Hypertension (High Blood Pressure) – Symptoms, Causes & Treatment

Verified clinical guidelines and emergency management protocols.

Protocol Content

HYPERTENSION — INDIA

COMPREHENSIVE CLINICAL MANAGEMENT GUIDELINE

For Healthcare Professionals Only | Not for Public Use

Applicable Settings: Primary Care → Secondary Care → Tertiary Care → ICU

Version: 3.0
Last Updated: July 2025

SYMBOL LEGEND

Symbol	Meaning
✅	Recommended / First-line / Strong evidence
⚠️	Use with caution / Monitor closely / Conditional
❌	Contraindicated / Avoid
💊	Drug name
📌	Clinical pearl / Key point
🔬	Evidence-based recommendation
⏱️	Time-critical action
🚨	Emergency / Life-threatening

SECTION 1: DEFINITION, CLASSIFICATION & DIAGNOSIS

1.1 CLASSIFICATION OF BLOOD PRESSURE

Office BP Classification (ESC/ESH 2023, ISH 2020)

Category	SBP (mmHg)		DBP (mmHg)
Optimal	< 120	and	< 80
Normal	120–129	and/or	80–84
High Normal	130–139	and/or	85–89
Grade 1 HTN (Mild)	140–159	and/or	90–99
Grade 2 HTN (Moderate)	160–179	and/or	100–109
Grade 3 HTN (Severe)	≥ 180	and/or	≥ 110
Isolated Systolic HTN	≥ 140	and	< 90

📌 When SBP and DBP fall into different categories, classify by the higher category.

1.2 BLOOD PRESSURE MEASUREMENT

Patient Preparation

Patient seated comfortably for ≥ 5 minutes
Back supported, feet flat on floor, legs uncrossed
Arm supported at heart level on table or armrest
Empty bladder
No caffeine, exercise, or smoking in preceding 30 minutes
No talking during measurement
Remove clothing from upper arm — do not measure over rolled-up tight sleeves

Cuff Selection

Arm Circumference	Cuff Size
22–26 cm	Small adult (12 × 22 cm)
27–34 cm	Standard adult (16 × 30 cm)
35–44 cm	Large adult (16 × 36 cm)
45–52 cm	Adult thigh cuff (16 × 42 cm)

📌 Incorrect cuff size is the most common source of measurement error. A cuff that is too small overestimates BP by 5–15 mmHg. A cuff that is too large underestimates BP by 3–10 mmHg.

Measurement Protocol

Place cuff bladder centre over brachial artery
Lower edge of cuff 2–3 cm above antecubital fossa
Take ≥ 2 readings, 1–2 minutes apart
Record the average of the last 2 readings
On first visit: measure in both arms
- If persistent inter-arm difference > 15 mmHg → use the higher arm for all subsequent measurements
- If persistent inter-arm difference > 20 mmHg → investigate for subclavian stenosis, coarctation, or aortic disease
In elderly, diabetics, and patients on treatment: check standing BP at 1 and 3 minutes
- Orthostatic hypotension = SBP drop ≥ 20 mmHg or DBP drop ≥ 10 mmHg on standing

Device

Validated oscillometric (automated) upper arm device preferred
Wrist devices are not recommended for clinical use
Calibrate devices annually
Mercury sphygmomanometers are being phased out (Minamata Convention on Mercury)

1.3 OUT-OF-OFFICE BLOOD PRESSURE MEASUREMENT

Diagnostic Thresholds

Measurement Method	SBP (mmHg)	DBP (mmHg)
Office BP	≥ 140	≥ 90
Home BP (HBPM)	≥ 135	≥ 85
ABPM — daytime mean	≥ 135	≥ 85
ABPM — night-time mean	≥ 120	≥ 70
ABPM — 24-hour mean	≥ 130	≥ 80

📌 Home and ambulatory thresholds are approximately 5 mmHg lower than office thresholds.

Home BP Monitoring (HBPM) Protocol

Use validated upper arm device
Measure in the morning (before medication, before breakfast) AND evening
Perform for 7 consecutive days (minimum 3 days)
Take 2 readings each session, 1 minute apart
Discard all Day 1 readings
Calculate the average of the remaining readings
Hypertension confirmed if average ≥ 135/85 mmHg

BP Phenotypes

Phenotype	Office BP	Out-of-Office BP	CV Risk	Management
Sustained Normotension	Normal (< 140/90)	Normal (< 135/85)	Low	Reassure; periodic screening
White Coat HTN	Elevated (≥ 140/90)	Normal (< 135/85)	Slightly above normal	Lifestyle; annual monitoring; do NOT routinely start drug therapy
Masked HTN	Normal (< 140/90)	Elevated (≥ 135/85)	Similar to sustained HTN	Treat as sustained hypertension
Sustained HTN	Elevated (≥ 140/90)	Elevated (≥ 135/85)	High	Full treatment per guideline

📌 White coat hypertension has a prevalence of 15–30% among patients with elevated office BP. These patients should not be labelled hypertensive or started on drug therapy based on office readings alone.

📌 Masked hypertension is the most dangerous phenotype — office BP appears normal, but the patient sustains organ damage. Suspect when target organ damage is present despite normal office readings.

Indications for ABPM

Suspected white coat hypertension
Suspected masked hypertension
Resistant hypertension
Assessment of nocturnal BP and dipping status
Episodic or labile BP
Autonomic dysfunction
Pregnancy with borderline readings

Nocturnal BP and Dipping Status (from ABPM)

Pattern	Night-time SBP Dip
Normal dipper	10–20% decline
Non-dipper	0–10% decline
Reverse dipper	Nocturnal BP rise
Extreme dipper	> 20% decline

Non-dipping and reverse dipping patterns are associated with increased CV risk and target organ damage. They are common in CKD, diabetes, OSA, and secondary hypertension. Consider evening dosing of at least one antihypertensive if non-dipping is confirmed.

1.4 CONFIRMING THE DIAGNOSIS

Diagnostic Pathway

ELEVATED OFFICE BP DETECTED

(≥ 140/90 mmHg)

│

┌─────────────┴─────────────┐

│ │

GRADE 2–3 HTN GRADE 1 HTN

(≥ 160/100) OR (140–159/90–99)

evidence of HMOD │

│ │

▼ ▼

Confirm with repeat Offer ABPM or HBPM

same-visit reading to confirm diagnosis

→ Diagnosis confirmed │

→ Start treatment ┌─────┴─────┐

│ │

ABPM/HBPM ABPM/HBPM

confirms does NOT

(≥ 135/85) confirm

│ │

▼ ▼

Diagnosis White Coat HTN

confirmed → Lifestyle

→ Treat → Annual

monitoring

Number of Readings Required

Scenario	Readings Required
Grade 2–3 HTN (≥ 160/100)	Confirm with second reading same visit; can diagnose same day
Grade 1 HTN (140–159/90–99)	Confirm with ABPM or HBPM (preferred) OR repeat office readings on ≥ 2 separate occasions
Grade 1 HTN + HMOD or high CV risk	Can diagnose and start treatment sooner
Hypertensive emergency (any level + acute organ damage)	Single reading sufficient; treat immediately

1.5 PATHOPHYSIOLOGY — MECHANISM-TO-DRUG RATIONALE

Major Mechanisms and Corresponding Drug Targets

Mechanism	Pathways	Targeted By
RAAS Activation	↑ Angiotensin II → Vasoconstriction + Na⁺ retention + Aldosterone release	ACE-I, ARB, ARNI, MRA, Direct Renin Inhibitors
Sympathetic Overactivity	↑ Heart rate, ↑ Cardiac output, ↑ Vascular tone	Beta-blockers, Central agents (Clonidine, Methyldopa)
Volume Expansion	↑ Na⁺ and water retention	Thiazide diuretics, Loop diuretics
Vascular Stiffness	Arterial wall changes, ↓ Compliance	CCBs, Nitrates
Endothelial Dysfunction	↓ Nitric oxide, ↑ Endothelin	CCBs, ACE-I, ARB

Age and Ethnicity Affect Predominant Mechanism

Patient Group	Predominant Mechanism	Best Initial Drug
Young (< 55 years)	High renin, RAAS-driven	ACE-I or ARB
Elderly (≥ 55 years)	Low renin, volume/stiffness	CCB or Thiazide
Black/African ethnicity (any age)	Low renin, salt-sensitive	CCB or Thiazide
Obese	RAAS activation + volume	ACE-I/ARB + Diuretic
Diabetes	RAAS activation	ACE-I or ARB

🔬 This physiological basis underpins the age-based drug selection algorithm in Section 6.3.

SECTION 2: CLINICAL EVALUATION

2.1 ROUTINE INVESTIGATIONS (ALL HYPERTENSIVE PATIENTS)

Test	Purpose	Key Interpretation
Haemoglobin / CBC	Anaemia (CKD), Polycythaemia (OSA, renal tumour)	Hb < 12 g/dL (F) or < 13 g/dL (M) suggests anaemia
Fasting Glucose	Diabetes screening	≥ 126 mg/dL = DM; 100–125 = prediabetes
HbA1c	Diabetes screening/control	≥ 6.5% = DM; 5.7–6.4% = prediabetes
Lipid Profile	CV risk assessment	LDL, HDL, TG; calculate non-HDL-C
Serum Creatinine	Renal function	Elevated suggests CKD
eGFR	CKD staging	Use CKD-EPI equation
Serum Na⁺, K⁺	Baseline electrolytes; secondary HTN clues	K⁺ < 3.5 unprovoked → screen for primary aldosteronism
Serum Uric Acid	Baseline before diuretics; CV risk marker	Diuretics elevate uric acid
Urinalysis	Proteinuria, haematuria, casts	Simple but informative
Urine ACR (spot)	Microalbuminuria — HMOD marker	> 30 mg/g = abnormal; > 300 mg/g = overt proteinuria
12-Lead ECG	LVH, ischaemia, arrhythmia, prior MI	All hypertensive patients

2.2 ECG INTERPRETATION IN HYPERTENSION

Finding	Criteria	Significance
LVH (voltage)	Sokolow-Lyon: S(V1) + R(V5/V6) ≥ 35 mm	Left ventricular hypertrophy
	Cornell: R(aVL) + S(V3) > 28 mm (M), > 20 mm (F)	More specific
LVH with strain	ST depression + T inversion in lateral leads	Worse prognosis
Left atrial enlargement	P mitrale (notched P in II, biphasic in V1)	Diastolic dysfunction
Ischaemia	ST depression, T wave changes	CAD
Atrial fibrillation	Irregularly irregular, absent P waves	↑ Stroke risk
Prior MI	Pathological Q waves	Established CVD

📌 ECG has low sensitivity (~50%) for LVH. If clinical suspicion is high and ECG is negative, order echocardiography.

