31 August 2026Chapter 12: Other conditionsPDF page 394
Essential hypertension in adults
Comprehensive clinical guide to adult essential hypertension classification, evaluation, long-term treatment, drug choices, crisis care, monitoring, and education.
This guide supports clinical education and care navigation. It does not replace bedside judgement, emergency care, specialist advice, or local treatment protocol.
Seek urgent care
- Blood pressure around 180/110 mmHg or higher with confusion, seizures, coma, severe headache, chest pain, breathlessness, or reduced urination.
- Stroke-like symptoms such as face drooping, arm weakness, speech difficulty, sudden severe headache, or vision loss.
- Pregnancy with high blood pressure, headache, visual symptoms, swelling, abdominal pain, or seizures.
Definition and complications
Hypertension is blood pressure that remains elevated at rest over time, classically confirmed by three measurements during three separate consultations over about three months when there is no emergency.
Essential hypertension means high blood pressure without a single identified cause and accounts for most adult cases.
Serious complications may be acute, such as hypertensive encephalopathy, left-sided heart failure, and acute renal failure, or delayed, such as stroke, ischaemic heart disease, peripheral arterial disease, and chronic kidney disease.
Hypertension in pregnancy requires a separate obstetric pathway because pre-eclampsia and eclampsia need urgent maternal and fetal assessment.
Blood pressure classification in adults
- Use correctly sized cuffs and repeat measurements after rest. Confirm non-urgent hypertension on separate visits before committing to long-term treatment when possible.
- Severe hypertension is defined clinically by end-organ damage as much as by the BP number. A patient with severe symptoms or organ injury needs emergency assessment even if the number is lower than expected.
| Category | Systolic BP | Diastolic BP |
|---|---|---|
| Mild hypertension | 140 mmHg or above | 90 mmHg or above |
| Moderate hypertension | 160 mmHg or above | 100 mmHg or above |
| Severe hypertension | 180 mmHg or above | 110 mmHg or above |
Clinical assessment and investigations
- History should look for medicines that worsen blood pressure, including NSAIDs, corticosteroids, opioids, and oral oestroprogestogens; stop or replace the causative medicine when possible.
- Assess for stroke signs, heart failure, cardiac ischaemia, arrhythmia, diabetes, renal impairment, smoking, alcohol use, obesity, pregnancy, and family or cardiovascular risk history.
- Investigations may include serum electrolytes, especially potassium, serum creatinine, diabetes testing, urine testing when available, ECG, and echocardiogram if heart failure, coronary disease, or arrhythmia is suspected.
- Look for secondary hypertension when onset is young, severe, resistant, abrupt, associated with hypokalaemia, renal disease, endocrine symptoms, or medicine triggers.
Treatment goals and lifestyle care
- Lifestyle and dietary advice is recommended for all hypertensive adults: reduce salt and excess calories, exercise regularly, lose weight if BMI is 25 or above, stop smoking, and stop alcohol consumption.
- In mild hypertension without cardiovascular disease, stroke, or diabetes, start with lifestyle advice and reassess. Start medicines for SBP >= 160 or DBP >= 100, hypertension with cardiovascular disease, stroke or diabetes, or failure of lifestyle measures to control BP.
- Treat comorbid diabetes, kidney disease, heart failure, coronary disease, smoking, and obesity as part of BP care rather than as separate problems.
| Patient group | Target |
|---|---|
| Most adults | SBP under 140 mmHg and DBP under 90 mmHg. |
| Adults with diabetes | SBP under 140 mmHg and DBP under 80 mmHg when tolerated. |
| Adults over 80 years | SBP under 150 mmHg and DBP under 90 mmHg. |
First-line medicine options
- Start with monotherapy in many uncomplicated patients. If BP remains high after 4 weeks of correct treatment, add a second antihypertensive. If BP remains high after 4 weeks of dual therapy, consider triple therapy.
- In diabetes, if BP is not controlled after 4 weeks of correctly taken ACE inhibitor therapy, add a calcium-channel blocker.
