Hypertension

Last updated 1 Jun 2026 · Cardiology

📋 Key Information Summary

📋

Definition: Hypertension is defined as persistently elevated office systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg, confirmed on at least two separate occasions, or ≥ 135/85 mmHg on ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM).
Classification (ACC/AHA 2017 & ESH/ESC 2023): Normal (< 120/80), Elevated (120–129 / < 80), Stage 1 (130–139 / 80–89), Stage 2 (≥ 140 / ≥ 90); hypertensive crisis (≥ 180/120).
Prevalence in Australia: Affects approximately 6 million Australian adults (34% of those aged ≥ 18 years), and is the leading modifiable risk factor for cardiovascular disease, stroke, chronic kidney disease, and heart failure.
Secondary causes account for 5–15% of cases — consider in young patients, resistant hypertension, abrupt onset, or severe hypertension. Key causes include renal artery stenosis, primary aldosteronism, phaeochromocytoma, Cushing syndrome, obstructive sleep apnoea, and medication/substance-related causes.
Confirm the diagnosis with ABPM (gold standard) or HBPM before initiating treatment in most patients; white-coat hypertension affects 15–30% of individuals with elevated office readings.
Cardiovascular risk stratification uses the Australian Cardiovascular Risk Calculator (or Framingham Risk Score) alongside assessment of target organ damage (left ventricular hypertrophy, retinopathy, nephropathy, peripheral arterial disease).
First-line pharmacotherapy: ACE inhibitors (ramipril, perindopril), ARBs (irbesartan, telmisartan), calcium channel blockers (amlodipine), and thiazide-like diuretics (indapamide) — all PBS-listed and recommended as first-line agents in Australian guidelines.
Treatment targets: Generally < 130/80 mmHg for high-risk patients (diabetes, CKD, established CVD); < 140/90 mmHg for lower-risk patients; individualise targets in the elderly (≥ 80 years).
Lifestyle modifications are the foundation of management: sodium restriction (< 5 g/day), DASH-style diet, regular aerobic exercise (≥ 150 min/week), weight loss, alcohol moderation (< 10 standard drinks/week), and smoking cessation.
Resistant hypertension (uncontrolled on ≥ 3 agents including a diuretic) requires specialist review, screening for secondary causes, assessment of adherence, and consideration of spironolactone (25–50 mg daily) as fourth-line agent.
Aboriginal and Torres Strait Islander Australians experience hypertension at 1.3–1.5 times the rate of non-Indigenous Australians, with significantly higher rates of end-organ damage and earlier onset — targeted screening and culturally safe care pathways are essential.
Pregnancy: Labetalol, nifedipine, and methyldopa are first-line antihypertensives; ACE inhibitors and ARBs are absolutely contraindicated. Pre-eclampsia requires urgent obstetric review.

🩺 Introduction & Australian Epidemiology

Hypertension is the single most common chronic condition managed in Australian general practice and the leading modifiable contributor to the burden of cardiovascular disease (CVD). It is a major risk factor for myocardial infarction, ischaemic and haemorrhagic stroke, heart failure, chronic kidney disease (CKD), peripheral arterial disease, and vascular dementia. Despite the availability of effective, well-tolerated, and inexpensive treatments, hypertension remains suboptimally controlled in up to 50% of those diagnosed in Australia.

General practitioners play a central role in the detection, confirmation, risk stratification, initiation of therapy, and long-term monitoring of hypertension. The condition is frequently asymptomatic, earning its reputation as the "silent killer," and patients often present with target organ damage (e.g., left ventricular hypertrophy, microalbuminuria, retinopathy) before the diagnosis is made. This underscores the importance of opportunistic screening at every primary care encounter.

Australian Epidemiology

According to the Australian Bureau of Statistics (ABS) National Health Survey 2022, approximately 34% of Australian adults (aged ≥ 18 years) have measured hypertension (SBP ≥ 140 or DBP ≥ 90 mmHg, or taking antihypertensive medication).
Prevalence increases sharply with age: ~20% of those aged 25–44, ~50% of those aged 55–64, and > 65% of those aged ≥ 65 years.
Hypertension is responsible for an estimated 28% of all cardiovascular deaths in Australia and is the second leading risk factor for attributable burden of disease after tobacco use (AIHW 2023).
Control rates remain suboptimal: only approximately 30–40% of Australians with diagnosed hypertension achieve target blood pressure on treatment.
Aboriginal and Torres Strait Islander Australians are disproportionately affected, with prevalence 1.3–1.5 times higher than non-Indigenous Australians and significantly higher rates of hypertensive end-organ disease, particularly CKD and stroke.
The economic burden of hypertension in Australia is estimated at over billion annually in direct healthcare costs and lost productivity.