2.3 ADDITIONAL INVESTIGATIONS (BY CLINICAL INDICATION)

Test	When to Order	Purpose
Echocardiography	Suspected LVH, HF, murmur, abnormal ECG	LVMI, LVEF, diastolic function, valve disease
Renal Ultrasound	Elevated creatinine, abnormal urinalysis, family history PKD	Size, asymmetry, cysts, obstruction
Renal Artery Doppler	Resistant HTN, abdominal bruit, flash pulmonary oedema, renal impairment on ACE-I/ARB	Renal artery stenosis
CT/MR Angiography	Suspected RAS, coarctation, adrenal mass	Detailed anatomy
Fundoscopy	Grade 2–3 HTN, diabetes, visual symptoms	Retinopathy grading
Carotid Ultrasound	Carotid bruit, high CV risk	Plaque, IMT, stenosis
ABI	Suspected PAD, claudication	< 0.9 = PAD
NT-proBNP / BNP	Suspected HF	Elevated in HF
Chest X-ray	Suspected HF, coarctation, aortic disease	Cardiomegaly, pulmonary congestion, rib notching

2.4 SECONDARY HYPERTENSION: WHEN TO SCREEN AND HOW

When to Screen

Red Flag	Action
Age < 30 years without obesity or family history	Screen
Sudden onset of HTN	Screen
Acute worsening of previously controlled HTN	Screen
Resistant HTN (uncontrolled on ≥ 3 drugs including diuretic)	Screen
Grade 3 HTN with acute HMOD	Screen
Unprovoked hypokalaemia (K⁺ < 3.5) or severe diuretic-induced hypokalaemia	Screen
Abdominal bruit	Screen
Labile BP with paroxysmal symptoms (sweating, palpitations, headache)	Screen
Features of specific syndrome (Cushing, thyroid, acromegaly)	Screen
> 30% rise in creatinine after starting ACE-I/ARB	Screen
Flash pulmonary oedema with preserved LV function	Screen

Screening and Confirmatory Tests by Cause

Suspected Cause	Screening Test	Confirmatory Test
Primary Aldosteronism	Aldosterone-to-Renin Ratio (ARR)	Salt loading test; Adrenal CT; Adrenal vein sampling
Renovascular Disease	Renal artery Doppler	CT/MR angiography
Phaeochromocytoma	Plasma free metanephrines (preferred) OR 24-hr urine metanephrines/catecholamines	CT/MRI abdomen; MIBG scan
Cushing Syndrome	24-hr urine free cortisol OR overnight 1 mg dexamethasone suppression test OR late-night salivary cortisol	ACTH level; Pituitary MRI; Adrenal CT
Thyroid Dysfunction	TSH	Free T4, Free T3
Obstructive Sleep Apnoea	STOP-BANG questionnaire; Epworth Sleepiness Scale	Polysomnography
Coarctation of Aorta	Arm-leg BP gradient > 20 mmHg; CXR (rib notching, “3” sign)	CT/MR angiography; Echocardiography
Renal Parenchymal Disease	Creatinine, eGFR, Urinalysis, Urine ACR, Renal ultrasound	Renal biopsy if indicated

SECTION 3: RISK STRATIFICATION

3.1 HYPERTENSION-MEDIATED ORGAN DAMAGE (HMOD)

Organ	Marker	Detection
Heart	LVH	ECG (Sokolow-Lyon, Cornell); Echo (LVMI: M > 115, F > 95 g/m²)
	Diastolic dysfunction	Echo (E/e’ ratio, LA volume)
Arteries	Carotid IMT ≥ 0.9 mm or plaque	Carotid ultrasound
	Aortic stiffness (PWV > 10 m/s)	Pulse wave velocity
	ABI < 0.9	Ankle-brachial index
Kidney	eGFR 30–59 (CKD Stage 3)	Serum creatinine calculation
	Microalbuminuria (ACR 30–300 mg/g)	Spot urine ACR
Eye	Retinopathy (Grade III–IV)	Fundoscopy
Brain	White matter lesions, silent infarcts	MRI (not routine)

3.2 ESTABLISHED CARDIOVASCULAR/RENAL DISEASE

Category	Examples
Cerebrovascular	Ischaemic stroke, Haemorrhagic stroke, TIA
Coronary	MI, Angina, PCI, CABG
Heart Failure	HFrEF, HFpEF
Peripheral Arterial	Symptomatic PAD, revascularisation, amputation
Renal	CKD Stage 4–5 (eGFR < 30), ESKD, Transplant
Retinal	Advanced retinopathy (Grade III–IV)
Aortic	Aneurysm, Prior dissection

3.3 RISK STRATIFICATION MATRIX

BP Category	No Other RF	1–2 RF	≥ 3 RF	HMOD, CKD 3, or DM without HMOD	CVD, CKD ≥ 4, or DM with HMOD
High Normal (130–139/85–89)	Low	Low	Low–Mod	Mod–High	Very High
Grade 1 (140–159/90–99)	Low	Mod	Mod–High	High	Very High
Grade 2 (160–179/100–109)	Mod	Mod–High	High	High	Very High
Grade 3 (≥ 180/110)	High	High	High	Very High	Very High

Interpretation

Risk Category	10-Year CV Risk	Action
Low	< 5%	Lifestyle; drug if HTN persists
Moderate	5–10%	Lifestyle + consider drug
High	10–20%	Lifestyle + drug
Very High	> 20%	Lifestyle + drug urgently

3.4 CARDIOVASCULAR RISK CALCULATORS

Calculator	Population	Notes
WHO/ISH Risk Charts	Global including SEAR-D (India)	Free, simple; uses age, sex, BP, DM, smoking, cholesterol
QRISK3	UK population	Includes South Asian ethnicity adjustment
SCORE2 / SCORE2-OP	European	Age-specific; updated
ASCVD Risk Estimator	US population	ACC/AHA
Framingham Risk Score	US population	Original; may underestimate in South Asians

📌 WHO/ISH charts (SEAR-D region) or QRISK3 (with South Asian ethnicity adjustment) are reasonable choices for Indian patients.

SECTION 4: TREATMENT TARGETS

4.1 EVIDENCE FOR BP TARGETS

🔬 Key Trials:

SPRINT (2015): Intensive (< 120 mmHg) vs Standard (< 140 mmHg) in non-diabetics reduced CV events by 25% and all-cause mortality by 27%, but with more adverse events (hypotension, syncope, AKI, electrolyte disturbances)
ACCORD-BP (2010): In Type 2 diabetics, intensive SBP target (< 120) vs standard (< 140) did not reduce the primary composite CV endpoint, but did significantly reduce stroke. Increased adverse effects.
Meta-analyses (Ettehad et al., Lancet 2016): Every 10 mmHg SBP reduction → 20% reduction in major CV events, 28% reduction in HF, 27% reduction in stroke, 13% reduction in all-cause mortality.

Balancing Benefits and Risks

Target	Benefits	Risks
< 120/80	Maximum CV risk reduction	More hypotension, syncope, AKI, electrolyte disturbances
< 130/80	Significant CV benefit with acceptable risk profile	Mild increase in adverse effects
< 140/90	Clear benefit, fewer side effects	Suboptimal protection in high-risk patients

4.2 TARGET BP — QUICK REFERENCE

Population	SBP Target	DBP Target	Lower Limit	Key Notes
General < 65 years	< 130	< 80	> 110/70	If tolerated
General 65–79 years	< 140 (ideal < 130 if tolerated)	< 80	> 110/70	Individualise; check orthostatic BP
≥ 80 years	< 150 (< 140 if fit)	< 90	> 110/70	Avoid overtreatment; function over numbers
Diabetes	< 130	< 80	> 110/70	ACE-I/ARB preferred
CKD (no proteinuria)	< 140	< 90	> 110/70	Any agent acceptable
CKD (proteinuria present)	< 130 (< 120 SBP if tolerated)	< 80	> 110/70	ACE-I/ARB mandatory; KDIGO 2021
CAD / Post-MI	< 130	70–80	DBP > 60–70	J-curve concern
Heart Failure	< 130	< 80	Tolerate SBP 100–110	Use GDMT
Post-Stroke (chronic)	< 130	< 80	> 110/70	After acute phase
Pregnancy	< 140	< 90	> 110/70	Avoid hypoperfusion
Frail elderly	Individualise	—	Avoid falls, syncope	Function over numbers

SECTION 5: NON-PHARMACOLOGICAL MANAGEMENT

📌 Every patient with hypertension — regardless of BP level, risk category, or drug treatment — should receive structured lifestyle advice.

5.1 LIFESTYLE INTERVENTIONS — SUMMARY OF EVIDENCE

Intervention	Recommendation	Expected SBP Reduction
Salt restriction	< 5 g/day (< 2 g sodium/day)	5–6 mmHg
Dietary pattern (DASH-style)	Rich in fruits, vegetables, whole grains, low-fat dairy; low in saturated fat	8–14 mmHg
Potassium intake	Increase dietary potassium to 3.5–5 g/day (fruits, vegetables); avoid supplements if on ACE-I/ARB/MRA	2–4 mmHg
Weight loss	Target BMI 18.5–22.9 (Asian cut-offs); waist < 90 cm (M), < 80 cm (F)	~1 mmHg per kg lost
Aerobic exercise	≥ 150 min/week moderate intensity OR ≥ 75 min/week vigorous	4–9 mmHg
Resistance exercise	2–3 days/week, moderate intensity	2–4 mmHg
Alcohol reduction	≤ 2 standard drinks/day (men); ≤ 1 standard drink/day (women)	2–4 mmHg
Smoking cessation	Complete cessation of all tobacco	Minimal direct BP effect; major CV risk reduction
Stress management	Meditation, yoga, relaxation techniques	Variable

📌 Combined lifestyle modifications can reduce SBP by 10–20 mmHg — equivalent to one antihypertensive drug.

📌 Central obesity (waist circumference) is more important than BMI for cardiovascular risk assessment in South Asians.

