referral criteria from primary care - hypertension

Last edited 09/2019

Suggested indications for referral include:

  • if there is urgent treatment indicated
    • severe hypertension (e.g. 220/120 mmHg) (1)
    • impending complications e.g. TIA (1)

    • NICE (2) state:
      • specialist investigations and referral for hypertension is indicated in the following circumstances:

        • identifying who to refer for same-day specialist review

          • if a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral, carry out investigations for target organ damage as soon as possible:
            • if target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
            • If no target organ damage is identified, repeat clinic blood pressure measurement within 7 days
          • refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:
            • signs of retinal haemorrhage or papilloedema (accelerated hypertension) or
            • life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury
          • refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis)

        • consider the need for the specialist investigations in people with signs and symptoms suggesting secondary cause of hypertension

        • for adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks

        • for people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice

        • if blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4 drugs, seek specialist advice
  • hypertension with a possible underlying cause (1)
    • patients with hypokalaemia/increased plasma sodium (e.g. Conn's syndrome)
    • haematuria or proteinuria
    • raised serum creatinine
    • young age (any hypertension under 20 years: needing treatment < 30 years)
    • sudden-onset or worsening hypertension
    • hypertension that is resistant to multi-drug regimen, that is, >= 3 drugs

  • for the evaluation of therapeutic failures or problems (1)

  • special circumstances e.g. pregnancy, possible white coat hypertension, unusually variable blood pressure (1)


  • accelerated hypertension
    • a severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension

  • resistant hypertension
    • when more than 3 drugs are needed to treat hypertension

  • Stage 1 hypertension
    • clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg
  • Stage 2 hypertension
    • clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher
  • Stage 3 or severe hypertension
    • clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher


  1. Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004;BHS IV. J Hum Hypertens 2004;18: 139-85
  2. NICE (August 2019). Hypertension - management of hypertension in adults in primary care.