Understanding the nurse’s role in the clinical management of hypertension

Introduction

Hypertension or high blood pressure (BP) affects around one third of adults worldwide, with approximately half of these individuals being unaware they have the disease, and only a fifth of cases being effectively managed (World Health Organization (WHO), 2024). Approximately 16 million adults in the UK have hypertension, with almost half of these not receiving adequate treatment to manage the disease (British Heart Foundation (BHF), 2025). It is thought that up to 8 million adults in the UK have undiagnosed or uncontrolled hypertension (BHF, 2025).

Hypertension is a main cause of premature death in adults globally (WHO, 2023). The WHO (2024) states that, “an increase in the number of patients effectively treated for hypertension to levels observed in high-performing countries could prevent 76 million deaths, 120 million strokes, 79 million heart attacks, and 17 million cases of heart failure between now and 2050”.

Because of this high prevalence and poor outcomes, European Society of Hypertension (ESH) guidelines say clinicians should aim to reduce the BP of people with hypertension to their personalised BP target within three months to improve health outcomes (Mancia et al, 2023).

While the first article in this series explored diagnosis of hypertension, this second article focuses on its clinical management and how nurses and other clinicians can help improve health outcomes for people with hypertension. This includes assessing people’s cardiovascular disease (CVD) risk and setting personalised BP targets, along with lifestyle measures and treatment that can help manage BP.

Cardiovascular risk assessment

Hypertension is often linked with other diseases, such as raised cholesterol and type 2 diabetes, which increase the risk of cardiovascular events, such as heart disease or stroke (Mancia et al, 2023). An individual’s CVD risk must, therefore, be assessed before discussing personalised BP targets and treatment options. Assessing CVD risk is important to improve the quality of life and mortality risk of an individual with hypertension (National Institute for Health and Care Excellence (NICE) 2023). A person’s CVD risk should be assessed every five years, or earlier if their health or circumstances change (NICE, 2024). CVD risk assessment is a broad topic, but this article will focus on CVD risk relating to hypertension.

While there are many CVD risk assessment tools, NICE (2024) recommends using the QRISK3 for adults aged 25 to 84 with hypertension; this tool can also be used for people with type 2 diabetes who are hypertensive. QRISK3 uses an individual’s demographics and relevant clinical information to estimate a person’s CVD risk over the next 10 years (Hippisley-Cox et al, 2017) (Box 1). The score is calculated as a percentage and needs to be discussed with the individual in terms they can understand (Box 1). Clinicians must make it clear that it is only an estimate and not a prediction of what will occur.

Use of QRISK3 for calculating CVD risk is not appropriate for certain cohorts of people (NICE, 2024) (Box 2). Caution must also be exercised when assessing individuals with added CVD risk from chronic diseases on certain treatments, because their CVD risk could be much higher than that indicated by their QRISK3 score (NICE, 2024) (Box 2). NICE (2024) advises clinicians to use clinical judgement and to consult national and local disease-related guidance when deciding on treatment options for this cohort.

Individualised blood pressure targets

Setting a personalised BP target is important to lower an individual’s risk of developing CVD, such as heart disease, transient ischaemic attacks (mini strokes) or stroke. Criteria for setting BP targets include the place where BP readings are taken (such as the clinic or home), the person’s age and any comorbidities that increase CVD risk, such as diabetes and renal disease (Mancia et al, 2023; NICE, 2023). Table 1 shows the criteria for setting BP targets in individuals according to age and comorbidities.

Setting BP targets for older persons living with frailty and multiple comorbidities can be challenging for clinicians because of a need to prevent periodic episodes of hypotension, which can cause poor health outcomes for these groups (Ermasova and Shvarts, 2022). Periodic hypotension can be postural, which is treated to the standing BP measurement (NICE, 2023). However, periodic hypotension may also be medication- or exercise-related, post-prandial (after eating) or of unknown cause, requiring careful consideration of treatment options and targets (Ermasova and Shvarts, 2022). As a result, most hypertension guidelines adopt higher BP targets for people over 80 years old (Table 1).

Shared decision making

Only one fifth of individuals with hypertension are estimated to have their BP under control (WHO, 2024). It is thought non-adherence to a clinical management plan is one of the main reasons for poor BP control, and that shared decision making and education can help address this (Kulkarni and Graggaber, 2022). The process of developing a therapeutic relationship and taking part in shared decision making helps patients choose the right treatment options for them and take ownership of their clinical management plan, which encourages adherence (NICE, 2021).