Exercise Cautions

If Patient Has	Precaution
BP > 180/110	Control BP before commencing vigorous exercise
CAD	Graded exercise; consider stress test if new to exercise
Orthopaedic limitations	Low-impact activities
Autonomic dysfunction	Avoid sudden position changes

SECTION 6: PHARMACOLOGICAL MANAGEMENT

6.1 WHEN TO START DRUG THERAPY

Decision Matrix

BP Grade	Low–Moderate CV Risk	High CV Risk (or DM, CKD, CVD, HMOD)
High Normal (130–139/85–89)	Lifestyle only	Consider drugs (especially if CAD, DM with HMOD, HFrEF)
Grade 1 (140–159/90–99)	Lifestyle × 3–6 months → Drug if not controlled	Lifestyle + Drug immediately
Grade 2 (160–179/100–109)	Lifestyle + Drug immediately	Lifestyle + Drug immediately
Grade 3 (≥ 180/110)	Lifestyle + Drug immediately	Lifestyle + Drug immediately

Start Drug Therapy Immediately If:

BP ≥ 160/100 mmHg (Grade 2 or 3)
BP ≥ 140/90 mmHg + Diabetes Mellitus
BP ≥ 140/90 mmHg + CKD (eGFR < 60 or albuminuria)
BP ≥ 140/90 mmHg + Established CVD (CAD, stroke, PAD, HF)
BP ≥ 140/90 mmHg + HMOD (LVH, retinopathy, microalbuminuria)
BP ≥ 140/90 mmHg + High 10-year CV risk (> 10%)
Any hypertensive emergency

Trial Lifestyle First If:

Grade 1 HTN (140–159/90–99) AND
Low–moderate CV risk AND
No diabetes, CKD, CVD, or HMOD AND
Patient is motivated and close follow-up is possible
Duration: 3–6 months with regular monitoring

6.2 FIRST-LINE DRUG CLASSES

Overview

Class	Letter	Key Drugs	Mechanism	Key Advantage
ACE Inhibitors	A	Ramipril, Enalapril, Perindopril, Lisinopril	Block ACE → ↓ Angiotensin II	Renoprotection; HF benefit
ARBs	A	Telmisartan, Losartan, Olmesartan, Valsartan, Azilsartan, Candesartan	Block AT₁ receptor	Like ACE-I but no cough
CCBs (DHP)	C	Amlodipine, Cilnidipine, Nifedipine ER	Block L-type Ca²⁺ channels	Potent; metabolically neutral
Thiazide-like Diuretics	D	Chlorthalidone, Indapamide	Inhibit Na-Cl cotransporter	Volume control; inexpensive

🔬 All four classes reduce CV events and mortality comparably. Choice depends on compelling indications, contraindications, and patient characteristics.

Comparison of First-Line Classes

Feature	ACE-I	ARB	CCB	Thiazide-like
Efficacy	+++	+++	++++	+++
Renoprotection	++++	++++	+	+
HF benefit	++++	+++	±	++
Metabolic neutrality	+++	+++	++++	+
Cough	5–20%	Rare	No	No
Peripheral oedema	No	No	Yes	No
Hypokalaemia	No (↑ K⁺)	No (↑ K⁺)	No	Yes

6.3 INITIAL DRUG SELECTION

Age/Ethnicity-Based Selection (No Compelling Indication)

NO COMPELLING INDICATION

│

┌──────────────┴──────────────┐

│ │

AGE < 55 YEARS AGE ≥ 55 YEARS

│ or Black/African

│ ethnicity

▼ ▼

┌──────────┐ ┌──────────┐

│ ACE-I │ │ CCB │

│ or │ │ or │

│ ARB │ │Thiazide │

└──────────┘ └──────────┘

6.4 COMPELLING INDICATIONS — MASTER TABLE

Condition	✅ Preferred	⚠️ Caution	❌ Avoid
Diabetes (no albuminuria)	ACE-I/ARB	High-dose thiazide	—
DM + Albuminuria	ACE-I/ARB (mandatory)	—	—
CKD	ACE-I/ARB	Monitor K⁺, Cr	—
CKD (eGFR < 30)	Loop diuretic	ACE-I/ARB (with caution)	Thiazides (less effective)
HFrEF (EF ≤ 40%)	ACE-I/ARB → ARNI, BB, MRA, SGLT2i	—	Non-DHP CCB (Verapamil, Diltiazem)
HFpEF	Any agent; SGLT2i; consider MRA	—	—
Post-MI	ACE-I, BB	—	—
CAD (stable)	ACE-I, BB, CCB	—	—
Post-Stroke (chronic)	ACE-I + Thiazide	—	—
Atrial Fibrillation (rate control)	BB or Non-DHP CCB	—	—
Aortic aneurysm	BB	—	—
Pregnancy	Methyldopa, Labetalol, Nifedipine ER	—	ACE-I, ARB, ARNI, MRA
Asthma	CCB, ACE-I, ARB, Thiazide	Cardioselective BB only if compelling cardiac indication and no alternative; specialist supervision	Non-selective BB (Propranolol, Carvedilol, Labetalol)
COPD (without reversible airway disease)	Any; cardioselective BB generally safe	—	—
Gout / Hyperuricaemia	Losartan (uricosuric)	—	Thiazides
BPH	Alpha-blocker (add-on, not first-line)	Orthostatic hypotension	—
Osteoporosis	Thiazide (↓ urinary Ca²⁺)	—	—
Bradycardia / Heart block	DHP CCB, ACE-I, ARB	—	BB, Non-DHP CCB
Bilateral renal artery stenosis	CCB, Thiazide	—	ACE-I, ARB
Prior ACE-I angioedema	ARB (with caution), CCB, others	—	ACE-I (absolute)
Hyperkalaemia (K⁺ > 5.5)	CCB, Thiazide	—	ACE-I, ARB, MRA (until K⁺ corrected)

Compelling Indications — Expanded Notes

Diabetes Mellitus:

Target: < 130/80 mmHg
ACE-I/ARB mandatory if any degree of albuminuria
Consider SGLT2 inhibitor for combined cardiorenal benefit (see Section 8.1)
Consider Finerenone if albuminuria persists on maximal ACE-I/ARB (see Section 8.1)

Heart Failure (HFrEF):

Guideline-directed medical therapy: ACE-I/ARB → ARNI + BB + MRA + SGLT2i ± diuretic
ARNI (Sacubitril/Valsartan) is preferred over ACE-I/ARB once stable (PARADIGM-HF: 20% reduction in CV death/HF hospitalisation vs enalapril)
❌ Never combine ARNI with ACE-I; 36-hour washout required when switching from ACE-I to ARNI

CAD / Post-MI:

⚠️ J-curve: Keep DBP > 60–70 mmHg in CAD patients to maintain coronary perfusion

Post-Stroke/TIA:

Acute ischaemic stroke: do NOT lower BP unless > 220/120 (or > 185/110 if thrombolysis planned)
Chronic secondary prevention: ACE-I + Thiazide preferred (PROGRESS trial); target < 130/80

6.5 MONOTHERAPY VS COMBINATION THERAPY

🔬 Evidence:

Monotherapy controls BP in only 30–50% of patients
Low-dose combination is more effective than high-dose monotherapy
Combination therapy reaches target faster with fewer side effects
Single-pill combinations (SPC) improve adherence by 20–30%

When to Use Monotherapy

Grade 1 HTN (140–159/90–99) with low CV risk
BP within 20/10 mmHg of target
Very elderly or frail (risk of hypotension)

When to Start with Dual Combination

Grade 2–3 HTN (≥ 160/100)
BP > 20/10 mmHg above target
High or very high CV risk
Diabetes mellitus
CKD
Established CVD
HMOD
Most patients (default strategy in modern practice)

Recommended Combinations

Combination	Suitability	Notes
ACE-I/ARB + CCB	✅ Preferred for most patients	Reduces CCB-induced oedema; metabolically neutral; strong evidence (ACCOMPLISH)
ACE-I/ARB + Thiazide-like	✅ Preferred	Good for volume-related HTN; HF
CCB + Thiazide-like	✅ Acceptable	When ACE-I/ARB intolerant
CCB + BB	✅ Acceptable	Especially if tachycardia or angina
BB + Diuretic	⚠️ Limited use	HF or post-MI; not first-line for uncomplicated HTN

Combinations to AVOID

❌ Combination	Reason
ACE-I + ARB	No added benefit; ↑ hyperkalaemia, ↑ AKI (ONTARGET)
ACE-I/ARB + Aliskiren	↑ Hyperkalaemia, AKI
Non-DHP CCB + BB	Risk of severe bradycardia and heart block
Two drugs of the same class	No added benefit

6.6 STEP-BY-STEP TREATMENT PROTOCOL

STEP 1: Initial Therapy

Select drug(s) based on compelling indications (Section 6.4) or age-based algorithm (Section 6.3). Start with monotherapy or dual combination per Section 6.5. Reassess in 4–6 weeks.

STEP 2: If Not at Target

Current Therapy	If NOT at Full Dose	If AT Full Dose
Monotherapy	Uptitrate to full dose	Add 2nd drug → Dual combination
Dual combination	Uptitrate both to full doses	Add 3rd drug → Triple combination

STEP 3: Triple Combination

Standard triple therapy:

ACE-I or ARB (full dose) + CCB (full dose) + Thiazide-like diuretic (Chlorthalidone or Indapamide)

Use single-pill triple combination if available.

STEP 4: Resistant Hypertension

See Section 8.5. Key steps:

Rule out pseudo-resistance (adherence, white coat, measurement error, interfering drugs)
Optimise diuretic: switch to Chlorthalidone 25 mg or Indapamide 2.5 mg
Screen for secondary causes (especially primary aldosteronism, OSA)
Add Spironolactone 25–50 mg as 4th drug (PATHWAY-2)
Specialist referral if still uncontrolled

STEP 5: Refractory Hypertension

Uncontrolled on ≥ 5 drugs at optimal doses including chlorthalidone and spironolactone → mandatory specialist referral.

6.7 COMPLETE TREATMENT ALGORITHM

HYPERTENSION CONFIRMED

│

▼

┌───────── COMPELLING INDICATION? ─────────┐

│ │

YES NO

│ │

▼ ▼

USE INDICATED DRUG(S) AGE-BASED SELECTION

• DM/CKD → ACE-I/ARB • < 55 → ACE-I/ARB

• HF → ACE-I→ARNI+BB+MRA • ≥ 55 → CCB/Thiazide

• CAD → ACE-I+BB

• Pregnancy → Methyldopa/Labetalol

│ │

└────────────────┬─────────────────────────┘

│

▼

┌────── GRADE & RISK? ──────┐

│ │

Grade 1 + Low Risk Grade 2-3 or High Risk

│ │

▼ ▼

MONOTHERAPY DUAL COMBINATION

(ACE-I/ARB or CCB) (ACE-I/ARB + CCB preferred)

│ │

└─────────────┬─────────────┘

│

▼

REASSESS 4–6 WEEKS

│

┌────────────┴────────────┐

│ │

AT TARGET NOT AT TARGET

│ │

▼ ▼

Continue; UPTITRATE or ADD DRUG

F/U 3–6 months │

┌────────────┴────────────┐

│ │

On Monotherapy On Dual Therapy

│ │

▼ ▼

DUAL THERAPY TRIPLE THERAPY

(ACE-I/ARB + CCB) (ACE-I/ARB + CCB + Thiazide)

│ │

└────────────┬────────────┘

│

▼

REASSESS 4–6 WEEKS

│

┌────────────┴────────────┐

│ │

AT TARGET NOT AT TARGET

│ │

▼ ▼

Continue RESISTANT HTN WORKUP

│

▼

• Confirm adherence

• ABPM (rule out white coat)