⚠️

Diagnostic pitfall: Office blood pressure measurement alone is insufficient for diagnosis. Up to 15–30% of patients with elevated office readings have white-coat hypertension, and 10–15% with normal office readings have masked hypertension. Always confirm with ABPM or HBPM before initiating long-term pharmacotherapy.

📊 Definition & Classification of Blood Pressure

Blood pressure classification is based on the average of two or more properly measured readings taken on two or more separate occasions. Measurements should be taken with the patient seated, rested for at least five minutes, using a validated oscillometric device with an appropriately sized cuff, and with the arm supported at heart level.

Blood Pressure Classification

Category	Systolic (mmHg)	Diastolic (mmHg)	Office / ABPM / HBPM
Optimal	< 120	< 80	Office & ABPM/HBPM
Normal	120–129	80–84	Office & ABPM/HBPM
High Normal	130–139	85–89	Office & ABPM/HBPM
Grade 1 Hypertension (Mild)	140–159	90–99	Office ≥ 140/90; ABPM daytime ≥ 135/85
Grade 2 Hypertension (Moderate)	160–179	100–109	Office ≥ 160/100; ABPM daytime ≥ 150/95
Grade 3 Hypertension (Severe)	≥ 180	≥ 110	Office ≥ 180/110; ABPM daytime ≥ 170/105
Isolated Systolic Hypertension	≥ 140	< 90	Common in elderly; same grading by SBP

White-Coat Hypertension & Masked Hypertension

Phenotype	Office BP	ABPM / HBPM	Management
White-coat hypertension	Elevated	Normal	Lifestyle measures; periodic ABPM; CVD risk assessment
Masked hypertension	Normal	Elevated	Treat as true hypertension; associated with increased CVD risk
Sustained hypertension	Elevated	Elevated	Standard management pathway

Hypertensive Urgency & Emergency

Uncomplicated Severe

Grade 3 Hypertension

BP ≥ 180/110 mmHg without acute target organ damage. Often asymptomatic or with headache, epistaxis.

Setting: Same-day GP review or ED — gradual BP reduction over 24–48 hours

Urgency

Hypertensive Urgency

BP ≥ 180/110 mmHg with symptoms (severe headache, dyspnoea, anxiety) but no acute end-organ damage.

Setting: ED or urgent GP — oral agents, reduce BP over 24–48 h; avoid rapid drops

Emergency

Hypertensive Emergency

BP typically ≥ 180/120 mmHg WITH acute target organ damage: encephalopathy, ACS, acute pulmonary oedema, aortic dissection, eclampsia, acute kidney injury, retinal haemorrhage.

Setting: ICU / HDU — IV agents, reduce MAP by ≤ 25% in first hour, then 160/100 over next 2–6 h

🚨

Aortic dissection exception: In confirmed or suspected aortic dissection, target SBP < 120 mmHg within 20 minutes and heart rate < 60 bpm using IV esmolol or labetalol. Rapid, aggressive reduction is required — do not follow the general rule of gradual reduction.

🔍 Causes & Secondary Hypertension

Primary (essential) hypertension accounts for 85–95% of cases and is a multifactorial condition arising from the interplay of genetic susceptibility, dietary factors (sodium intake, low potassium), obesity, physical inactivity, insulin resistance, and age-related arterial stiffening. Secondary hypertension accounts for 5–15% of cases and is important to identify because specific treatment may be curative or significantly improve blood pressure control.

Indications to Screen for Secondary Hypertension

⚠️

Consider secondary causes if any of the following are present:

Age of onset < 30 years without obesity or family history
Abrupt onset or sudden worsening of previously controlled hypertension
Resistant hypertension (uncontrolled on ≥ 3 agents at optimal doses including a diuretic)
Severe or accelerated hypertension (Grade 3, hypertensive emergency)
Disproportionate target organ damage for the degree of hypertension
Clinical features suggestive of specific endocrine or renal causes
Hypokalaemia (spontaneous or diuretic-induced) — think primary aldosteronism
Incidental adrenal mass discovered on imaging

