Which patients with severely elevated blood pressure should be referred to secondary care for further management?

Patients with severely elevated blood pressure (clinic blood pressure of 180/120 mmHg or higher) should be referred to secondary care for same-day specialist assessment if they have:

• Signs of retinal haemorrhage or papilloedema (accelerated hypertension).
• Life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
• Suspected phaeochromocytoma (e.g., labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis).

If no such symptoms or signs are present, investigations for target organ damage should be carried out as soon as possible. If target organ damage is identified, antihypertensive treatment should be started immediately, and referral to secondary care considered. If no target organ damage is found, diagnosis should be confirmed by repeat blood pressure measurement or ambulatory/home monitoring within 7 days, with clinical review, before referral decisions are made.