• Screen secondary causes

• Optimise diuretic

│

▼

ADD SPIRONOLACTONE 25–50 mg

│

▼

REASSESS 4–6 WEEKS

│

┌────────────────┴───────────────┐

│ │

AT TARGET NOT AT TARGET

│ │

▼ ▼

Continue SPECIALIST REFERRAL

6.8 DRUG DOSING — COMPLETE REFERENCE

ACE Inhibitors

Drug	Starting Dose	Target Dose	Maximum Dose	Frequency	Notes
💊 Ramipril	2.5 mg	10 mg	10 mg	OD	Most evidence (HOPE trial); preferred
💊 Perindopril erbumine	4 mg	8 mg	8 mg	OD	EUROPA, ADVANCE. Note: Perindopril arginine 5 mg ≈ erbumine 4 mg
💊 Enalapril	5 mg	20 mg	40 mg	BD	BD dosing usually required for 24-hour coverage
💊 Lisinopril	5 mg	20–40 mg	40 mg	OD	No hepatic metabolism

Class side effects:

Dry cough (5–20%; higher in Asians) → switch to ARB
Hyperkalaemia → monitor K⁺
Angioedema (rare but serious) → discontinue permanently; avoid rechallenge
First-dose hypotension → start low in elderly, volume-depleted patients
AKI → check creatinine at 1–2 weeks after initiation

ARBs

Drug	Starting Dose	Target Dose	Maximum Dose	Frequency	Notes
💊 Telmisartan	40 mg	80 mg	80 mg	OD	Longest half-life (24 hrs); PPARγ activity; metabolically neutral
💊 Olmesartan	20 mg	40 mg	40 mg	OD	Potent BP reduction
💊 Azilsartan	40 mg	80 mg	80 mg	OD	Most potent ARB in head-to-head comparisons
💊 Losartan	50 mg	100 mg	100 mg	OD	Unique uricosuric effect; shortest half-life
💊 Valsartan	80 mg	160–320 mg	320 mg	OD	Strong HF evidence (Val-HeFT)
💊 Candesartan	8 mg	32 mg	32 mg	OD	Strong HF evidence (CHARM)

📌 Telmisartan and Azilsartan provide the best 24-hour BP coverage. Losartan is preferred when hyperuricaemia or gout is present.

ARNI (Angiotensin Receptor-Neprilysin Inhibitor)

Drug	Starting Dose	Target Dose	Maximum Dose	Frequency	Notes
💊 Sacubitril/Valsartan	24/26 mg	97/103 mg	97/103 mg	BD	Preferred over ACE-I/ARB in HFrEF (PARADIGM-HF)

Key prescribing rules:

✅ Indicated for HFrEF; replaces ACE-I/ARB once patient is stable
✅ Potent antihypertensive effect
❌ Never combine with ACE-I (risk of angioedema)
⚠️ Requires 36-hour washout after stopping ACE-I before starting ARNI
⚠️ No washout needed when switching from ARB
⚠️ Can cause hypotension — start low, uptitrate gradually
Monitor K⁺ and renal function as with ACE-I/ARB

CCBs — Dihydropyridines

Drug	Starting Dose	Target Dose	Maximum Dose	Frequency	Notes
💊 Amlodipine	5 mg	10 mg	10 mg	OD	Most widely used; ankle oedema common at higher doses
💊 S-Amlodipine	2.5 mg	5 mg	5 mg	OD	Purified S-isomer; may have less oedema
💊 Cilnidipine	10 mg	20 mg	20 mg	OD	N+L type blockade; less reflex tachycardia, less oedema
💊 Nifedipine ER	30 mg	60 mg	90 mg	OD	Extended-release formulation ONLY
💊 Felodipine	5 mg	10 mg	10 mg	OD	Alternative

❌ Never use immediate-release Nifedipine capsules for hypertension management. Causes unpredictable precipitous BP drops with risk of stroke and MI. This formulation should not be stocked for antihypertensive use.

CCBs — Non-Dihydropyridines

Drug	Starting Dose	Target Dose	Maximum Dose	Frequency	Notes
💊 Diltiazem SR	90 mg	180–240 mg	360 mg	OD–BD	Rate control in AF; constipation
💊 Verapamil SR	120 mg	240 mg	480 mg	OD–BD	Rate control; constipation; negative inotropy

❌ Do NOT combine non-DHP CCBs with beta-blockers (risk of severe bradycardia and heart block).
❌ Avoid Verapamil and Diltiazem in HFrEF (negative inotropy).

Thiazide and Thiazide-like Diuretics

Drug	Starting Dose	Target Dose	Maximum Dose	Frequency	Notes
💊 Chlorthalidone	12.5 mg	25 mg	50 mg	OD	Preferred; longer acting; greater potency per mg
💊 Indapamide	1.5 mg	2.5 mg	2.5 mg	OD	Preferred; fewer metabolic effects than other thiazides
💊 Hydrochlorothiazide	12.5 mg	25 mg	50 mg	OD	Shorter acting; less potent; widely available

📌 Chlorthalidone and Indapamide are preferred over HCTZ based on longer duration, greater potency, and superior outcome data (ALLHAT, SHEP). However, the DCP Trial (NEJM 2022) showed no significant difference in CV outcomes between chlorthalidone and HCTZ. HCTZ is acceptable when preferred agents are unavailable.

Class side effects:

Hypokalaemia — combine with ACE-I/ARB or K⁺-sparing diuretic
Hyponatraemia — especially in elderly women; monitor Na⁺ at 1–2 weeks after starting
Hyperuricaemia / gout precipitation — use Losartan if gout co-exists; avoid in severe gout
Glucose intolerance — use low doses; prefer Indapamide
Hypercalcaemia — usually mild; beneficial if osteoporosis co-exists

Beta-Blockers

Drug	Starting Dose	Target Dose	Maximum Dose	Frequency	Notes
💊 Bisoprolol	2.5–5 mg	10 mg	20 mg	OD	Cardioselective; HF evidence
💊 Metoprolol Succinate XL	25–50 mg	200 mg	400 mg	OD	Extended-release; HF evidence (MERIT-HF)
💊 Nebivolol	5 mg	10 mg	40 mg	OD	Vasodilating; less fatigue, less erectile dysfunction
💊 Carvedilol	6.25 mg BD	25 mg BD	25 mg BD (50 mg/day)	BD	α + β blocker; HF evidence. For HF: start 3.125 mg BD
💊 Atenolol	25–50 mg	100 mg	100 mg	OD	Less preferred; inferior stroke prevention (LIFE trial)
💊 Propranolol	40 mg	160 mg	320 mg	BD–TID	Non-selective; migraine, tremor, thyrotoxicosis
💊 Labetalol	100 mg	200–400 mg	1200 mg	BD	α + β; pregnancy-safe; hypertensive emergencies

📌 Metoprolol formulations are NOT interchangeable:

Succinate (XL/ER): Once daily; smooth BP control; HF mortality evidence (MERIT-HF). Preferred.
Tartrate (IR): Twice daily; peaks and troughs; NO HF mortality evidence. Not preferred for HTN or HF.

📌 Beta-blockers are NOT first-line for uncomplicated HTN. Indicated for:

Heart failure (HFrEF)
Post-MI
Coronary artery disease
Arrhythmias (AF, SVT)
Aortic aneurysm
Hyperkinetic states (anxiety, thyrotoxicosis)
Migraine prophylaxis, essential tremor

MRAs (Mineralocorticoid Receptor Antagonists)

Drug	Starting Dose	Target Dose	Maximum Dose	Frequency	Notes
💊 Spironolactone	12.5–25 mg	25–50 mg	100 mg	OD	Best 4th-line agent for resistant HTN (PATHWAY-2); gynecomastia in males
💊 Eplerenone	25 mg	50 mg	50 mg	OD	Selective MRA; much less gynecomastia; more expensive

⚠️ Monitor K⁺ closely, especially when combined with ACE-I/ARB. Avoid if K⁺ > 5.0 mmol/L or eGFR < 30.

Non-Steroidal MRA

Drug	Starting Dose	Target Dose	Maximum Dose	Frequency	Notes
💊 Finerenone	10 mg	20 mg	20 mg	OD	Indicated specifically for diabetic kidney disease with albuminuria; modest BP lowering; renal and CV benefit (FIDELIO-DKD, FIGARO-DKD)

Other Antihypertensive Agents

Drug	Dose Range	Frequency	Indication	Key Cautions
💊 Doxazosin	4–8 mg	OD (bedtime)	Resistant HTN; BPH	First-dose hypotension
💊 Prazosin	1–5 mg	BD–TID	Resistant HTN; BPH	First-dose syncope; start 1 mg at bedtime
💊 Clonidine	0.1–0.3 mg	BD–TID	Resistant HTN	Rebound HTN on sudden withdrawal
💊 Methyldopa	250–500 mg	BD–TID	Pregnancy (first-line)	Sedation; depression
💊 Hydralazine	25–100 mg	TID–QID	HF; pregnancy; resistant HTN	Reflex tachycardia; lupus-like syndrome at high doses
💊 Minoxidil	5–40 mg	OD–BD	Severe resistant HTN	Hirsutism; fluid retention; pericardial effusion; must combine with BB + diuretic

6.9 DRUG COMBINATIONS — SINGLE-PILL COMBINATIONS (SPCs)

📌 SPCs improve adherence by 20–30%, reach target faster, reduce pill burden, and are often more cost-effective than separate pills.

Dual SPCs

Combination	Commonly Available Strengths (mg)
Telmisartan + Amlodipine	40/5, 80/5, 40/10, 80/10
Olmesartan + Amlodipine	20/5, 40/5, 20/10, 40/10
Losartan + Amlodipine	50/5, 100/5, 50/10
Ramipril + Amlodipine	2.5/5, 5/5, 5/10, 10/5
Perindopril + Amlodipine	4/5, 8/5, 4/10, 8/10
Telmisartan + Chlorthalidone	40/12.5, 80/12.5
Telmisartan + HCTZ	40/12.5, 80/12.5, 80/25
Losartan + HCTZ	50/12.5, 100/25
Amlodipine + Atenolol	5/25, 5/50
Cilnidipine + Telmisartan	10/40, 10/80
Azilsartan + Cilnidipine	40/10, 80/10

Triple SPCs

Combination	Commonly Available Strengths (mg)
Telmisartan + Amlodipine + HCTZ	40/5/12.5, 80/5/12.5
Olmesartan + Amlodipine + HCTZ	20/5/12.5, 40/5/12.5
Losartan + Amlodipine + HCTZ	50/5/12.5

6.10 ASPIRIN AND STATIN CO-PRESCRIPTION IN HYPERTENSION

Aspirin

Indication	Recommendation
Primary prevention (HTN without established CVD)	❌ Do NOT use aspirin routinely. Risk of major bleeding exceeds benefit. (ARRIVE 2018; ASPREE 2018)
Secondary prevention (established CVD: prior MI, stroke/TIA, PCI, CABG, PAD)	✅ Aspirin 75–150 mg OD

⚠️ If prescribing aspirin, ensure BP is controlled first. Uncontrolled hypertension + aspirin increases bleeding risk, particularly intracranial haemorrhage.

