Office BP ≥140/90 mmHg on two or more occasions (JNC 8/ESC 2023); confirmed by home/ABPM.
History taking
- • Duration, prior readings, current/past antihypertensives & compliance
- • Headache, visual blurring, chest pain, dyspnoea, claudication
- • Risk factors: family history, diabetes, smoking, salt/alcohol intake, sleep apnoea
- • Symptoms of secondary HTN: paroxysmal sweating (pheo), muscle weakness (Conn), snoring
Examination
- • BP both arms, seated after 5 min rest; standing BP for orthostatic drop
- • BMI, waist circumference, fundus (Keith-Wagener grading)
- • Cardiovascular: apex, S4, murmurs; carotid/renal/femoral bruits
- • Peripheral pulses (coarctation), thyroid examination
Red flags
- • BP ≥180/120 with target organ damage (hypertensive emergency)
- • Chest pain, dyspnoea, focal neurologic deficit, papilloedema
- • Sudden severe headache, haematuria, oliguria
Differential diagnosis
- • Primary (essential) hypertension — 90%
- • Secondary: renal parenchymal/vascular, primary aldosteronism, pheochromocytoma, Cushing, coarctation, OSA
- • White-coat or masked hypertension
Recommended investigations
- • Urinalysis (protein, RBC), urine ACR
- • Serum electrolytes, creatinine, eGFR, fasting glucose, HbA1c, lipid profile
- • ECG (LVH, strain), echo if LVH/IHD suspected
- • TSH; renal Doppler / aldosterone-renin ratio if secondary suspected
Diagnosis
- • Stage 1: 140–159/90–99; Stage 2: ≥160/100
- • Confirm with home BP averaging ≥135/85 or 24-h ABPM ≥130/80
Initial treatment / management
- • Lifestyle: DASH diet, salt <5 g/day, weight loss, alcohol limit, regular aerobic exercise
- • Initiate pharmacotherapy if Stage 1 with high CV risk or Stage 2
- • Preferred initial agents: ACEI/ARB, CCB, thiazide-like diuretic
- • Combination therapy if BP >20/10 above target
Prescription examples
- • Tab Amlodipine 5 mg PO OD (titrate to 10 mg)
- • Tab Telmisartan 40 mg PO OD (titrate to 80 mg)
- • Tab Chlorthalidone 12.5–25 mg PO OD (or Indapamide 1.5 mg)
- • If young/IHD: Tab Metoprolol succinate 25–50 mg PO OD
Follow-up advice
- • Review BP in 2–4 weeks until at goal; then every 3–6 months
- • Annual renal function, electrolytes, lipid profile, ECG
- • Encourage home BP log (two readings AM/PM)
Patient counselling
- • Lifelong therapy in most — do not stop drugs even when BP normalises
- • Salt restriction, smoking cessation, stress management
- • Recognise emergency symptoms: chest pain, vision loss, weakness
Referral criteria
- • Resistant HTN despite 3 drugs incl. diuretic
- • Suspected secondary HTN, pregnancy with HTN
- • Hypertensive emergency — admit
Clinical pearls
- • Always measure BP in both arms at first visit — >15 mmHg difference suggests subclavian stenosis
- • Start two-drug combination from outset in Stage 2
- • Avoid ACEI + ARB combination
References
- • ESC/ESH 2023 Guidelines on Hypertension
- • ACC/AHA 2017 Hypertension Guideline
- • Indian Guidelines on Hypertension IV (2019)
Educational outpatient guide — verify against local guidelines before clinical use.