Common Secondary Causes

Cause	Prevalence	Key Clues	First-Line Investigation
Obstructive sleep apnoea (OSA)	30–50% of hypertensive patients	Obesity, snoring, daytime somnolence, resistant hypertension, nocturnal non-dipping pattern	Polysomnography (sleep study); Epworth Sleepiness Score
Primary aldosteronism (PA)	5–10% of hypertensive patients (underdiagnosed)	Hypokalaemia (spontaneous or diuretic), resistant hypertension, adrenal incidentaloma, family history	Aldosterone:renin ratio (ARR) — patient seated, corrected K⁺, off interfering meds where possible
Renal artery stenosis	1–5%	Abdominal bruit, flash pulmonary oedema, worsening renal function with ACEi/ARB, atherosclerotic peripheral vascular disease	Renal duplex ultrasound; CT angiography or MR angiography
Chronic kidney disease	Common cause & consequence	eGFR < 60, proteinuria, oedema, family history of PKD	eGFR, urine ACR, renal ultrasound
Phaeochromocytoma / Paraganglioma	0.1–0.6%	Episodic headache, sweating, palpitations, pallor; paroxysmal or sustained hypertension; adrenal incidentaloma	Plasma free metanephrines (preferred) or 24-hour urinary metanephrines/catecholamines
Cushing syndrome	Rare	Central obesity, striae, proximal myopathy, easy bruising, glucose intolerance, moon facies	24-hour urinary cortisol, overnight dexamethasone suppression test, midnight salivary cortisol
Thyroid disease	Common co-occurrence	Hyperthyroidism (↑ SBP, wide pulse pressure); hypothyroidism (↑ DBP, diastolic hypertension)	TSH, free T4
Medication/substance-related	Common iatrogenic cause	NSAIDs, oral contraceptives (oestrogen-containing), corticosteroids, decongestants, stimulants, cocaine, amphetamines, liquorice, cyclosporine/tacrolimus	Medication reconciliation; urine drug screen if suspected illicit use

Screening Pathway for Secondary Hypertension

Basic Screen (All Patients)

FBC, UEC, eGFR, urine ACR, lipid profile, fasting glucose/HbA1c, TSH, serum K⁺. Consider renal ultrasound if eGFR reduced or proteinuria present.

Targeted Endocrine Screen

If hypokalaemia or resistant HTN → aldosterone:renin ratio (ARR). If episodic symptoms → plasma metanephrines. If Cushingoid features → overnight DST.

Imaging & Specialist Referral

Renal duplex ultrasound for suspected renovascular disease. CT adrenals for incidentaloma or positive biochemistry. Refer to endocrinology/nephrology for confirmed secondary causes.

⚖️ Risk Stratification & Target Organ Damage

Cardiovascular risk assessment guides the decision to initiate pharmacotherapy, the aggressiveness of treatment targets, and the intensity of follow-up. In Australia, absolute cardiovascular risk (CVR) assessment should be performed for all adults aged ≥ 45 years (or ≥ 30 years for Aboriginal and Torres Strait Islander peoples) using the Australian Cardiovascular Risk Calculator, which is based on the Framingham Risk Score and incorporates local epidemiological data.

Absolute Cardiovascular Risk Categories

Low

< 10% 5-Year CVD Risk

No target organ damage, no diabetes, no CKD. Lifestyle modification for 3–6 months before considering pharmacotherapy (Grade 1 hypertension).

Setting: Primary care; review every 3–6 months initially

Moderate

10–15% 5-Year CVD Risk

May have mild target organ damage or one additional risk factor. Consider pharmacotherapy in addition to lifestyle measures; BP target < 140/90.

Setting: Primary care; review every 1–3 months until stable

High / Very High

≥ 15% 5-Year CVD Risk, or Established CVD/CKD/DM

Target organ damage present (LVH, retinopathy, eGFR < 60, microalbuminuria, established CVD, diabetes). Pharmacotherapy initiated immediately alongside lifestyle measures. BP target < 130/80 mmHg.

Setting: Primary care ± specialist co-management

Assessment of Target Organ Damage

All patients with confirmed hypertension should be assessed for evidence of target organ damage as this influences both risk category and treatment intensity:

Organ	Assessment	Findings
Heart	ECG (all patients); echocardiography (if ECG abnormal or high-risk)	Left ventricular hypertrophy (LVH), diastolic dysfunction, left atrial enlargement, regional wall motion abnormalities
Kidneys	eGFR + urine albumin:creatinine ratio (ACR)	eGFR < 60 mL/min/1.73 m²; microalbuminuria (ACR ≥ 2.5 mg/mmol ♂, ≥ 3.5 mg/mmol ♀); overt proteinuria
Retina	Fundoscopy (direct ophthalmoscopy or retinal photography)	Arteriolar narrowing, arteriovenous nicking, cotton-wool spots, flame haemorrhages, papilloedema (Grade IV — emergency)
Vasculature	Ankle-brachial index (ABI); carotid duplex if indicated	ABI < 0.9 indicates peripheral arterial disease; carotid intima-media thickening or stenosis
Brain	Clinical assessment; CT/MRI if neurological signs	Previous stroke/TIA (clinical history); cerebral small vessel disease (white matter hyperintensities)

Baseline Investigations for All Patients with Hypertension

Essential

ECG (12-lead)

Screen for LVH (Sokolow–Lyon or Cornell criteria), ischaemic changes, arrhythmia, conduction abnormalities. MBS item 11700.