- Monitor renal function and potassium with ACE inhibitors and diuretics according to patient risk and test availability.
| Patient profile | Preferred options |
|---|---|
| No comorbidity | Start with a thiazide diuretic, then check BP after 4 weeks. |
| Age over 65 years | Thiazide diuretic or calcium-channel blocker. |
| Black patient | Thiazide diuretic or calcium-channel blocker; avoid ACE inhibitor monotherapy unless another indication exists. |
| After stroke | Thiazide diuretic. |
| Diabetes | ACE inhibitor, or beta-blocker if there is concomitant cardiovascular disease. |
| Renal impairment | ACE inhibitor when appropriate and monitored. |
| Heart failure or coronary heart disease | ACE inhibitor plus beta-blocker is often needed from the start. |
| Medicine | Dose |
|---|---|
| Hydrochlorothiazide | 12.5 to 25 mg PO once daily in the morning; maximum 25 mg/day. |
| Enalapril | Start 5 mg PO once daily, increase every 1 to 2 weeks according to BP to 10 to 20 mg once daily; maximum 40 mg/day. Start 2.5 mg once daily in older adults, patients on diuretics, or renal impairment. |
| Amlodipine | 5 mg PO once daily, increase to 10 mg once daily if needed; maximum 10 mg/day. Start 2.5 mg once daily in older adults or hepatic impairment. |
| Bisoprolol | 5 to 10 mg PO once daily in the morning. Avoid in asthma and do not stop abruptly because of malaise or angina risk. |
Hypertensive crisis and emergency
- In hypertensive encephalopathy, aim to reduce BP by about 10 to 15% in the first hour and not more than 25% during the first 24 hours.
- In stroke, do not reduce BP during the first 3 days unless SBP is >= 220 mmHg and/or DBP is >= 120 mmHg, in which case labetalol may be used according to protocol.
- For acute pulmonary oedema, follow the acute heart failure pathway while treating severe hypertension.
| Category | Clinical definition | Management |
|---|---|---|
| Uncomplicated hypertensive crisis | SBP >= 180 and/or DBP >= 110 with symptoms such as moderate headache, epistaxis, dizziness, tinnitus, or visual floaters, but no end-organ damage signs. | Reassure, rest, avoid rapid BP reduction, and recheck BP within a few days to start or adapt long-term treatment. |
| Hypertensive emergency | SBP >= 180 and/or DBP >= 110 with end-organ damage such as encephalopathy, seizures, coma, heart failure, cardiac ischaemia, rapid or irregular heart rate, oliguria, or anuria. | Treat in an intensive-care or high-dependency setting with close monitoring and controlled BP reduction. |
| Medicine | Dose and precautions |
|---|---|
| Labetalol IV | 20 mg IV over at least 1 minute. Repeat after 10 minutes if BP has not decreased; if needed, give 40 mg every 10 minutes until controlled, maximum 300 mg total. Contraindicated in asthma. |
| Hydralazine IV if labetalol contraindicated | 5 to 10 mg diluted in 10 ml of 0.9% sodium chloride by slow IV injection; repeat after 20 to 30 minutes if necessary. |
Monitoring, education, and handover
- Check BP and weight about every 3 months initially, then every 6 months or individualised according to stability, adherence, risk, and comorbidities.
- Check serum electrolytes and creatinine every 6 to 12 months when using diuretics, ACE inhibitors, or other medicines that affect renal function or potassium, and sooner after initiation or dose change in high-risk patients.
- Ask about cough with ACE inhibitors, oedema with calcium-channel blockers, erectile dysfunction or fatigue with beta-blockers, dizziness, falls, dehydration, pregnancy, and adherence barriers.
- Teach that hypertension is usually long-term and often asymptomatic; treatment should continue even when the patient feels well unless a clinician changes it.
- Return urgently for severe headache, confusion, seizures, chest pain, dyspnoea, weakness or speech problems, visual loss, anuria, pregnancy danger signs, epistaxis with severe BP, or treatment adverse effects.
- Handover should include BP readings and dates, cuff context if relevant, end-organ symptoms, comorbidities, renal function and potassium, medicines and doses, adverse effects, adherence, lifestyle plan, crisis management if given, and next review date.
Medicines in this guide
Hydrochlorothiazide oralThiazide diuretic first-line option for many adults and after stroke.Enalapril oralACE inhibitor option, especially with diabetes or renal impairment when not contraindicated.Amlodipine oralCalcium-channel blocker option, including many older adults and Black patients.Bisoprolol oralBeta-blocker option when cardiovascular disease indicates it; avoid in asthma.Labetalol injectableIV option for selected hypertensive emergencies and severe BP elevation in stroke protocols.Labetalol oralOral beta-blocking antihypertensive used in selected clinical contexts.Hydralazine injectableAlternative IV medicine for hypertensive emergency when labetalol is contraindicated, such as asthma.Sodium chloride 0.9%Diluent for selected injectable hypertensive-emergency medicines.
Source
MSF Clinical guidelines - Diagnosis and treatment manual (December 2024)
This page is a paraphrased clinician-oriented guide derived from the source topic on PDF page 394. Medicine-specific details should be checked against local protocol and the linked drug-information pages.