Shared decision making is a valuable process involving the individual and clinician. Nurses and other clinicians have an essential role in helping individuals identify their CVD risk and understand the importance of managing their BP to reduce their chances of heart attack or stroke (Mancia et al, 2023; NICE, 2023). Likewise, it is the clinician’s responsibility to ensure individuals understand their care and the treatment options available to them, along with the risks and benefits (NHS England, 2019).

Mental capacity is an essential element of shared decision making. Before any clinical decision can be made, an individual’s mental capacity must be considered in relation to the decisions that need to be made (NICE, 2019a). Clinicians also need to ensure the individual understands all the clinical information given to them.

There are several techniques to support shared decision making (Box 3). These can be used in conjunction with decision aids, tools that support patients and clinicians to explore treatment options and their risks and benefits (BHF, 2023; NICE, 2021; NHS England, 2019).

In 2019, NICE produced a decision support tool to give to patients when a hypertension diagnosis is made, to help inform treatment and frame discussions between patients and the treating clinicians. The tool explores what hypertension is and why it is important to manage it, along with CVD risk and what this means (NICE, 2019b). It also details the risks and benefits of treatment, such as lifestyle changes and different medications, using charts and diagrams. Patients can use it to formulate their own opinion and decide on the right hypertension treatment for them. This tool continues to be endorsed by NICE (2023) as an effective clinical tool to support shared decision making.

Treating hypertension

How hypertension is managed depends on the individual and their clinical needs. The aim of treatment is to reduce an individual’s BP to their personalised BP target to minimise their risk of developing CVD. Usually, hypertension is managed by a combination of lifestyle interventions and antihypertensive medication.

Lifestyle measures

As hypertension can be affected by lifestyle (Box 4), the most important message for nurses and other clinicians to give their patients is that living more healthily can help control their BP, or even help reduce it (BHF, 2023). NICE (2023) says that lifestyle advice should be revisited regularly by clinicians and an annual hypertension review is an excellent opportunity to do this.

Signposting to local groups that support healthy living and provide tools that can help, such as written materials and audio-visual resources, is important to endorse the message that healthy living can help in managing hypertension. By considering and offering appropriate tools at each consultation, nurses can make every contact count to help improve outcomes for people with hypertension (BHF, 2023; Mancia et al, 2023; NICE, 2023).

Medication

Nurses should consult local and national clinical guidelines when drawing up a clinical management plan, including medication selection and titration to BP targets (Mancia et al, 2023; NICE, 2023). The British and Irish Hypertension Society (BIHS) (no date) recommends the NICE guideline (2023) Hypertension in Adults: Diagnosis and Management as a clinical decision-making tool. In addition, NICE recommendations are often mirrored in local guidelines, which give a regional focus on the available treatments.

NICE (2023) recommends a stepwise approach to introducing anti-hypertensive medications, starting with a single medication titrated to achieve an individual’s BP target. If the BP target is not reached, clinicians are advised to check the person’s adherence to the clinical management plan before adding other medications (NICE, 2023). This approach is known as monotherapy (Mancia et al, 2023).

Monotherapy verses combination therapy

A single medication is not always effective in managing hypertension (Mancia et al, 2023; NICE, 2023) and less than 25% of individuals achieve their BP target using monotherapy (Shina, 2020). For this reason, updated ESH guidelines favour a combination therapy approach (Mancia et al, 2023). However, NICE (2023) maintains more evidence is needed to support this, and there is a wealth of evidence supporting monotherapy for hypertension, as well as it being cost-effective.

Clinicians using monotherapy must ensure medications are titrated efficiently to achieve an individual’s BP target. Lack or reluctance of titration is known as clinical or therapeutic inertia and research shows this is a major cause of poor BP control globally (Pathak et al, 2021).

The ESH guidelines suggest that adopting combination therapy for most hypertension patients could address this problem of clinical inertia, saying recent evidence shows this may achieve better BP control initially, which is important in reducing CVD risk (Mancia et al, 2023). However, the ESH concedes monotherapy has its place in clinical practice and is especially useful where there are issues with non-adherence in people with low CVD risk (Mancia et al, 2023).