Essential

Serum biochemistry: UEC, eGFR, electrolytes (K⁺, Na⁺)

Screen for CKD, electrolyte disturbances suggesting secondary causes (hypokalaemia in PA). MBS item 66503.

Essential

Urine albumin:creatinine ratio (ACR)

Microalbuminuria is an early marker of hypertensive nephropathy and independently increases CVR. MBS item 66503.

Essential

Fasting lipids (total cholesterol, LDL, HDL, triglycerides)

Part of comprehensive CVD risk assessment. MBS item 66512.

Essential

Fasting glucose and HbA1c

Screen for diabetes mellitus — a major CVD risk modifier. MBS item 66512.

Available

Echocardiography

If ECG suggests LVH, heart failure symptoms, or high-risk patient. More sensitive than ECG for LVH detection. MBS item 55114 (via specialist request).

Available

ABPM (24-hour ambulatory blood pressure monitoring)

Gold standard for confirming diagnosis, identifying white-coat and masked hypertension. MBS item 11606.

💡

MBS tip: ABPM (MBS item 11606) is rebateable when used to confirm a diagnosis of hypertension or to assess white-coat effect. HBPM is not MBS-rebateable but is a validated and cost-effective alternative. Ensure patients use a validated, cuff-based oscillometric device and provide training on proper technique.

💊 Pharmacological Management

Pharmacological therapy is initiated in addition to lifestyle measures when: (1) BP is persistently ≥ 140/90 mmHg in the presence of target organ damage, established CVD, diabetes, or CKD; (2) absolute CVD risk is ≥ 10–15%; or (3) BP is ≥ 160/100 mmHg regardless of risk. For Grade 1 hypertension in low-risk patients (< 10% CVD risk), a 3–6 month trial of lifestyle modification alone is reasonable before initiating drug therapy.

Treatment Targets

Population	Target BP	Notes
General adult (< 65 years)	< 130/80 mmHg	Preferred target per ACC/AHA 2017 and ESH/ESC 2023; Australian guidelines accept < 140/90 as acceptable for lower-risk patients
Diabetes mellitus	< 130/80 mmHg	Accord and SPRINT trials support lower targets in high-risk; avoid SBP < 110 mmHg in frail elderly diabetics
Chronic kidney disease (CKD)	< 130/80 mmHg	ACEi or ARB mandatory if proteinuria present (ACR ≥ 30 mg/mmol); monitor K⁺ and eGFR closely
Elderly (65–79 years)	< 130–140 systolic	Avoid excessive lowering; SPRINT showed benefit to SBP < 120 but exclude frail patients; individualise
Very elderly (≥ 80 years)	< 150 systolic	HYVET trial supports treatment; avoid SBP < 120; prioritise quality of life and falls risk
Established CVD / Post-stroke	< 130/80 mmHg	Caution in bilateral carotid stenosis; avoid hypotension in first 48 h of acute ischaemic stroke

First-Line Antihypertensive Agents

Four classes of antihypertensive agents are recommended as first-line monotherapy in Australian practice, all PBS-listed as General Benefits or Authority Required for hypertension indication:

💊

Perindopril

Coversyl® · ACE inhibitor

Adult dose 5 mg PO once daily; max 10 mg daily. Start 2.5 mg daily in elderly or volume-depleted patients.

Renal adjustment Start 2.5 mg daily if eGFR 30–60; dose every 2 days if eGFR < 30. Contraindicated if bilateral renal artery stenosis.

Key side effects Dry cough (10–15%), hyperkalaemia, angioedema (rare), acute kidney injury (esp. with NSAIDs). Monitor K⁺ and eGFR at 1–2 weeks.

PBS status ✔ PBS General Benefit

💊

Ramipril

Tritace® · ACE inhibitor

Adult dose 2.5–5 mg PO once daily; titrate to 10 mg daily. HOPE trial evidence for CVD protection at 10 mg daily.

Renal adjustment Start 1.25 mg daily if eGFR 30–60; avoid or use with extreme caution if eGFR < 30.

