Why home targets are lower than the ones you hear in a surgery
| Clinic | Home or ambulatory average | |
|---|---|---|
| Under 80 | 140/90 | 135/85 |
| 80 and over | 150/90 | 145/85 |
| Kidney disease with significant proteinuria | 130/80, and the specifics belong with whoever manages it | |
The gap is the white-coat effect, and it is real rather than imagined. Being measured raises blood pressure in a large minority of people, so a threshold designed for clinic readings is set higher to allow for it. Applying the clinic number to home readings is a common and consequential mistake: it makes people think they are controlled when they are not.
The dosing-time question, which has now been answered
So the practical answer is adherence, not chronobiology. The exception worth knowing is documented high night-time blood pressure, where evening dosing may still be considered — but that is a specific finding on ambulatory monitoring, not a general rule, and not something to infer from home readings.
On the recall stories
What is worth carrying is regulatory change that outlasts a batch — and there is a current one. In June 2026 the MHRA required the product information for all ACE inhibitors to be updated, strengthening the warning that angioedema can appear after weeks or years of uneventful treatment, with a reminder that bradykinin-mediated angioedema does not respond to standard anaphylaxis treatment. That is not a reason to stop an ACE inhibitor. It is a reason to know that swelling of the lips, face, tongue or throat is not ruled out just because you have taken the tablet for years, and that tongue or throat swelling is a 999 call. See section 7.
What defeats treatment, in rough order of how often
Doses not taken
Roughly half of people prescribed a long-term cardiovascular drug have stopped within a year. This is the commonest reason treatment appears to fail, and the one least often said out loud — and a dose increased to cover missed doses becomes a problem the moment they are taken reliably. Combination tablets and once-daily formulations exist precisely for this.
Readings that are not what they seem
Wrong arm, wrong cuff, no rest, talking, full bladder. Several of those individually shift a reading by 10 mmHg, which is the size of a treatment decision. The technique page.
Drugs and habits working against it
Regular NSAIDs — ibuprofen and naproxen, usually bought rather than prescribed and rarely mentioned. Salt, mostly from processed food. Alcohol above a modest amount. Decongestants, liquorice, and some herbal preparations.
Untreated sleep apnoea
A common and correctable cause of blood pressure that will not come down, and one that is routinely missed. Snoring with witnessed pauses, or waking unrefreshed, is worth raising.
A secondary cause
Uncommon but not rare, and worth looking for when blood pressure stays high on three drugs including a diuretic — the definition of resistant hypertension. Primary aldosteronism is the one most often present and least often sought.
What the drugs are, how they are sequenced, and the side effects that get blamed on ageing are all in the blood pressure chapter.