Statin

Indication	Statin Intensity
Established ASCVD (MI, stroke, PAD, PCI, CABG)	High-intensity (Atorvastatin 40–80 mg or Rosuvastatin 20–40 mg)
Diabetes mellitus, age 40–75	Moderate-intensity (Atorvastatin 10–20 mg or Rosuvastatin 5–10 mg); high-intensity if additional risk factors
LDL ≥ 190 mg/dL	High-intensity
10-year CV risk > 10%, age 40–75	Moderate-to-high intensity
10-year CV risk 7.5–10% with risk enhancers	Consider moderate-intensity

📌 South Asian ethnicity is recognised as a cardiovascular risk enhancer; a lower threshold for statin initiation is appropriate.

⚠️ Drug interaction: Simvastatin — avoid with Diltiazem or Verapamil (CYP3A4 inhibition → ↑ statin levels → myopathy risk). Use ≤ 10 mg simvastatin, or switch to Atorvastatin or Rosuvastatin.

6.11 SIDE EFFECT SUMMARY TABLE

Drug Class	Side Effect	Frequency	Management
ACE-I	Dry cough	5–20%	Switch to ARB
	Angioedema	< 1%	Stop permanently; avoid rechallenge; use ARB with caution
	Hyperkalaemia	2–5%	Check K⁺; reduce dose; avoid K⁺ supplements
	First-dose hypotension	Variable	Start low; caution in volume-depleted
	AKI	Variable	Check Cr at 1–2 weeks; accept ≤ 30% rise if stable
ARB	Similar to ACE-I but cough rare	—	—
DHP CCB	Ankle oedema	10–25%	Add ACE-I/ARB; switch to Cilnidipine; switch class
	Headache, flushing	5–10%	Usually transient
	Gum hyperplasia	Rare	Dental hygiene; switch
Non-DHP CCB	Constipation	10–20%	Fibre; switch
	Bradycardia	Variable	Reduce dose; never combine with BB
Thiazides	Hypokalaemia	10–40%	Combine with ACE-I/ARB or K⁺-sparing agent
	Hyponatraemia	5–10%	Monitor Na⁺ at 1–2 weeks; reduce dose or switch
	Hyperuricaemia/gout	5–10%	Losartan; avoid in severe gout
	Hyperglycaemia	2–5%	Use low doses; prefer Indapamide
BB	Fatigue	10–20%	Switch to Nebivolol or Carvedilol
	Bradycardia	Variable	Reduce dose; switch
	Sexual dysfunction	5–15%	Switch to Nebivolol
	Bronchospasm	Variable	Avoid in asthma; generally safe in COPD
	Masking of hypoglycaemia	—	Caution in insulin-treated DM
MRA	Hyperkalaemia	5–15%	Monitor K⁺; reduce dose
	Gynecomastia (Spironolactone)	10–20% in males	Switch to Eplerenone
Alpha-blockers	First-dose hypotension	Variable	Start low; give at bedtime
	Orthostatic hypotension	5–15%	Caution in elderly

📌 CCB-induced ankle oedema is NOT fluid retention — it is caused by precapillary vasodilation increasing capillary hydrostatic pressure. Diuretics do NOT help. Adding ACE-I/ARB (postcapillary venodilation) counteracts this effect.

6.12 DRUG INTERACTIONS

Clinically Important Interactions

Drug	Interacts With	Effect	Action
ACE-I/ARB	NSAIDs	↓ Antihypertensive effect; ↑ AKI risk	Minimise NSAID use
	K⁺-sparing diuretics / supplements	↑ Hyperkalaemia	Monitor K⁺
	Lithium	↑ Lithium levels	Monitor levels
	Other ACE-I/ARB	No added benefit; ↑ AKI, hyperkalaemia	Never combine
	Aliskiren	↑ Hyperkalaemia, AKI	Avoid combination
Thiazides	NSAIDs	↓ Diuretic effect; ↑ AKI risk	Minimise NSAIDs
	Lithium	↑ Lithium toxicity	Monitor levels
	Digoxin	Hypokalaemia → ↑ Digoxin toxicity	Monitor K⁺
BB	Non-DHP CCBs	Severe bradycardia, heart block	Avoid combination
	Digoxin	↑ Bradycardia	Monitor HR
	Insulin/Sulfonylureas	Masks hypoglycaemia symptoms	Caution; educate patient
	Clonidine	Rebound HTN if clonidine withdrawn	Stop BB first, then clonidine
Non-DHP CCB	BB	Severe bradycardia, heart block	Avoid combination
	Simvastatin	↑ Statin levels (CYP3A4)	Use ≤ 10 mg simvastatin; or switch statin
	Digoxin	↑ Digoxin levels	Monitor levels
All antihypertensives	NSAIDs	↓ BP-lowering effect	Minimise chronic NSAID use
	Alcohol (excess)	↑ Hypotensive effect acutely	Moderate alcohol
	PDE5 inhibitors	↑ Hypotension	Caution; contraindicated with nitrates

The “Triple Whammy”

ACE-I/ARB + Diuretic + NSAID = significantly increased risk of AKI

Mechanism: NSAID blocks prostaglandin-mediated afferent arteriolar dilation + ACE-I/ARB causes efferent dilation + diuretic causes volume depletion → marked reduction in GFR
Action: Avoid chronic NSAIDs in patients on ACE-I/ARB + diuretic. If unavoidable, monitor creatinine closely and ensure adequate hydration.

📌 Self-prescribed NSAID use is extremely common. Ask about over-the-counter analgesic use at every visit.

6.13 ADHERENCE

Assess adherence at every visit using non-judgemental questioning
Use once-daily dosing whenever possible
Use single-pill combinations to reduce pill burden
Proactively manage side effects — they are the most common reason for discontinuation
Confirm adherence before diagnosing resistant hypertension

📌 Non-adherence affects 30–50% of hypertensive patients and is the most common cause of apparent treatment failure.

SECTION 7: HYPERTENSIVE CRISES

7.1 DEFINITIONS

Term	Definition	Key Feature	Management Setting
Hypertensive Emergency	Severe HTN (usually > 180/120) WITH acute target organ damage	Organ damage present	ICU; IV therapy
Hypertensive Urgency	Severe HTN (usually > 180/120) WITHOUT acute target organ damage	Organ damage absent	Outpatient/observation; oral therapy

🚨 The presence of acute organ damage — NOT the absolute BP number — defines an emergency.

7.2 TARGET ORGAN DAMAGE IN HYPERTENSIVE EMERGENCY

Organ	Condition	Key Features	Key Investigations
Brain	Hypertensive encephalopathy	Headache, confusion, visual changes, seizures, coma	CT head
	Ischaemic stroke	Focal neurological deficits	CT head (initially normal); MRI
	Haemorrhagic stroke (ICH)	Sudden severe headache, focal deficits, ↓ consciousness	CT head (hyperdense lesion)
	PRES	Headache, visual changes, seizures, altered mental status	MRI (posterior white matter oedema)
Heart	Acute Coronary Syndrome	Chest pain, dyspnoea, diaphoresis	ECG, Troponin
	Acute Pulmonary Oedema	Severe dyspnoea, orthopnoea, pink frothy sputum, crackles	CXR, BNP
	Aortic Dissection	Tearing chest/back pain, pulse deficit, inter-arm BP difference	CT aortogram
Kidney	Acute Kidney Injury	Oliguria, rising creatinine	Creatinine, Urinalysis
Eye	Acute severe retinopathy	Visual changes	Fundoscopy (haemorrhages, exudates, papilloedema)
Vascular	MAHA	Haemolysis	Peripheral smear (schistocytes), ↑ LDH, ↓ haptoglobin
Pregnancy	Eclampsia	Seizures in pregnant/postpartum woman with HTN	Clinical diagnosis
	HELLP Syndrome	RUQ pain, nausea, vomiting	↑ LFTs, ↓ Platelets, Haemolysis

7.3 INITIAL RAPID EVALUATION

The First 15 Minutes

Step	Action
1	Confirm BP — both arms; proper technique; repeat if very high
2	Focused history — headache? Chest pain? Dyspnoea? Visual changes? Neurological symptoms? Pregnancy? Medication adherence? Drug use (cocaine, amphetamines)?
3	Focused examination — GCS, focal neurological deficits; Fundoscopy; Cardiac (JVP, S3, murmurs); Lungs (crackles); Peripheral pulses
4	Determine: Emergency (organ damage) vs Urgency (no organ damage)
5	Act accordingly

Urgent Investigations

Test	Purpose
12-lead ECG	Ischaemia, LVH, arrhythmia
Troponin	ACS
BNP / NT-proBNP	Heart failure
Serum Creatinine, Electrolytes	Renal function, K⁺
CBC with peripheral smear	Anaemia, MAHA (schistocytes)
Urinalysis	Proteinuria, haematuria, casts
Chest X-ray	Pulmonary oedema, aortic contour, cardiomegaly
CT Head (non-contrast)	If neurological symptoms — stroke, haemorrhage
CT Aortogram	If aortic dissection suspected
Urine pregnancy test	All women of childbearing age

7.4 BP REDUCTION GOALS

General Principles

⚠️ Do NOT normalise BP rapidly in hypertensive emergencies. Chronic hypertensives have shifted cerebral autoregulation curves. Rapid normalisation risks watershed ischaemia (stroke, MI, AKI).