PBS status ✔ PBS General Benefit

💊

Irbesartan

Avapro® · Angiotensin receptor blocker (ARB)

Adult dose 150 mg PO once daily; max 300 mg daily. Preferred in patients intolerant of ACEi cough.

Renal adjustment No dose adjustment required in mild-moderate impairment; caution in severe CKD. Monitor K⁺ and eGFR.

Key side effects Hyperkalaemia, dizziness, rare angioedema. No cough (vs ACEi). Contraindicated in pregnancy.

PBS status ✔ PBS General Benefit

💊

Amlodipine

Norvasc® · Calcium channel blocker (dihydropyridine)

Adult dose 5 mg PO once daily; max 10 mg daily. Start 2.5 mg daily in elderly or hepatic impairment.

Renal adjustment No dose adjustment required. Safe in CKD.

Key side effects Ankle oedema (10–15%), flushing, headache, gingival hyperplasia. Avoid in severe aortic stenosis.

PBS status ✔ PBS General Benefit

💊

Indapamide

Natrilix® · Thiazide-like diuretic

Adult dose 1.5 mg SR PO once daily (morning). Preferred over hydrochlorothiazide due to superior evidence for CVD outcome reduction.

Renal adjustment Ineffective if eGFR < 30 mL/min/1.73 m² — switch to loop diuretic (frusemide).

Key side effects Hypokalaemia, hyponatraemia, hyperuricaemia (gout), hyperglycaemia, photosensitivity. Monitor UEC at 1–2 weeks and 3-monthly.

PBS status ✔ PBS General Benefit

Second-Line & Add-On Agents

💊

Telmisartan

Micardis® · ARB

Adult dose 40–80 mg PO once daily. Long half-life (24 h); good 24-hour BP coverage.

PBS status ✔ PBS General Benefit

💊

Lercanidipine

Zanidip® · Calcium channel blocker (dihydropyridine)

Adult dose 10 mg PO once daily, titrate to 20 mg daily. Less peripheral oedema than amlodipine.

PBS status ✔ PBS General Benefit

💊

Spironolactone

Aldactone® · Mineralocorticoid receptor antagonist

Adult dose 25–50 mg PO once daily. Fourth-line agent for resistant hypertension (PATHWAY-2 trial). Also first-choice for primary aldosteronism screening-positive patients.

Renal adjustment Avoid if eGFR < 30 (risk of severe hyperkalaemia). Monitor K⁺ at 1 week, 4 weeks, then 3-monthly.

Key side effects Hyperkalaemia, gynaecomastia (dose-dependent, ~10% at 50 mg), menstrual irregularities. Use eplerenone if sexual side effects intolerable.

PBS status ✔ PBS General Benefit

💊

Bisoprolol

Bicor® · Beta-blocker (cardioselective)

Adult dose 5–10 mg PO once daily. Not first-line for uncomplicated hypertension; indicated when compelling indication (heart failure, post-MI, rate control for AF).

PBS status ✔ PBS General Benefit

Treatment Algorithm: Stepwise Approach

Step 1

Monotherapy

Start one first-line agent at low dose: ACEi or ARB or CCB or thiazide-like diuretic. Choose based on patient age, ethnicity, comorbidities, and side-effect profile.

Step 2

Dual Therapy (Single Pill Combination Preferred)

If target not achieved after 4–8 weeks at full dose: ACEi/ARB + CCB (preferred combination) or ACEi/ARB + thiazide-like diuretic. Single-pill combinations improve adherence. PBS-listed combination products available.

Step 3

Triple Therapy

If still uncontrolled: ACEi/ARB + CCB + thiazide-like diuretic (triple combination). Use single-pill combination where available (e.g., perindopril/amlodipine/indapamide — PBS-listed).

Step 4

Resistant Hypertension

If uncontrolled on triple therapy at optimal doses: add spironolactone 25 mg daily (PATHWAY-2 trial evidence). Review adherence, screen for secondary causes, refer to specialist if still uncontrolled. Consider moxonidine or doxazosin as fifth-line.

⚠️

Never combine ACE inhibitor + ARB: The ONTARGET trial demonstrated that dual renin-angiotensin system blockade (ACEi + ARB) increases the risk of hyperkalaemia, acute kidney injury, and hypotension without additional cardiovascular benefit. This combination is contraindicated.

