NICE NG136 Hypertension Update, February 2026: New Advice for Raised Blood Pressure Before Diagnosis

NICE updated NG136, its guideline on hypertension in adults, on 26 February 2026. The change is small and specific: a new recommendation to offer healthy-living advice to people who have raised blood pressure but do not have diagnosed hypertension.

This is not a prescribing overhaul. The diagnosis thresholds, the treatment thresholds, the drug algorithm, and the blood pressure targets are all unchanged. But the addition is worth a moment's attention, because it formalises something good clinicians already do — and it is an easy thing to let slide in a ten-minute appointment.

This post is a plain-English summary for busy clinicians. The authoritative source is the NICE guideline itself. We summarise; we do not replace NICE, and nothing here substitutes for clinical judgement on an individual patient.

What actually changed

The new recommendation reads, in essence: offer advice on healthy living, in line with NHS healthy-living information, to people who have raised blood pressure but have not been diagnosed with hypertension.

Two things are worth noting.

First, NICE did not attach a number to "raised blood pressure" here. The recommendation points to NHS healthy-living resources rather than a diagnostic threshold. In practice it covers the group whose readings sit above optimal but below the cut-offs for stage 1 hypertension — people who do not yet warrant a diagnosis, a label, or a prescription, but whose trajectory you would rather change early.

Second, this is primary prevention framed as an opportunistic act. It does not ask for a new clinic, a recall, or a register. It asks that a raised reading in someone who is not hypertensive is not simply filed as "normal for now" — that it prompts the same lifestyle conversation you would have at any cardiovascular-risk touchpoint.

The essentials, refreshed

Since the update leaves the rest of NG136 intact, here is the working core of the guideline in one place.

Diagnosis

NICE diagnoses hypertension on a clinic reading confirmed by ambulatory (ABPM) or home (HBPM) monitoring, not on clinic readings alone.

• Stage 1 — clinic 140/90 to 159/99 mmHg, with an ABPM/HBPM daytime average of 135/85 to 149/94 mmHg.
• Stage 2 — clinic 160/100 mmHg to under 180/120 mmHg, with ABPM/HBPM of 150/95 mmHg or higher.
• Severe (stage 3) — clinic systolic 180 mmHg or higher, or diastolic 120 mmHg or higher. Investigate for target organ damage as soon as possible. Refer for same-day specialist assessment only if there are signs of accelerated hypertension (retinal haemorrhage or papilloedema) or life-threatening symptoms such as new confusion, chest pain, heart failure, or acute kidney injury.

When to treat

• Stage 2, any age — offer drug treatment, with clinical judgement in frailty and multimorbidity.
• Stage 1, under 80 — offer treatment where there is target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk of 10% or more. In people under 60 whose estimated risk is below 10%, treatment can still be considered — NICE notes that a 10-year figure may underestimate the lifetime probability of cardiovascular disease in a younger patient.
• 80 or over — consider treatment if clinic blood pressure is over 150/90 mmHg.

Lifestyle advice, and the offer of treatment, sit alongside a formal cardiovascular risk assessment. Our summary of the 2026 statins and CVD-prevention changes covers the risk-threshold side of that decision.

The drug algorithm

NG136 keeps the familiar A/C/D structure, sequenced by age, ethnicity, and diabetes status.

• Step 1 — an ACE inhibitor or ARB for people under 55, and for people with type 2 diabetes of any age or family origin (an ARB is preferred over an ACE inhibitor for people of Black African or African-Caribbean family origin). A calcium-channel blocker for people aged 55 or over without type 2 diabetes, and for people of Black African or African-Caribbean family origin without type 2 diabetes.
• Step 2 — combine an ACE inhibitor or ARB with a calcium-channel blocker or a thiazide-like diuretic.
• Step 3 — an ACE inhibitor or ARB, plus a calcium-channel blocker, plus a thiazide-like diuretic.
• Step 4 (resistant hypertension) — confirm the raised readings on ABPM or HBPM and check adherence first. Then consider low-dose spironolactone if the blood potassium is 4.5 mmol/L or lower, or an alpha- or beta-blocker if it is higher. Seek specialist advice if blood pressure stays uncontrolled on four drugs.

Targets

• Under 80 — clinic below 140/90 mmHg; ABPM/HBPM below 135/85 mmHg.
• 80 or over — clinic below 150/90 mmHg; ABPM/HBPM below 145/85 mmHg.

Targets are individualised in frailty and multimorbidity, and differ in type 1 diabetes and chronic kidney disease — our CKD and SGLT2 summary covers the renal overlap, where ACE inhibitors and ARBs do more than lower pressure.

What it means in practice

For most UK clinicians the 26 February 2026 update changes very little on paper and quite a lot in habit. The prescribing thresholds are the same. What NICE now says out loud is that the raised-but-not-diagnosed reading is a moment to act, not a moment to wait.

The practical version is a single sentence added to an existing consultation: the reading is up, it is not yet hypertension, and here is what would help keep it that way. It costs nothing, it needs no new system, and it is exactly the kind of small, repeatable act that a busy week tends to swallow.

That is also the argument for a routine that surfaces changes like this one before a patient or an appraisal does. A once-a-week read of what actually changed in your specialty is how a one-line guideline update becomes a change in practice rather than a change you meant to make. That is what we built The Monday Clinical Brief to do, and it is the theme of our pillar guide on keeping up with the medical literature.