Timeframe	Goal
First 1 hour	Reduce MAP by 20–25% OR reduce DBP to 100–110 mmHg
Next 2–6 hours	Reduce to approximately 160/100–110 mmHg
Next 24–48 hours	Gradual further reduction toward target

Condition-Specific Targets

Condition	Target	Timeframe	Key Notes
Aortic Dissection 🚨	SBP < 120 mmHg AND HR < 60/min	Within 20 minutes	Beta-blocker FIRST before vasodilator
Acute Ischaemic Stroke (thrombolysis candidate)	< 185/110 before tPA; < 180/105 for 24h after	Before tPA administration
Acute Ischaemic Stroke (no thrombolysis)	Do NOT lower unless > 220/120	—	Permissive hypertension
Haemorrhagic Stroke (ICH) — presenting SBP 150–220	Target SBP ~140 mmHg	Within 1 hour	INTERACT2: reduced haematoma expansion. Do NOT target < 130 (ATACH-2: no benefit, more renal AEs)
Haemorrhagic Stroke (ICH) — presenting SBP > 220	Target SBP 140–160 mmHg	—	Aggressive lowering reasonable; limited evidence
Hypertensive Encephalopathy	↓ MAP by 20–25%	Over 1–2 hours
Acute Pulmonary Oedema	Reduce gradually with therapy	—	Preload reduction key
ACS	Reduce gradually; avoid hypotension	—	DBP > 60 mmHg for coronary perfusion
Eclampsia / Severe Preeclampsia	< 160/110 mmHg	Immediately	MgSO₄ for seizure prophylaxis/treatment
Phaeochromocytoma Crisis	Reduce gradually	—	Alpha-blocker first, then beta-blocker

7.5 IV ANTIHYPERTENSIVES

First-Line Agents

Drug	Mechanism	Dose	Onset	Duration	Best For	Avoid In
💊 Labetalol	α + β blocker	20 mg IV bolus; repeat 20–80 mg q10min OR 0.5–2 mg/min infusion	5–10 min	3–6 hrs	Most emergencies; Aortic dissection; Eclampsia	HF, Asthma, Bradycardia, Heart block
💊 Nicardipine	DHP CCB	5–15 mg/hr infusion	5–15 min	30–40 min	Most emergencies; Stroke; Post-operative	Severe aortic stenosis
💊 Nitroglycerin	Venodilator (+ coronary vasodilator)	5–200 mcg/min infusion	2–5 min	5–10 min	ACS; Pulmonary oedema	RV infarct; Concomitant PDE5 inhibitors
💊 Nitroprusside	Arterial + venous dilator	0.25–10 mcg/kg/min infusion	Immediate	1–2 min	Severe emergency; last resort	Prolonged use > 24–48 hrs (cyanide toxicity); hepatic/renal impairment; ↑ ICP. Monitor thiocyanate if > 24 hrs or > 2 mcg/kg/min
💊 Esmolol	Cardioselective ultra-short β-blocker	500 mcg/kg bolus → 50–200 mcg/kg/min infusion	1–2 min	10–20 min	Aortic dissection; Perioperative	HF, Asthma, Bradycardia

Second-Line / Specific Agents

Drug	Mechanism	Dose	Indication
💊 Hydralazine	Direct vasodilator	10–20 mg IV q4–6h	Eclampsia; Pregnancy
💊 Phentolamine	α-blocker	5–15 mg IV bolus	Phaeochromocytoma; Cocaine/amphetamine crisis
💊 Fenoldopam	Dopamine-1 agonist	0.1–0.3 mcg/kg/min	AKI; Renal protection desired
💊 Clevidipine	Ultra-short DHP CCB	1–16 mg/hr infusion	Perioperative
💊 Enalaprilat	IV ACE-I	1.25–5 mg IV q6h	HF with HTN (avoid in AKI)

Drug Selection by Clinical Scenario

Scenario	First Choice	Alternative	Avoid
Aortic Dissection	Esmolol or Labetalol (HR control first) ± Nitroprusside	—	Vasodilators before beta-blockade
ACS	Nitroglycerin ± Esmolol/Labetalol	—	Nitroprusside (coronary steal); Hydralazine (reflex tachycardia)
Acute Pulmonary Oedema	Nitroglycerin + Furosemide	Nitroprusside	—
Hypertensive Encephalopathy	Nicardipine or Labetalol	Nitroprusside (with caution)	—
Ischaemic Stroke	Labetalol or Nicardipine	—	Excessive lowering
Haemorrhagic Stroke	Nicardipine or Labetalol	—	—
Eclampsia	Labetalol or Hydralazine + MgSO₄	Nicardipine	ACE-I, ARB, Nitroprusside
Phaeochromocytoma	Phentolamine	Nicardipine	Beta-blockers before alpha-blockade
Cocaine/Amphetamine	Phentolamine or Nicardipine + Benzodiazepines	—	Pure beta-blockers (unopposed alpha stimulation)

7.6 SPECIFIC EMERGENCY PROTOCOLS

🚨 AORTIC DISSECTION

⏱️ Mortality increases 1–2% per hour if untreated.

Priority	Action	Details
1	Pain control	💊 Morphine 2–4 mg IV (pain drives sympathetic activation)
2	HR control FIRST	💊 Esmolol 500 mcg/kg bolus → 50–200 mcg/kg/min OR 💊 Labetalol 20 mg IV bolus → infusion. Target: HR < 60/min
3	Then BP control	Add 💊 Nitroprusside 0.25–0.5 mcg/kg/min if needed after HR controlled. Target: SBP < 120 mmHg
4	Imaging	CT aortogram
5	Surgical consult	Cardiothoracic / Vascular surgery — STAT

Type A (Ascending): Usually surgical emergency
Type B (Descending): Medical management; surgery/endovascular if complicated

❌ NEVER give vasodilators BEFORE beta-blocker in aortic dissection. Reflex tachycardia increases aortic shear stress and propagates the dissection.

🚨 ACUTE PULMONARY OEDEMA

Priority	Action	Details
1	Position	Sit upright; legs dangling
2	Oxygen	High-flow O₂; NIV (CPAP/BiPAP) if needed
3	Preload reduction	💊 Furosemide 40–80 mg IV + 💊 Nitroglycerin 10–200 mcg/min infusion
4	Afterload reduction	💊 Nitroprusside if severe and refractory
5	Morphine	2–4 mg IV (use cautiously; may worsen respiratory depression)
6	Treat underlying cause	ACS? Arrhythmia? Valvular disease?

⚠️ Avoid beta-blockers acutely in decompensated HF.

🚨 HYPERTENSIVE ENCEPHALOPATHY

Step	Action
1	CT head — rule out stroke/haemorrhage before aggressive BP lowering
2	Reduce MAP by 20–25% over 1–2 hours
3	💊 Nicardipine 5–15 mg/hr OR 💊 Labetalol infusion
4	Avoid Nitroprusside if possible (may ↑ ICP)
5	Symptoms should improve as BP lowers — if not, reconsider diagnosis

7.7 HYPERTENSIVE URGENCY — OUTPATIENT MANAGEMENT

Principles

Severe HTN (> 180/120) WITHOUT acute organ damage
Goal: gradual BP reduction over 24–48 hours
Oral therapy; restart or intensify existing regimen

Oral Agents

Drug	Dose	Onset	Notes
💊 Captopril	12.5–25 mg PO	15–30 min	Avoid if bilateral RAS, hyperkalaemia
💊 Labetalol	200–400 mg PO	30–120 min	Avoid if asthma, bradycardia
💊 Clonidine	0.1–0.2 mg PO; repeat q1h (max 0.6 mg)	30–60 min	Sedation; rebound on withdrawal
💊 Amlodipine	5–10 mg PO	1–2 hrs	Gradual onset
💊 Telmisartan	40–80 mg PO	1–2 hrs	Long-acting
💊 Furosemide	20–40 mg PO	30–60 min	If volume overload

❌ Do NOT use sublingual Nifedipine. Causes unpredictable precipitous BP drops with risk of stroke and myocardial infarction.

Disposition

Step	Details
Observe	2–6 hours
Goal	BP trending down (does not need to normalise)
Medications	Restart or intensify oral regimen
Follow-up	Within 24–72 hours

SECTION 8: SPECIAL POPULATIONS

8.1 HYPERTENSION IN DIABETES MELLITUS

Key Principles

70–80% of patients with T2DM have co-existing hypertension
HTN + DM confers 2–4× cardiovascular risk
HTN accelerates diabetic nephropathy
Target: < 130/80 mmHg
Achieving BP target is as important as glycaemic control for preventing complications

Treatment Approach

Step	Recommendation
1	Lifestyle: salt restriction, dietary modification, exercise, weight management
2	ACE-I or ARB — mandatory if any degree of albuminuria; preferred in all diabetic hypertensives
3	Add CCB (Amlodipine) if not at target
4	Add Thiazide-like diuretic if still not at target
5	Add SGLT2 inhibitor for cardiorenal benefit (see below)
6	Consider Finerenone if albuminuria persists despite maximally tolerated ACE-I/ARB (see below)

SGLT2 Inhibitors in Diabetic Hypertension

Drug	BP Effect	Key CV/Renal Evidence
💊 Empagliflozin 10 mg OD	↓ 3–5 mmHg SBP	EMPA-REG OUTCOME: ↓ CV death; ↓ HF hospitalisation; ↓ renal progression
💊 Dapagliflozin 10 mg OD	↓ 3–5 mmHg SBP	DECLARE-TIMI 58: ↓ HF hospitalisation. DAPA-HF: ↓ CV death/HF. DAPA-CKD: ↓ renal progression
💊 Canagliflozin 100 mg OD	↓ 3–5 mmHg SBP	CANVAS: ↓ MACE. CREDENCE: ↓ renal progression

📌 SGLT2 inhibitors are now considered foundational therapy in T2DM with HTN, particularly if co-existing CVD, HF, or CKD.

Finerenone in Diabetic Kidney Disease

💊 Finerenone 10–20 mg OD — non-steroidal MRA
Indicated for DKD with persistent albuminuria despite maximal ACE-I/ARB
FIDELIO-DKD: 18% reduction in renal composite endpoint
FIGARO-DKD: 13% reduction in CV composite endpoint
⚠️ Monitor K⁺ closely; do not initiate if K⁺ > 5.0 mmol/L

8.2 HYPERTENSION IN CHRONIC KIDNEY DISEASE

BP Targets in CKD

Guideline	Target	Notes
KDIGO 2021	< 120 mmHg SBP (if tolerated)	Based on SPRINT; requires standardised office measurement
Practical target	< 130/80 mmHg	Especially if proteinuria present
Conservative	< 140/90 mmHg	If intolerant to lower targets

Drug Selection by CKD Stage

eGFR (mL/min/1.73m²)	ACE-I/ARB	Diuretic	CCB	Notes
> 45	✅ First-line	Thiazide-like ✅	✅	Standard approach
30–44	✅ (monitor K⁺, Cr)	Thiazide-like still effective	✅	More frequent monitoring
15–29	✅ (with caution)	Loop diuretic (thiazides less effective)	✅	Close monitoring
< 15 / Dialysis	Variable; often held	Loop diuretic	✅	Individualise

SGLT2 Inhibitors in CKD (With or Without Diabetes)

Drug	Evidence	Indication
💊 Dapagliflozin 10 mg OD	DAPA-CKD: 39% reduction in renal composite; benefit regardless of diabetes status	eGFR 20–90 + UACR ≥ 200 mg/g
💊 Empagliflozin 10 mg OD	EMPA-KIDNEY: 28% reduction in renal progression; includes non-diabetic CKD	eGFR 20–90 (with or without albuminuria)

Key points:

✅ Can be initiated down to eGFR 20 mL/min/1.73m²
✅ Continue even if eGFR falls below 20 (unless dialysis or transplant)
⚠️ Expected initial eGFR dip of 3–5 mL/min (haemodynamic; not harmful; recovers)
⚠️ Risk of genital mycotic infections; counsel on hygiene
⚠️ May cause volume depletion — consider reducing diuretic dose

📌 SGLT2 inhibitors are now considered foundational therapy in CKD with significant albuminuria, alongside ACE-I/ARB, regardless of diabetes status.