Compelling Indications — Preferred Agent Selection

Comorbidity	Preferred Agent(s)	Rationale
Diabetes with proteinuria / CKD	ACEi or ARB	Renoprotective; reduces proteinuria progression; ONTARGET/RENAAL evidence
Heart failure (HFrEF)	ACEi (or ARB if intolerant) + beta-blocker + MRA ± ARNI	Guideline-directed medical therapy for HFrEF reduces mortality
Post-myocardial infarction	ACEi + beta-blocker	Reduces remodelling and mortality post-MI
Atrial fibrillation (rate control)	Beta-blocker or non-DHP CCB (verapamil/diltiazem)	Rate control and BP reduction; avoid verapamil + beta-blocker combination
Primary aldosteronism confirmed	Spironolactone (unilateral) or eplerenone	Targets underlying mineralocorticoid excess; surgical adrenalectomy if unilateral adenoma
Benign prostatic hyperplasia	Alpha-blocker (doxazosin) as add-on	Dual benefit for BPH and BP; not first-line for BP alone
Elderly (isolated systolic HTN)	CCB (amlodipine) or thiazide-like diuretic	Syst-Eur and HYVET trial evidence; effective for isolated systolic hypertension

Hypertensive Emergency — Acute Management

Hypertensive emergencies (BP ≥ 180/120 with acute end-organ damage) require immediate hospital admission and IV antihypertensive therapy in an intensive care or high-dependency setting. The goal is to reduce mean arterial pressure (MAP) by no more than 25% in the first hour, then to approximately 160/100 mmHg over the next 2–6 hours, followed by gradual normalisation over 24–48 hours.

💉

Labetalol (IV)

Trandate® · Combined alpha/beta blocker

Adult dose IV bolus 20 mg over 2 min, then 20–80 mg every 10 min (max 300 mg total); or infusion 0.5–2 mg/min. Also available PO 200–400 mg BD–TDS.

Indications Most hypertensive emergencies (except acute pulmonary oedema). Preferred in aortic dissection (with esmolol). Safe in pregnancy.

PBS status ✔ PBS General Benefit

💉

GTN (Glyceryl trinitrate IV)

Nitrostat® · Nitrate vasodilator

Adult dose 5–200 mcg/min IV infusion, titrated to BP response.

Indications Acute pulmonary oedema, acute coronary syndrome with hypertension. Causes headache; tolerance with prolonged use.

PBS status ✔ PBS General Benefit

💉

Esmolol (IV)

Brevibloc® · Ultra-short-acting beta-1 selective blocker

Adult dose Loading dose 500 mcg/kg over 1 min; infusion 25–300 mcg/kg/min.

Indications Aortic dissection (first-line for rate and BP control), perioperative hypertension. Ultra-short half-life (~9 min) allows rapid titration.

PBS status 🔶 Authority Required

📈 Monitoring

Long-term monitoring of hypertension serves three purposes: confirming blood pressure control, detecting adverse effects of therapy, and screening for the development of target organ damage or progression of comorbid disease.

Monitoring Schedule

1–2 weeks

After initiating or changing antihypertensive therapy: check BP (office or HBPM), serum K⁺, and eGFR (essential if ACEi/ARB/diuretic commenced). Assess for side effects and adherence.

4–6 weeks

Repeat BP measurement. Reassess UEC if on diuretic or RAAS inhibitor. Confirm target BP achieved. If not, consider dose titration or addition of second agent.

3 months

Comprehensive review: BP (office + HBPM review), UEC, lipids, HbA1c (if diabetic), urine ACR. Assess lifestyle measures, medication adherence, and side effects. Update CVD risk assessment.

6-monthly

Once stable at target: BP, UEC, urine ACR (annually if CKD), medication review. ECG annually for patients on RAAS inhibitors or with LVH.

Annually

Comprehensive cardiovascular review: BP, weight, waist circumference, UEC, lipids, HbA1c, urine ACR, ECG. Update absolute CVD risk calculation. Review medication appropriateness and adherence. Reassess target organ damage.

Monitoring for Specific Agents

Agent Class	Key Monitoring	Frequency
ACE inhibitors / ARBs	Serum K⁺, eGFR, creatinine	1–2 weeks post-initiation, then 3-monthly, then 6-monthly once stable
Thiazide-like diuretics (indapamide)	Serum K⁺, Na⁺, eGFR, uric acid, glucose	1–2 weeks post-initiation, then 3-monthly. Monitor gout symptoms.
Spironolactone	Serum K⁺, eGFR (essential)	1 week, 4 weeks, then 3-monthly. Higher risk of hyperkalaemia in CKD, diabetes, elderly.
Calcium channel blockers	BP, heart rate, peripheral oedema assessment	Routine BP monitoring; no specific blood test required
Beta-blockers	Heart rate, BP, symptoms (fatigue, bronchospasm)	1–2 weeks post-initiation; do not stop abruptly (taper over 2 weeks)

