NICE clinical guidelines
Issued: August 2011

Hypertension: Clinical management of primary hypertension in adults

This is an extract from the guidance. The complete guidance is available at


This guidance updates and replaces NICE clinical guideline 34 (published in 2006). NICE clinical guideline 34 updated and replaced NICE clinical guideline 18 (published in 2004).

High blood pressure (hypertension) is one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension is usually associated with a progressive rise in blood pressure. The vascular and renal damage that this may cause can culminate in a treatment-resistant state.

Blood pressure is normally distributed in the population and there is no natural cut-off point above which 'hypertension' definitively exists and below which it does not. The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke. Hypertension is remarkably common in the UK and the prevalence is strongly influenced by age. In any individual person, systolic and/or diastolic blood pressures may be elevated. Diastolic pressure is more commonly elevated in people younger than 50. With ageing, systolic hypertension becomes a more significant problem, as a result of progressive stiffening and loss of compliance of larger arteries. At least one quarter of adults (and more than half of those older than 60) have high blood pressure.

The clinical management of hypertension is one of the most common interventions in primary care, accounting for approximately £1 billion in drug costs alone in 2006.

The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

This guideline recommends drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. Where recommendations have been made for the use of drugs outside their licensed indications ('off-label use'), these drugs are marked with a footnote in the recommendations.

Changes in this update

Recommendations are marked as [2004], [2004, amended 2011], [2006], [2008], [2009], [2010] or [new 2011].

  • [2004] indicates that the evidence has not been updated and reviewed since 2004

  • [2004, amended 2011] indicates that the evidence has not been updated and reviewed since 2004 but a small amendment has been made to the recommendation

  • [2006] indicates that the evidence has not been updated and reviewed since 2006

  • [2008] applies to recommendations from 'Lipid modification' (NICE clinical guideline 67), published in 2008

  • [2009] applies to recommendations from 'Medicines adherence' (NICE clinical guideline 76), published in 2009

  • [2010] applies to recommendations from 'Hypertension in pregnancy' (NICE clinical guideline 107), published in 2010

  • [new 2011] indicates that the evidence has been reviewed and the recommendation has been updated or added.