Monitoring ACE-I/ARB in CKD

When	What to Check	Action
Baseline	Cr, K⁺	Document
1–2 weeks after starting or uptitrating	Cr, K⁺	If Cr ↑ ≤ 30% and stable → continue. If Cr ↑ > 30% or K⁺ > 5.5 → hold and investigate
Stable	Every 3–6 months	Ongoing monitoring

When to Refer to Nephrology

eGFR < 30 (CKD Stage 4–5)
Rapid eGFR decline (> 5 mL/min/year)
Significant proteinuria (ACR > 300 mg/g)
Refractory hyperkalaemia
Suspected renovascular disease
Uncertain aetiology of CKD

8.3 HYPERTENSION IN THE ELDERLY (≥ 65 YEARS)

Key Considerations

Issue	Implication
White coat HTN common	Confirm with HBPM/ABPM before treatment
Isolated Systolic HTN predominates	Treat based on SBP; CCB/Thiazide most effective
Orthostatic hypotension	Check standing BP before and after starting treatment
Polypharmacy	Review interactions; simplify regimen
Frailty	Individualise targets; function over numbers
Falls risk	Avoid excessive lowering; caution with alpha-blockers

BP Targets

Age	Target	Notes
65–79 years	< 140/90 (< 130/80 if tolerated)	Individualise based on fitness
≥ 80 years	< 150/90 (< 140/90 if fit)	HYVET trial
Frail elderly	Individualise	Prioritise functional status over numerical targets

Drug Selection

Preferred	Notes
CCB (Amlodipine)	Effective for ISH; well-tolerated
Thiazide-like (Indapamide, Chlorthalidone)	Effective; watch for hyponatraemia
ACE-I / ARB	If CKD, DM, or HF

Use with Caution	Reason
Beta-blockers (unless CAD/HF)	Less effective for ISH
Alpha-blockers	Orthostatic hypotension; falls
High-dose diuretics	Volume depletion; electrolyte disturbance

Practical Principles

Start low, go slow
Check orthostatic BP before and after starting/changing therapy
Monitor for hyponatraemia, especially with thiazides
Avoid DBP < 70 mmHg (J-curve risk)
Use SPCs to reduce pill burden
Reassess targets periodically — goals may change with increasing frailty

8.4 HYPERTENSION IN PREGNANCY

Classification

Type	Definition
Chronic HTN	HTN present before pregnancy or diagnosed before 20 weeks
Gestational HTN	New HTN after 20 weeks WITHOUT proteinuria or end-organ dysfunction
Preeclampsia	New HTN after 20 weeks WITH proteinuria (≥ 300 mg/24h or ACR ≥ 30 mg/mmol) OR end-organ dysfunction
Eclampsia	Preeclampsia + seizures
Chronic HTN + Superimposed Preeclampsia	Chronic HTN with new/worsening proteinuria or end-organ features
HELLP Syndrome	Haemolysis + Elevated Liver enzymes + Low Platelets

Preeclampsia — End-Organ Features

Organ	Features
Renal	Proteinuria ≥ 300 mg/24h; Cr > 1.1 mg/dL
Hepatic	Transaminases > 2× ULN; RUQ/epigastric pain
Neurological	Severe headache; visual disturbances; altered mental status; seizures
Haematological	Platelets < 100,000; haemolysis (HELLP)
Fetal	IUGR; oligohydramnios

BP Targets in Pregnancy

Scenario	Target
Chronic / Gestational HTN	< 140/90 mmHg
Severe HTN (≥ 160/110)	< 160/110 mmHg urgently
Lower limit	Do NOT lower below 110/70 mmHg (uteroplacental perfusion)

Safe Antihypertensives in Pregnancy

Drug	Dose	Notes
💊 Methyldopa	250–500 mg BD–TID (max 3 g/day)	First-line; longest safety record; may cause sedation, depression
💊 Labetalol	100–400 mg BD–TID (max 2.4 g/day)	First-line; avoid in asthma
💊 Nifedipine ER	30–60 mg OD (max 120 mg/day)	Safe; extended-release formulation only
💊 Hydralazine	25–50 mg TID–QID	Add-on; reflex tachycardia

Contraindicated in Pregnancy

❌ Drug	Reason
ACE-I	Fetal renal dysgenesis, oligohydramnios, IUGR, neonatal renal failure
ARB	Same teratogenic risks as ACE-I
ARNI	Contains ARB component
MRA (Spironolactone, Eplerenone)	Anti-androgen effects on fetus
Atenolol	IUGR, neonatal bradycardia
Nitroprusside	Fetal cyanide toxicity

Postpartum Considerations

BP may rise in the first 3–5 days postpartum — monitor closely
Can switch to ACE-I, ARB, CCB, most beta-blockers (safe in breastfeeding)
Avoid Atenolol if breastfeeding (concentrated in breast milk)
Methyldopa may worsen postpartum depression — consider switching
Monitor for postpartum preeclampsia (can occur up to 6 weeks after delivery)

Preeclampsia Prevention

High-Risk Women	Recommendation
Prior preeclampsia, chronic HTN, DM, CKD, autoimmune disease, multiple gestation	💊 Low-dose Aspirin 75–150 mg OD, started at ≤ 16 weeks gestation (ideally by 12 weeks for maximum benefit), continued until 36 weeks

8.5 RESISTANT AND REFRACTORY HYPERTENSION

Definitions

Term	Definition
Resistant HTN	BP above target despite ≥ 3 drugs at optimal doses, including a diuretic
Controlled Resistant HTN	BP at target but requiring ≥ 4 drugs
Refractory HTN	BP above target despite ≥ 5 drugs at optimal doses, including chlorthalidone and spironolactone

Prevalence

Resistant HTN: 10–15% of treated hypertensives
Refractory HTN: ~5% of resistant HTN cases

Exclude Pseudo-Resistance Before Diagnosing

Cause	How to Address
Non-adherence	Pill counts, pharmacy refill records, directly observed therapy, drug levels
White coat effect	ABPM or HBPM
Improper BP measurement	Verify technique, cuff size
Suboptimal doses	Review; uptitrate to maximum tolerated
Inadequate diuretic	Switch HCTZ to Chlorthalidone or Indapamide
Interfering drugs	NSAIDs, corticosteroids, OCP, decongestants, liquorice
Excess salt or alcohol intake	Dietary assessment

Causes of True Resistant HTN

Primary	Secondary (Screen For)
Advanced vascular disease	Primary aldosteronism (most common secondary cause in resistant HTN)
	Obstructive sleep apnoea
	Renal artery stenosis
	CKD
	Phaeochromocytoma
	Cushing syndrome

Management of Confirmed Resistant HTN

Step	Action
1	Confirm true resistance (adherence, ABPM, technique, interfering drugs)
2	Optimise diuretic: Chlorthalidone 25 mg or Indapamide 2.5 mg
3	Screen for primary aldosteronism (ARR) and OSA (STOP-BANG)
4	Add 💊 Spironolactone 25–50 mg OD as 4th drug
5	If spironolactone not tolerated: 💊 Eplerenone 50 mg OD, OR 💊 Amiloride 10–20 mg OD, OR 💊 Bisoprolol 5–10 mg OD
6	Specialist referral if uncontrolled on 4 drugs
7	Consider renal denervation in selected cases at specialised centres

🔬 PATHWAY-2 trial: Spironolactone was the most effective 4th-line agent for resistant HTN, reducing SBP by an additional 8–10 mmHg compared to placebo, bisoprolol, and doxazosin.

Fourth-Line Drug Options

Drug	Dose	Evidence Level	Key Consideration
💊 Spironolactone	25–50 mg OD	✅✅ Strongest (PATHWAY-2)	Gynecomastia; monitor K⁺
💊 Eplerenone	50 mg OD	✅ Good	Less gynecomastia; more expensive
💊 Amiloride	10–20 mg OD	✅ Moderate	K⁺-sparing
💊 Bisoprolol	5–10 mg OD	✅ Moderate	If not already on beta-blocker
💊 Doxazosin	4–8 mg OD (bedtime)	✅ Moderate	Orthostatic hypotension
💊 Clonidine	0.1–0.3 mg BD	⚠️ Limited	Rebound HTN on withdrawal

Refractory Hypertension

Mandatory specialist referral
Confirm adherence with supervised drug intake or drug levels
Re-evaluate for rare secondary causes
Consider renal denervation (selected cases; specialised centres)
Consider bariatric surgery referral if obese

Renal Denervation

Sham-controlled trials (SPYRAL HTN-ON MED, RADIANCE-HTN TRIO, RADIANCE II) demonstrate SBP reduction of 4–9 mmHg
Not first-line; reserve for confirmed resistant/refractory HTN or documented persistent non-adherence
Available only at select specialised centres
Long-term (> 5 year) durability data still emerging

SECTION 9: MONITORING AND FOLLOW-UP

9.1 FOLLOW-UP SCHEDULE

Phase	Frequency	Purpose
Initial (titration)	Every 2–4 weeks	Adjust drugs until BP at target
Newly at target	Every 3 months × 2 visits	Confirm stability
Stable	Every 3–6 months	Maintain control; adherence; side effects
Annual	Yearly	Comprehensive review; labs; CV risk reassessment

9.2 PARAMETERS AT EACH VISIT

Parameter	Action
Blood pressure	Office BP (proper technique); review home BP log if available
Symptoms	Side effects? New symptoms?
Adherence	Non-judgemental assessment
Lifestyle	Salt, weight, exercise, alcohol, smoking
Medications	Any changes? New prescriptions? OTC drugs (especially NSAIDs)?

