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19th June 2026
Diagnosis and staging
The evaluation of patients with hypertension involves a combination of clinical examination, laboratory tests, and imaging to assess for evidence of target-organ damage (for example, left ventricular hypertrophy and hypertensive retinopathy) and presence of comorbidities.
NICE guidelines recommend that initial investigations should include
- Measurement of blood pressure in both arms
- Physical examination to identify secondary causes of hypertension
- Assessment of cardiovascular risk. Formal assessment may involve using risk calculators such as the Framingham Risk Calculator 1991 or the Q-RISK2
Table 2. Directions by NICE for diagnosing hypertension
| Blood pressure measurement | Direction |
|---|---|
| Clinic blood pressure | Measure blood pressure in both arms If the difference in measurements between arms is > 15 mmHg, repeat the measurements. If the difference remains > 15 mmHg, subsequent measurements should be taken from the arm with the higher reading If the clinic blood pressure is ≥140/90 mmHg, take a second reading. Record the lower of the 2 measurements as the clinic blood pressure |
| Ambulatory blood pressure monitoring (ABPM) – used to confirm the diagnosis of hypertension | Offer to patients if the clinic’s blood pressure is between 140/90 mmHg and 180/120 mmHg. At least 2 measurements should be taken per hour. An average of at least 14 measurements should be taken during a person’s usual waking hours. |
| Home blood pressure monitoring (HBPM): offer if ABPM is unsuitable or the patient is unable to tolerate it | Two consecutive measurements should be taken at least 1 minute apart with the person seated. Record blood pressure twice daily, ideally in the morning and evening, for at least 4 days, but ideally for 7 days. Discard the first day’s readings and use the average values of all remaining measurements |
In those diagnosed or whilst awaiting confirmation of diagnosis:
- Albumin-creatinine ratio (ACR) and urinalysis: to assess for renal impairment, as indicated by elevated ACR and proteinuria/haematuria
- Fundoscopy: to assess for hypertensive retinopathy
- 12-lead ECG: to assess for abnormalities in heart rhythm, structure or function
- Bloods: HbA1c, U&Es, total cholesterol and HDL cholesterol
Hypertension is confirmed if:
- Clinic blood pressure is ≥ 140/90 mmHg.
- ABPM or HBPM provide average values of ≥ 135/85 mmHg.
Table 3. Diagnostic criteria of hypertension by NICE
| Hypertension category | Clinic reading (mmHg) | ABPM/HBPM (mmHg) |
|---|---|---|
| Stage 1 | ≥140/90 | ≥135/85 |
| Stage 2 | ≥160/100 | ≥150/95 |
| Stage 3 (severe hypertension) | SBP ≥ 180 or DBP ≥ 120 Carry out same-day referral |
|
| Accelerated (malignant) hypertension | ≥180/120 with signs of retinal damage, haemorrhage or papilloedema. Usually associated with new or progressive target-organ damage. | |
| Isolated systolic hypertension | SBP ≥ 160 |
NICE, National Institute for Health and Care Excellence; ABPM, Ambulatory Blood Pressure Monitoring; HBPM, Home Blood Pressure Monitoring; SBP, systolic blood pressure; DBP, diastolic blood pressure
Table 4. Investigations for hypertension
| Investigation | Notes |
|---|---|
| Blood pressure measurement | All patients 24-hour ABPM or HBPM in suspected white coat hypertension or masked hypertension |
| Fasting blood glucose and lipid profile | Assessment of cardiovascular risk profile |
| Serum U&Es | Assessment of renal function |
| Endocrine investigations (e.g. renin/aldosterone ratio, TFTs) | Suspected secondary hypertension |
| Urinalysis | Assessment of proteinuria and haematuria |
| ECG | Assessment of abnormalities in heart rhythm, structure or function |
| Echocardiogram | |
| Renal artery imaging | Suspected renal artery stenosis |
ABPM, Ambulatory Blood Pressure Monitoring; HBPM, Home Blood Pressure Monitoring; U&Es, urea and electrolytes; TFTs, thyroid function tests
Cardiovascular disease risk assessment
Assessment of cardiovascular disease (CVD) risk is an important component in the management of hypertension. The NICE guidelines recommend using the QRISK3 risk assessment tool to calculate the 10-year risk of developing CVD in people with hypertension who are not already known to be at high risk.
The QRISK3 tool takes into account various factors, including age, sex, ethnicity, smoking status, systolic blood pressure, total cholesterol to HDL ratio, body mass index, family history of coronary heart disease, and other medical conditions such as diabetes, atrial fibrillation, and chronic kidney disease.
For individuals with a 10-year CVD risk of 10% or greater, NICE recommends offering statin therapy for primary prevention, in addition to lifestyle modifications and appropriate antihypertensive treatment. This emphasises the importance of considering overall cardiovascular risk, rather than treating hypertension in isolation.
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