BP ≥130/80 on repeat measurement
Start: Lifestyle → upfront low-dose two-drug single-pill combination for most non-frail patients (ESC 2024); agent choice by compelling indication (thiazide-like/ACEi/CCB)
Compelling indication: diabetes/CKD → ACE-ARB; post-MI → β-blocker; osteoporosis → thiazide (add amlodipine/others as needed)
Emergency (end-organ damage) → IV labetalol/nicardipine, ↓MAP ≤25% in 1st hour
Decision tree
Acute end-organ damage (emergency)?
YesIV therapy (labetalol/nicardipine); lower MAP ≤25% in first hour
NoVery high BP, no end-organ damage (urgency)?
YesOral agents; gradual reduction over hours–days; arrange follow-up
NoLifestyle + oral agent by indication; outpatient titration
Order set
- Confirm with repeat/ABPM
- U&E, glucose, lipids
- Urine ACR
- ECG
- Fundoscopy
Criteria
AdmitHypertensive emergency (end-organ damage)
ICUEmergency needing IV titration/monitoring
DischargeControlled/trending down (≤25% MAP in emergency), agents by indication, follow-up
Key
- Investigate secondary HTN only if uncontrolled on 2–3 drugs. Goal <130/80; ESC 2024 SBP target 120–129 if tolerated; spironolactone first-line for resistant HTN.
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- End-organ damage (emergency)
- Very high BP with symptoms
Differentials
- White-coat
- Secondary (renal, endocrine)
- Medication/substance
Common mistakes
- Treating a single reading
- Rapid BP drop in emergency (>25% MAP)
Disposition & follow-up
Lifestyle + agent by indication; investigate secondary if resistant.
Discharge package
MedicationsAntihypertensive by indication
Follow-upBP review + titration; end-organ screening
LifestyleSalt reduction, weight, exercise, alcohol
Warning symptomsSevere headache, chest pain, visual/neuro symptoms
💊 Treatment detail — doses & preparation
Amlodipinedihydropyridine CCB
Dose5 mg OD, titrate to 10 mg OD
Preparation5/10 mg tablets
MonitorAnkle oedema, flushing; LFTs if jaundice
LisinoprilACE inhibitor
DoseStart 2.5–5 mg OD, target 20–40 mg OD
Preparation2.5/5/10/20 mg tablets
MonitorCreatinine + K⁺ 1–2 wk after each titration
Indapamide/chlorthalidonethiazide-like diuretic
DoseIndapamide 1.5 mg MR OD or chlorthalidone 12.5–25 mg OD
PreparationTablets in the morning
MonitorNa⁺, K⁺, uric acid, glucose at 2–4 wk
📖 ACC/AHA 2017 + ESC 2024 HypertensionReviewed July 2026