Home Blood Pressure Monitoring (HBPM) — Patient Instructions

💡

Key HBPM guidance for patients:

Use a validated, upper-arm oscillometric device (validated device lists: stridebp.org)
Sit quietly for 5 minutes before measurement; back supported, feet flat on floor, arm at heart level
Take two readings, 1 minute apart, in the morning (before medication) and evening — record all values
Avoid caffeine, exercise, and smoking for 30 minutes before measuring
Average the readings over 5–7 days (discard first day's readings) — home BP ≥ 135/85 mmHg = hypertension
Have the cuff size checked at the pharmacy or GP clinic — an inappropriately small cuff overestimates BP

👥 Special Populations

🤰

Pregnancy

First-line agents: Labetalol 100–200 mg PO BD–TDS, nifedipine (modified-release) 20–60 mg PO daily, methyldopa 250–500 mg PO TDS

Absolute contraindication: ACE inhibitors and ARBs — teratogenic (renal agenesis, oligohydramnios, fetal pulmonary hypoplasia, skull defects). Discontinue at conception or prior to pregnancy planning.

Target BP: 110–140/80–85 mmHg (aim to reduce without causing placental hypoperfusion). For pre-eclampsia: IV labetalol or IV hydralazine; urgent obstetric review; magnesium sulphate for seizure prophylaxis if severe features.

👶

Paediatrics

Paediatric hypertension defined as BP ≥ 95th percentile for age, sex, and height on ≥ 3 occasions. Increasing prevalence linked to childhood obesity. Most cases are secondary (renal disease most common in young children).

First-line pharmacotherapy: ACEi (enalapril 0.08 mg/kg/day, max 0.6 mg/kg/day) or CCB (amlodipine 0.06 mg/kg/day, max 0.3 mg/kg/day). Doses in paediatric formulation.

Lifestyle interventions paramount: weight management, dietary sodium reduction, physical activity, screen time reduction. Refer to paediatric nephrology for persistent hypertension or suspected secondary cause.

👴

Elderly (≥ 65 years)

Isolated systolic hypertension is the most common pattern. Treatment reduces stroke, heart failure, and cardiovascular mortality (HYVET trial for ≥ 80 years; SPRINT for ≥ 75 years). Start low, go slow.

Preferred agents: CCB (amlodipine 2.5 mg start), thiazide-like diuretic (indapamide), ACEi (perindopril 2.5 mg start). Avoid alpha-blockers (falls risk, orthostatic hypotension).

Assess orthostatic BP (standing BP at 1 and 3 minutes) at every visit. Avoid excessive BP lowering — SBP target 130–150 mmHg depending on frailty, cognitive status, and patient preference. Review polypharmacy regularly.

🫘

Renal Impairment

ACEi or ARB mandatory if proteinuria present (ACR ≥ 30 mg/mmol). Monitor K⁺ and eGFR closely (within 1–2 weeks of initiation). Accept up to 25% rise in creatinine or fall in eGFR — if greater, check for renal artery stenosis.

Thiazide-like diuretics ineffective if eGFR < 30 mL/min/1.73 m² — switch to frusemide (loop diuretic) 20–80 mg daily. Higher doses may be needed in nephrotic syndrome.

Avoid spironolactone if eGFR < 30. Target BP < 130/80. Refer to nephrology for CKD stage 4–5, rapidly declining eGFR, or nephrotic-range proteinuria.

🫁

Hepatic Impairment

Amlodipine: start 2.5 mg daily in severe hepatic impairment (reduced clearance). ACEi: use with caution (risk of hepatotoxicity, rare). Labetalol: avoid in severe hepatic impairment (first-pass metabolism).

Spironolactone may be preferred in cirrhotic patients with ascites and hypertension (dual benefit as diuretic and antihypertensive). Monitor electrolytes and hepatic function closely.

🛡️

Immunocompromised

Post-transplant hypertension is common (cyclosporine/tacrolimus-induced). Preferred agents: CCB (amlodipine — counteracts afferent arteriolar vasoconstriction from calcineurin inhibitors), ACEi/ARB (if proteinuria present). Avoid diltiazem/verapamil with cyclosporine (CYP3A4 interaction — dramatically increases cyclosporine levels).

HIV-positive patients: interactions between antiretrovirals (esp. protease inhibitors) and CCBs (amlodipine — CYP3A4 substrate); labetalol generally safe. Monitor BP more frequently in patients on corticosteroid-containing regimens.

