Setting a national research agenda for hypertension

The burden of hypertension in the UK is profound.¹ It is the leading modifiable risk factor for cardiovascular disease, chronic kidney disease and vascular dementia, affecting approximately 30% of adults, with an estimated 4.2 million remaining undiagnosed – an alarming figure that underscores longstanding gaps between evidence and implementation in routine care.^2–5 Against this backdrop, the British and Irish Hypertension Society (BIHS), in partnership with the British Heart Foundation Clinical Research Collaborative (BHF‑CRC), has developed the first national, consensus‑driven effort to define future research priorities in hypertension.⁶ This represents a landmark initiative: a structured attempt to align research, policy, and clinical services with the realities of modern hypertension care.

Methodology

The priority‑setting project employed a modified Delphi approach grounded in James Lind Alliance principles, combining methodological rigour with inclusive stakeholder engagement. Beginning with a long list of 66 adult and 18 children and young people (CYP) research questions derived from national and international guidelines, as well as expert discussion, the steering group systematically refined and consolidated these into a shortlist of 38 adult and 18 CYP questions.

Two rounds of surveys then captured perspectives of clinicians and individuals with lived experience of hypertension, generating a reduced set of 19 questions (15 adult, four CYP). Ultimately, a workshop of diverse clinicians and patients undertook structured consensus discussions to arrive at a final top 10 research priorities.

This multi‑stage process is its strength. Hypertension affects many clinical environments – primary, secondary, specialist and community – and the study methodology appropriately reflects that breadth. Equally important is the inclusion of patient voices: their perspectives shaped priorities around digital tools, treatment adherence and equitable access, reaffirming the need for research that delivers real‑world impact rather than theoretical insights alone.

Results: the top 10 UK hypertension research priorities

The final ranked list is the centrepiece of the study. In narrative form, the priorities are:

1. Clinical performance of cuffless blood pressure (BP) devices
   Are emerging non-cuff technologies accurate and useful in real-world hypertension management?
2. Reducing inequalities in detection and treatment
   How can hypertension best be identified and managed in underserved groups, including low-income and minority ethnic communities?
3. Improving medication adherence
   What strategies are most effective in helping patients sustain long-term antihypertensive therapy?
4. Prevention of dementia
   Can treating hypertension reduce the risk of cognitive decline and dementia?
5. Impact of new obesity pharmacotherapies
   How do modern agents (e.g. semaglutide, tirzepatide) affect BP, heart health, and kidney health?
6. Management of resistant hypertension
   How does controlling hard-to-treat hypertension affect long-term cardiovascular and kidney outcomes?
7. Treating hypertension in the very elderly
   What are appropriate treatment goals for frail adults aged ≥80 years?
8. Home vs. clinic-based BP monitoring for treatment guidance
   Does home-based monitoring improve outcomes compared with office-based measurements?
9. Risk thresholds for treatment initiation
   What level of cardiovascular risk best identifies who will benefit most from treatment?
10. Optimal BP targets for home and clinic settings
    What target BP values should be used across different measurement modalities?

What do the priorities tell us about the state of hypertension care in the UK?

The final ranking offers a striking window into contemporary concerns in hypertension research and clinical practice.

1. Digital health is moving faster than the evidence-base. The highest‑ranked question asks whether cuffless BP devices are accurate and clinically useful. In an era of rapidly proliferating consumer technologies, robust validation is essential before such devices can be adopted within National Health Service (NHS) pathways.⁷ The prioritisation of this question reflects an urgent unmet need: digital innovation must be supported by rigorous evidence before it can safely inform clinical decision‑making.
2. Persistent health inequalities demand research‑driven solutions. The second priority – improving detection and treatment in underserved communities – captures a painful truth: social deprivation and minority ethnic status continue to predict worse hypertension outcomes.⁸ The pandemic widened these gaps, and the need for targeted, community‑embedded interventions is now more pressing than ever.
3. Poor adherence remains a major barrier to BP control. Despite effective and inexpensive antihypertensive treatments, long‑term adherence remains low.⁹ Stakeholders prioritised research into behavioural support, digital adherence strategies, and simplified treatment models. This aligns with everyday clinical experience: medicines work only when taken.
4. The role of hypertension in cognitive decline is now front‑and‑centre. The inclusion of dementia prevention reflects a growing understanding that midlife BP control has lifelong implications.¹⁰ With dementia now one of the most significant causes of death in the UK, this cross‑disciplinary priority is both sensible and overdue.
5. The obesity–hypertension nexus is evolving rapidly. The emergence of glucagon-like peptide-1 (GLP‑1) receptor agonists and dual gastric inhibitory polypeptide (GIP)/GLP‑1 agonists (e.g. semaglutide, tirzepatide) is transforming metabolic disease management.¹¹ Yet their long‑term impacts on cardiovascular and kidney outcomes in people with hypertension remain poorly defined, prompting their inclusion in the top 10. This reflects both clinical curiosity and the need for vigilance, as these therapies become widespread.
6. Resistant hypertension, frailty, and home monitoring remain enduring clinical challenges. The priorities highlighting resistant hypertension, hypertension in the very elderly, and home versus clinic monitoring reaffirm unresolved clinical uncertainties. Despite guideline evolution, clinicians still lack sufficiently robust evidence to confidently personalise targets and treatment pathways for these groups.
7. A noticeable gap: hypertension management in children and young people (CYP). Although 18 paediatric hypertension research questions were initially generated, none appeared in the final top 10. This is not due to lack of importance – childhood hypertension is increasing alongside obesity trends – but largely reflects methodological limitations, including under‑representation of CYP stakeholders in the workshop stage.

We acknowledge this shortcoming and explicitly encourage the wider community to examine the paediatric list closely. As early hypertension increasingly predicts adult cardiovascular risk, this gap represents a significant opportunity for future research investment.

Strengths and limitations of the initiative

The priority‑setting exercise stands out for its transparency, breadth, and systematic methodology. The appendices provide an unusually detailed account of each stage, from the long list to final ranking – offering a resource that can be replicated, scrutinised, or adapted for future conditions.

The limitations include over‑representation of clinical stakeholders in early stages, under‑representation of minority ethnic and socioeconomically deprived groups, and limited involvement of CYP stakeholders, as already stated. These limitations should inform future efforts, but do not detract from the significance of the overall achievement.

What does this mean for the future of cardiovascular research in the UK?

The BIHS–BHF-CRC priority list provides a coherent, stakeholder‑informed roadmap that academic institutions, research funders and policymakers can now use to align investment with need. Importantly, many of the identified priorities transcend hypertension itself: digital innovation, health inequalities, metabolic medicine, cognitive health, frailty and multi-morbidity. This reflects a broader shift toward research questions that span disciplines and acknowledge the complexity of cardiovascular risk in the 21^st century.

The challenge now is translation. Without targeted funding calls, cross‑sector partnerships and system‑level commitment, even the most thoughtful prioritisation will remain aspirational. But if acted upon, this initiative has the potential to transform the trajectory of hypertension research and, thereby, improve outcomes for millions across the UK and Ireland.

Conclusion

The BIHS–BHF-CRC research prioritisation initiative marks an important milestone in UK hypertension research. It articulates a clear, patient‑centred, forward‑looking agenda that addresses the pressures, inequities and technological transformations shaping contemporary practice. The final priorities highlight where evidence is urgently needed and offer a practical blueprint for funders and researchers.

If implemented effectively, this national agenda could catalyse the next generation of high‑impact research – improving diagnosis, personalising treatment, reducing inequalities and, ultimately, reducing the cardiovascular disease burden associated with hypertension.

Conflicts of interest

None declared.

Funding

None.

References

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