Hypertension medication review: controlled is not the same as right

A hypertension medication review often opens with good news: the latest reading is below target and nothing on the screen is flagged. The temptation is to code it as reviewed and move on. But a controlled number only tells you the dose worked, at some point, for some version of this patient. It does not tell you the medicine is still right today. Treating control as the start of the review, not the end, sits at the heart of a good structured medication review.

This is general guidance to support practice. Always individualise decisions and follow current NICE, BNF and local guidance.

First, confirm the reading story

Before you review the medicine, review the number. A single clinic reading below target is weak evidence of control. Look for the pattern: recent home readings, any ambulatory monitoring, and the trend over time. Home and ambulatory averages run lower than clinic readings and NICE sets lower home targets, so compare like with like. A patient who looks controlled on white-coat-inflated clinic numbers may be running low at home.

In older or frail patients, add a postural check. Measure blood pressure sitting or lying, then again after standing, and ask about dizziness on getting up, unsteadiness at night, and falls. NICE advises checking a standing blood pressure in people with type 2 diabetes, those with symptoms of postural hypotension, and people aged 80 and over; with a significant drop, the standing reading is the one to treat to. A seated 128/74 that becomes 100/60 on standing is not a controlled patient. It is a fall waiting for a hallway.

Does the drug still fit the patient in front of you?

Antihypertensives are chosen once and continued for years, while the patient keeps changing. Work through what has moved since the choice was made.

• Renal function. A declining eGFR changes the risk balance for ACE inhibitors, ARBs and diuretics. Check the bloods are recent, electrolytes were rechecked after any dose change, and the patient knows what to do during dehydrating illness.
• New interactions. Scan for additions since the last proper review: an NSAID (prescribed or bought over the counter) alongside an ACE inhibitor or ARB and a diuretic is a well-known kidney insult. Check anything you are unsure of against the BNF or an interaction checker.
• Frailty. The evidence that justified tight control in a fit 60-year-old was not generated in a frail 88-year-old with multimorbidity. As frailty accumulates, the balance of benefit and harm shifts, and the target itself deserves re-examination.
• Pregnancy potential. ACE inhibitors and ARBs can harm a developing baby. For any woman who could become pregnant, confirm this has been discussed and documented, with a clear plan if pregnancy is being considered.
• Ethnicity-informed choices. NICE recommends different first-line choices by age and by Black African or African-Caribbean family origin, including a preference for an ARB over an ACE inhibitor in that group. A regimen that predates the current guideline is worth re-checking against it, particularly if ACE inhibitor cough is in the record.

What does "controlled" mean if doses are being missed?

Ordering history is one of the most honest pieces of data in the record. If a 28-day repeat is being requested every six weeks, the blood pressure you measured is being achieved on partial dosing, or is not what it appears. Ask without judgement: "Lots of people miss doses, how often does that happen for you?" opens more doors than an audit tone. Sometimes the answer is a side effect the patient never mentioned, such as ankle swelling or waking at night to pass urine. Sometimes it reveals that a lower dose genuinely holds the target. Either way, a review that ignores adherence is describing a patient who does not exist.

When stepping down is the right move

Deprescribing is a legitimate outcome of a hypertension review, not a defeat. In older people, overtreatment causes postural hypotension, dizziness, syncope, falls, fractures and acute kidney injury, and the STOPP criteria explicitly flag antihypertensives in the presence of symptomatic postural hypotension. If readings run well below target and the patient is symptomatic, reducing or stopping an agent, one change at a time with follow-up readings, is often the intervention with the clearest benefit. Our guide to the STOPP/START criteria covers how these prompts fit into a review.

A fictional example. Ada is an entirely fictional 82-year-old on three antihypertensives, coded as well controlled at 110/68. On questioning she describes light-headedness on standing and has started holding the furniture on the way to the bathroom at night. Her standing blood pressure drops significantly. On paper she is a success story. In reality she is overtreated, and the right review outcome is a planned step-down with a repeat postural check, not a recall in twelve months.

When a controlled number still needs escalation of thought

Occasionally the number is fine and the picture is not. Signs of end-organ change, such as a rising urine albumin-to-creatinine ratio, declining renal function or left ventricular hypertrophy on an ECG, mean the condition needs more attention despite today's reading. Keep an eye out too for flags that a secondary cause was never excluded: hypertension diagnosed at a young age, persistent hypokalaemia, or a history of needing multiple agents to gain control. These are findings to raise with the GP, with your reasoning attached, not to sit on.

Document the reasoning, not just the number

The record should let the next clinician reconstruct your thinking: which readings you relied on (clinic, home average, standing), what you checked, what you decided and why, and the follow-up plan with safety-netting. "BP controlled, continue" tells the next reader nothing. "Home average at target, standing drop excluded, renal function stable, adherence confirmed, recheck bloods in 12 months" is a review someone can build on, and protection if the decision is ever questioned.

Building the habit

None of this takes long once it is routine: confirm the reading story, re-fit the drug to today's patient, check the doses are really being taken, consider stepping down as seriously as stepping up, stay alert to the quiet flags, and write the reasoning down. To sharpen the deprescribing side of that routine, our STOPP/START reference and drill lets you practise applying the criteria until the prompts come to mind unasked.

Frequently asked questions

How often should blood pressure medication be reviewed?

An annual review is the usual minimum, with earlier review after a dose change, significant illness, a change in renal function, or new symptoms such as dizziness or falls. Frail or older patients often warrant more frequent checks, including a standing blood pressure.

What counts as a significant postural drop in blood pressure?

A sustained fall of around 20 mmHg or more systolic (or around 10 mmHg diastolic) on standing is commonly used. Where a significant drop is present, guidance supports treating to the standing reading. Confirm thresholds against current NICE guidance.

Can blood pressure medicines be reduced or stopped in older people?

Yes. Where readings run well below target or the patient has postural symptoms, falls or frailty, a planned step-down with follow-up readings can be the safest option. Make one change at a time and document the rationale.