9.3 PERIODIC INVESTIGATIONS

Routine Monitoring

Test	Frequency	Notes
Creatinine, eGFR	Every 6–12 months	Renal function
K⁺, Na⁺	Every 6–12 months	Drug effects (diuretics, ACE-I/ARB, MRA)
Fasting glucose / HbA1c	Annually	Diabetes screening
Lipid profile	Annually	CV risk assessment
Urine ACR	Annually	Nephropathy screening
ECG	Every 1–2 years	LVH, arrhythmia
Body weight / BMI	Every visit	Weight management tracking

Accelerated Monitoring

Situation	What to Check	When
Starting or uptitrating ACE-I/ARB	Cr, K⁺	1–2 weeks
Starting or uptitrating diuretic	K⁺, Na⁺, Cr	1–4 weeks
Starting or uptitrating MRA	K⁺, Cr	1 week, then 4 weeks
CKD Stage 3–5	Cr, K⁺, eGFR	More frequently per CKD stage
Elderly on thiazides	Na⁺	1–2 weeks after starting; periodically

9.4 WHEN TO REFER

To Hypertension Specialist / Cardiologist

Resistant HTN (uncontrolled on ≥ 3 drugs including diuretic)
Suspected secondary HTN
Hypertensive emergency requiring ICU management
Complex comorbidities (HF, advanced CKD, multiple CV events)
Young-onset HTN (< 30 years)

To Nephrologist

CKD Stage 4–5 (eGFR < 30)
Rapidly declining eGFR (> 5 mL/min/year)
Significant proteinuria (ACR > 300 mg/g)
Suspected renovascular disease
Refractory hyperkalaemia

To Endocrinologist

Suspected primary aldosteronism (for confirmation and subtyping)
Phaeochromocytoma
Cushing syndrome
Acromegaly

To Sleep Specialist

Suspected OSA (loud snoring, witnessed apnoeas, daytime somnolence)
Resistant HTN with elevated STOP-BANG score

To Obstetrician (High-Risk)

Pregnancy with hypertension (any classification)
Preeclampsia or HELLP syndrome

SECTION 10: QUICK REFERENCE TABLES

10.1 BP TARGETS

Population	Target
General < 65 years	< 130/80
General 65–79 years	< 140/90 (< 130/80 if tolerated)
≥ 80 years	< 150/90 (< 140/90 if fit)
Diabetes	< 130/80
CKD	< 130/80 (< 120 SBP if tolerated)
CAD	< 130/80 (DBP > 60–70)
Post-Stroke	< 130/80
Heart Failure	< 130/80
Pregnancy	< 140/90 (> 110/70)

10.2 DRUG SELECTION

Situation	First Choice
Age < 55, no comorbidity	ACE-I or ARB
Age ≥ 55 or Black/African ethnicity, no comorbidity	CCB or Thiazide-like
Diabetes	ACE-I or ARB
CKD with proteinuria	ACE-I or ARB
Heart Failure (HFrEF)	ACE-I/ARB → ARNI + BB + MRA + SGLT2i
Post-MI	ACE-I + BB
CAD (stable)	ACE-I + BB (± CCB)
Pregnancy	Methyldopa or Labetalol or Nifedipine ER
Resistant HTN (4th drug)	Spironolactone

10.3 COMBINATIONS

✅ Recommended	❌ Avoid
ACE-I/ARB + CCB	ACE-I + ARB
ACE-I/ARB + Thiazide-like	Non-DHP CCB + BB
CCB + Thiazide-like	Two drugs from same class
Triple: ACE-I/ARB + CCB + Thiazide-like	ACE-I/ARB + Aliskiren

10.4 EMERGENCY DRUG SELECTION

Scenario	First-Line IV Drug	Target
Aortic Dissection	Esmolol or Labetalol	SBP < 120, HR < 60
ACS	Nitroglycerin	Gradual reduction; DBP > 60
Pulmonary Oedema	Nitroglycerin + Furosemide	Gradual reduction
Encephalopathy	Nicardipine or Labetalol	↓ MAP 20–25% in 1–2 hrs
ICH (SBP 150–220)	Nicardipine or Labetalol	SBP ~140 within 1 hr
Eclampsia	Labetalol or Hydralazine + MgSO₄	< 160/110
Phaeochromocytoma	Phentolamine	Gradual reduction
Cocaine/Amphetamine	Phentolamine or Nicardipine + Benzodiazepine	Gradual reduction

10.5 NEVER / ALWAYS TABLE

⛔ NEVER	✅ ALWAYS
Combine ACE-I + ARB	Check Cr and K⁺ after starting ACE-I/ARB
Use sublingual Nifedipine for BP lowering	Use appropriate cuff size for BP measurement
Give vasodilators before BB in aortic dissection	Control HR before BP in aortic dissection
Lower BP too rapidly in chronic hypertensives	Reduce gradually (20–25% MAP in first hour for emergencies)
Use ACE-I/ARB/ARNI in pregnancy	Use Methyldopa, Labetalol, or Nifedipine ER in pregnancy
Combine Non-DHP CCB + BB	Choose one or the other
Ignore orthostatic hypotension in elderly	Check standing BP in elderly before and after treatment changes
Use thiazides if eGFR < 30	Switch to loop diuretics in advanced CKD
Assume non-adherence without checking	Confirm adherence before adding drugs or diagnosing resistance
Forget to ask about NSAIDs	Ask about OTC analgesic use at every visit
Use aspirin for primary prevention in HTN	Reserve aspirin for secondary prevention (established CVD only)
Use immediate-release Nifedipine for HTN	Use only extended-release formulations for chronic BP management

ABBREVIATIONS

Abbreviation	Full Form
ABPM	Ambulatory Blood Pressure Monitoring
ABI	Ankle-Brachial Index
ACE-I	Angiotensin-Converting Enzyme Inhibitor
ACR	Albumin-to-Creatinine Ratio
ACS	Acute Coronary Syndrome
AKI	Acute Kidney Injury
ARB	Angiotensin Receptor Blocker
ARNI	Angiotensin Receptor-Neprilysin Inhibitor
ARR	Aldosterone-to-Renin Ratio
BB	Beta-Blocker
BNP	B-type Natriuretic Peptide
BP	Blood Pressure
BPH	Benign Prostatic Hyperplasia
CABG	Coronary Artery Bypass Grafting
CAD	Coronary Artery Disease
CCB	Calcium Channel Blocker
CKD	Chronic Kidney Disease
COPD	Chronic Obstructive Pulmonary Disease
CV	Cardiovascular
CVD	Cardiovascular Disease
CXR	Chest X-Ray
CT	Computed Tomography
DBP	Diastolic Blood Pressure
DHP	Dihydropyridine
DKD	Diabetic Kidney Disease
DM	Diabetes Mellitus
ECG	Electrocardiogram
eGFR	Estimated Glomerular Filtration Rate
ESKD	End-Stage Kidney Disease
GDMT	Guideline-Directed Medical Therapy
GCS	Glasgow Coma Scale
HBPM	Home Blood Pressure Monitoring
HELLP	Haemolysis, Elevated Liver enzymes, Low Platelets
HF	Heart Failure
HFpEF	Heart Failure with Preserved Ejection Fraction
HFrEF	Heart Failure with Reduced Ejection Fraction
HMOD	Hypertension-Mediated Organ Damage
HTN	Hypertension
HCTZ	Hydrochlorothiazide
HR	Heart Rate
ICH	Intracerebral Haemorrhage
ICP	Intracranial Pressure
IMT	Intima-Media Thickness
ISH	Isolated Systolic Hypertension
IUGR	Intrauterine Growth Restriction
IV	Intravenous
JVP	Jugular Venous Pressure
LVH	Left Ventricular Hypertrophy
LVMI	Left Ventricular Mass Index
MAHA	Microangiopathic Haemolytic Anaemia
MAP	Mean Arterial Pressure
MI	Myocardial Infarction
MRA	Mineralocorticoid Receptor Antagonist
MRI	Magnetic Resonance Imaging
NIV	Non-Invasive Ventilation
Non-DHP	Non-Dihydropyridine
NSAID	Non-Steroidal Anti-Inflammatory Drug
OCP	Oral Contraceptive Pills
OD	Once Daily
BD	Twice Daily
TID	Three Times Daily
QID	Four Times Daily
OSA	Obstructive Sleep Apnoea
OTC	Over-The-Counter
PAD	Peripheral Artery Disease
PCI	Percutaneous Coronary Intervention
PDE5	Phosphodiesterase Type 5
PO	Per Oral
PRES	Posterior Reversible Encephalopathy Syndrome
PWV	Pulse Wave Velocity
RAS	Renal Artery Stenosis
RF	Risk Factor
SBP	Systolic Blood Pressure
SGLT2i	Sodium-Glucose Cotransporter-2 Inhibitor
SPC	Single-Pill Combination
T2DM	Type 2 Diabetes Mellitus
TIA	Transient Ischaemic Attack
UACR	Urine Albumin-to-Creatinine Ratio
ULN	Upper Limit of Normal

REFERENCES

Source	Year
ESC/ESH Guidelines for the Management of Arterial Hypertension	2018 (with 2023 focused update)
ESC Guidelines on Elevated Blood Pressure and Hypertension	2024
ISH Global Hypertension Practice Guidelines	2020
ACC/AHA High Blood Pressure Clinical Practice Guideline	2017
NICE Hypertension in Adults: Diagnosis and Management (NG136)	2022 (updated)
KDIGO Clinical Practice Guideline for Blood Pressure Management in CKD	2021
SPRINT Trial (Systolic Blood Pressure Intervention Trial)	2015
ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes — Blood Pressure)	2010
PATHWAY-2 (Prevention and Treatment of Hypertension With Algorithm-based Therapy)	2015
PARADIGM-HF (Sacubitril/Valsartan in Heart Failure)	2014
DAPA-CKD (Dapagliflozin in CKD)	2020
EMPA-KIDNEY (Empagliflozin in CKD)	2022
FIDELIO-DKD (Finerenone in Diabetic Kidney Disease)	2020
FIGARO-DKD (Finerenone in Diabetic Kidney Disease — CV Outcomes)	2021
HOPE Trial (Heart Outcomes Prevention Evaluation)	2000
PROGRESS Trial (Perindopril Protection Against Recurrent Stroke Study)	2001
HYVET Trial (Hypertension in the Very Elderly Trial)	2008
ACCOMPLISH Trial (Avoiding Cardiovascular Events in Combination Therapy)	2008
INTERACT2 (Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial)	2013
ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage)	2016
DCP Trial (Diuretic Comparison Project)	2022
ONTARGET (Telmisartan, Ramipril, or Both in Patients at High Risk)	2008
ARRIVE (Aspirin to Reduce Risk of Initial Vascular Events)	2018
ASPREE (Aspirin in Reducing Events in the Elderly)	2018
SPYRAL HTN-ON MED (Renal Denervation)	2020
RADIANCE-HTN TRIO (Renal Denervation in Resistant HTN)	2022
API Textbook of Medicine	11th Edition
Harrison’s Principles of Internal Medicine	21st Edition

For Healthcare Professionals Only

Disclaimer: This guideline provides evidence-based recommendations for clinical decision-making. Individual clinical judgement must be exercised for each patient. Local protocols, drug availability, and patient-specific factors should guide management. Always verify doses and indications before prescribing.

End of Guideline

🛡️

Medical Advisory

Clinical guidelines are subject to change. Physicians should exercise their regular clinical judgment. This protocol does not replace individual institutional policies. Verified for Q1 2026.

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