Combination therapy also has its disadvantages. Prescribing more than one medication, along with more complex medication schedules, can lead to non-adherence, as well as missed doses and double dosing in error. This is a particular concern when it comes to people with multiple comorbidities and those living with frailty who are at risk of postural hypotension and falls that could lead to hospitalisation (Nguyen, 2019).

Treatment adherence

Non-adherence to clinical treatment plans is a main cause of poor BP control (Mancia et al, 2023; NICE 2023). Approximately one individual every four minutes will die from CVD in the UK, with hypertension being the primary risk factor (NHS England, 2024). Thus, checking that patients are taking their medications as prescribed is a fundamental role for nurses and other clinicians (NICE, 2009).

Box 5 shows how to check for medicines adherence.

Adherence is when an individual takes their medications as prescribed to achieve their treatment goals and improve clinical outcomes, and is important when considering the efficacy of a clinical management plan.

Non-adherence is the opposite of this and can be either:

• Intentional – when an individual chooses not to follow a treatment plan;
• Unintentional – when a person attempts to follow the treatment plan but meets problems, such as poor memory affecting dosing, unwanted side-effects or difficulty with dexterity, including struggling with packaging (Specialist Pharmacist Service, 2023).

Non-adherence is common but the reasons why patients do not take their medications as prescribed can be multifactorial and complex. A holistic assessment is needed (Aljofan et al, 2023), combined with a structured approach to assessing a patient’s adherence to their medications, to try to understand reasons for non-adherence. This requires spending time with patients and exploring the barriers to adherence, and helping them to devise a plan to help overcome them (Mancia et al, 2023) (Box 5).

Monitoring hypertension

Clinical inertia and poor adherence are thought to be the major contributing factors to lack of BP control and poor outcomes for those with hypertension worldwide (Mancia et al, 2023; Pathak et al, 2021). Therefore, when monitoring hypertensive patients, nurses and other clinicians must be proactive in helping individuals achieve their BP target to reduce their CVD risk.

When starting hypertension treatment, an individual needs reviewing at regular intervals to ensure treatment is effective to achieve their personalised BP target. A clinic BP measurement should be used for monitoring, except for people with a diagnosis of white coat hypertension (clinic BP elevated but home BP normal) or masked hypertension (clinic BP normal but home BP elevated), who should use HBPM. Nurses and other clinicians should measure both a lying and standing BP in individuals at risk of postural hypotension to help give a diagnosis (NICE, 2023).

If an individual’s BP target is not achieved, clinicians should discuss adherence with the patient prior to adding other medications. They should then adopt the stepwise approach to medication as per local or national guidelines, until the BP target is met without adverse effects to the individual (NICE, 2023). Again, the use of decision aids can be beneficial when adding in medications to explain the risks and benefits of achieving BP control (NICE, 2019a).

Once control of BP has been achieved, the individual should have an annual review. This should include:

• BP measurement;
• Height and weight to calculate body mass index (BMI);
• Blood tests to check renal function and cholesterol;
• Urine sample to give the albumin to creatinine ratio (ACR);
• Review of lifestyle measures;
• Treatment review, including adherence to the clinical management plan (Mancia et al, 2023; NICE, 2023).

Secondary care referrals

A same-day referral to secondary care is needed for those with severe hypertension (clinic BP ≥180/120mmHg) who are displaying signs of accelerated hypertension or showing associated signs and symptoms of critical illness (see article 1 of this series).

Referrals should be also made to secondary care for expert review if BP is uncontrolled with optimal or maximum tolerated doses of four drugs (NICE, 2024).

In addition, secondary care referrals are recommended for people aged under 40 years who develop hypertension to exclude probable causes of secondary hypertension; these can include renal, endocrine, or vascular disorders (NICE, 2023).

The case study in Box 6 describes a man being referred to secondary care with suspected resistant hypertension. It highlights the importance of clarifying a patient’s understanding of their medication regime and asking the right questions when assessing adherence. It also shows how taking a combination of drugs can cause confusion for patients, leading to poor clinical outcomes and adverse events (Mancia et al, 2023 and NICE 2023).

Conclusion

Poorly controlled hypertension is associated with poor health outcomes and is a major cause of CVD and premature death, therefore, the diagnosis and treatment of hypertension is a significant role for nurses and other clinicians. With only approximately 20% of individuals with a hypertension diagnosis achieving control of their BP, all nurses must take a proactive role in their patients’ hypertension management to ensure BP targets are achieved, with the aim of reducing CVD risk and improving health outcomes.