🏳️ Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Epidemiology

Aboriginal and Torres Strait Islander Australians experience hypertension at 1.3–1.5 times the rate of non-Indigenous Australians. The burden is compounded by earlier onset, higher rates of concurrent diabetes, CKD, rheumatic heart disease, and smoking, resulting in significantly greater end-organ damage (stroke, end-stage kidney disease, heart failure) and cardiovascular mortality. The age-standardised cardiovascular death rate is 1.7 times higher in Indigenous compared with non-Indigenous Australians (AIHW 2023).

Screening age

Absolute cardiovascular risk assessment should commence at age 30 years (rather than 45 years) for Aboriginal and Torres Strait Islander adults, as recommended by the RACGP and the National Vascular Disease Prevention Alliance. Opportunistic BP screening should be performed at every healthcare encounter, including non-presentation-based community health visits.

Barriers to management

Key barriers include: geographic remoteness and limited access to primary care and specialist services; health literacy and communication challenges; medication cost (despite PBS subsidies, co-payments may be prohibitive); cultural disconnection from mainstream health services; high rates of medication non-adherence related to transient living arrangements, competing health and social priorities, and limited pharmacy access in remote communities. Continuity of care is frequently disrupted by workforce turnover in remote Aboriginal Community Controlled Health Organisations (ACCHOs).

Culturally safe care

Deliver hypertension management through ACCHOs wherever possible. Use Aboriginal and Torres Strait Islander health practitioners and health workers to facilitate communication, medication education, and follow-up. Incorporate yarning-based approaches to health education. Ensure gender-sensitive care (male health workers for male patients where preferred). Acknowledge and integrate traditional healing practices alongside pharmacotherapy where the patient wishes.

Pharmacotherapy considerations

Medication adherence is a critical challenge. Prefer once-daily dosing and fixed-dose combination tablets (e.g., perindopril/amlodipine, perindopril/indapamide) to simplify regimens. Under Closing the Gap PBS co-payment measures, Aboriginal and Torres Strait Islander patients with a CTG annotation are eligible for PBS medicines at reduced or no co-payment — ensure CTG annotation is recorded on all prescriptions. Monitor renal function closely (CKD prevalence 2–3× higher). ACEi/ARB first-line, given high CKD and diabetes prevalence.

Remote and rural considerations

In remote communities, specialist referral for secondary hypertension screening, echocardiography, and renal ultrasound may require patient retrieval or telehealth. Use the Royal Flying Doctor Service and specialist outreach programmes. Ensure availability of basic pathology services (UEC, ACR, lipids) at remote clinics. HBPM is a practical alternative to ABPM in communities without access to monitoring equipment.

📚 References

1. National Heart Foundation of Australia & National Stroke Foundation of Australia. Guidelines for the management of absolute cardiovascular disease risk. Melbourne: NHF; 2012 (updated 2023).
2. Mancia G, Kreutz R, Brunström M, et al. 2023 ESH Guidelines for the management of arterial hypertension. J Hypertens. 2023;41(12):1874–2071.
3. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. J Am Coll Cardiol. 2018;71(19):e127–e248.
4. Williams B, MacDonald TM, Morant SV, et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015;386(10008):2059–2068.
5. SPRINT Research Group, Wright JT Jr, Williamson JD, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103–2116.
6. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older (HYVET). N Engl J Med. 2008;358(18):1887–1898.
7. ONTARGET Investigators, Yusuf S, Teo KK, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events (ONTARGET). N Engl J Med. 2008;358(15):1547–1559.
8. Australian Institute of Health and Welfare (AIHW). Cardiovascular disease. Cat. no. CVD 83. Canberra: AIHW; 2023.
9. Royal Australian College of General Practitioners (RACGP). Management of type 2 diabetes: A handbook for general practice. Melbourne: RACGP; 2020.
10. National Aboriginal Community Controlled Health Organisation (NACCHO). Proven programs and best practice in Aboriginal and Torres Strait Islander health: Cardiovascular disease. Canberra: NACCHO; 2022.
11. The Blood Pressure Lowering Treatment Trialists' Collaboration. Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure. Lancet. 2021;397(10285):1625–1636.
12. Stride BP. Validated blood pressure monitors. Available at: stridebp.org. Accessed 2024.
13. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Diagnosis and management of hypertensive disorders of pregnancy. C-Obs 36. Melbourne: RANZCOG; 2023.
14. Kidney Health Australia. Chronic Kidney Disease Management in Primary Care. 4th ed. Melbourne: Kidney Health Australia; 2020.
15. Australian Bureau of Statistics (ABS). National Health Survey 2022. Canberra: ABS; 2023.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).