Introduction

Hypertension continues to be an important, mostly preventable cause of premature cardiovascular morbidity and mortality.1 Population blood pressure (BP) is normally distributed with a continuous risk relationship, where each 2 mm Hg rise in systolic BP (SBP) is associated with an increased risk of mortality from ischaemic heart disease and stroke (of 7% and 10%, respectively), with SBPs upwards of 115 mm Hg.2 Therefore, there is no true level of BP at which ‘hypertension’ definitively exists, and therapies are therefore based on the assessment of benefits versus risks. This article concentrates on UK guidance3 and experience, but will also consider a worldwide perspective.4–10 The multitude of learned society guidelines is further expanded with the consideration of comorbidities such as renal disease,11 diabetes12 and coronary artery disease.13 However, as a common disease with a global burden, pragmatically, ‘there are situations where the most simple and empirical care for hypertension’ may be most appropriate.5 It is also important to recognise that as evidence available increases, guidelines inevitably evolve. The most recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines have lowered the BP threshold for diagnosis and treatment targets,10 and updated National Institute for Health and Care Excellence (NICE) guidance (for the UK) is due in 2019. Despite multiple therapeutic options, around 30% of the hypertensive population have suboptimally controlled BP.14 Numerous factors may contribute to this (box 1), including failure to adopt proven lifestyle interventions15 and physician inertia.16 Increasingly, non-adherence to pharmacotherapy is known to be a cause for uncontrolled BP despite prescribed treatment.