12][13] Offer contraception advice and switch before conception where possible.
• Women more generally: oral contraceptive and menopausal considerations affect BP; assess risk and family history.
• Follow-up annual review of BP, lifestyle, symptoms and medication for adults with hypertension, with a lower threshold for prompt investigation in younger adults. ^[2]

Provide an annual review for adults with hypertension (BP, lifestyle, symptoms, medication) and consider self-monitoring with HBPM. ^[2] Adjust treatment on the basis of validated out-of-office readings where white-coat or masked effect is suspected. ^[2] Step up one drug class at a time unless BP is very high; switch rather than endlessly add where tolerability is poor. Adults under 40 with hypertension merit specialist evaluation for secondary causes and long-term risk–benefit review. ^[2]

• Hypertension is largely a low- and middle-income disease: two thirds of affected adults live in these settings and control rates are lowest there. ^[5]
• A validated manual or automatic cuff, a tape measure, and a stethoscope make diagnosis possible; confirm with repeated measures and, where available, ABPM/HBPM. ^[2][5]
• Favour low-cost, heat-stable, once-daily classes—thiazide-like diuretics and CCBs are inexpensive and effective; use fixed-dose combinations to reduce pill burden where supply allows. ^[3]
• Use the WHO/ISH “essential vs optimal” mindset: if investigations are unavailable, treat based on confirmed BP, clinical comorbidity and simple labs (creatinine, K+, glucose, urinalysis) rather than delay. ^[4]
• Refer where essential (resistant/secondary hypertension, pregnancy, young stroke) and use task-sharing so nurses and community health workers can follow up; monthly follow-up until control is a practical interval. ^[4]
• Each 10 mmHg reduction matters; do not wait for perfect control to treat.

• Essential (primary) hypertension is high blood pressure without a single cause; it is the commonest form and the leading global cardiovascular risk.
• About 1.4 billion adults aged 30–79 years had hypertension in 2024; only ~23% are controlled globally.
• The major guidelines set different diagnostic lines: ESC 2024 ≥140/90, ACC/AHA 2017 and 2025 ≥130/80, NICE ≥140/90 confirmed on ABPM/HBPM ≥135/85, ISH >140/90, WHO treats ≥140/90 generally and 130–139 if high risk.
• Confirm with ABPM/HBPM; white-coat and masked patterns alter treatment.
• Measure carefully: both arms, appropriate cuff, standardised position, pulse first, postural checks in older adults.
• Lifestyle is for everyone: salt <2 g/day, normal weight, alcohol limits, ≥150 min/week moderate activity, no smoking, adequate potassium where safe.
• First-line drugs (ESC, AHA/ACC 2017 and 2025, WHO): ACEi or ARB, CCB, thiazide/thiazide-like diuretic; beta blockers are first-line in ESH/ISH.
• The 2025 AHA/ACC guideline keeps 130/80 as the hypertension line, uses the PREVENT risk calculator (high risk 7.5% or more), starts two drugs in one pill for stage 2 and prefers a target below 120/80 where feasible.
• Typical doses: lisinopril 10 mg (5 mg on a diuretic) up to 20–40 mg; losartan 50 up to 100 mg; amlodipine 5 up to 10 mg; hydrochlorothiazide 25 up to 50 mg; bisoprolol 5 up to 20 mg; spironolactone 25–50 mg as add-on.
• Treat to a target (ESC 120–129/70–79; NICE <140/90 or <150/90 at ≥80; ACC/AHA <130/80 in high-risk) and aim for single-pill combinations.
• Resistant hypertension needs confirmation, adherence testing, secondary-cause exclusion and spironolactone (if K ≤4.5 mmol/L, eGFR >45).
• Adults under 40 should be evaluated for secondary causes.
• Low-resource practice favours cheap once-daily drugs, task sharing and monthly follow-up until control.

• Hypertensive crises (follow-on topic)
• Chronic coronary syndrome is not hypertension, but hypertensive hearts produce heart-failure and atrial-fibrillation.
• ECG interpretation and cardiac physical examination.
• Secondary hypertension (follow-on topic), plus ventricular arrhythmias, bradyarrhythmias and AV block, supraventricular tachycardias and approach to tachyarrhythmias (MedGrasp topics).