nice guideline of hypertension
TRANSCRIPT
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Hypertension: NICE guideline DRAFT (February 2011) Page 1 of 39
Hypertension: clinical management of primary hypertension in adults
NICE guideline
Draft for consultation, February 2011
If you wish to comment on this version of the guideline, please be aware that
all the supporting information and evidence is contained in the full version.
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Contents
Introduction ............................................................................................................... 4
Person-centred care .................................................................................................. 5
Key priorities for implementation ............................................................................... 6
1 Guidance ........................................................................................................... 9
1.1 Measuring blood pressure ........................................................................... 9
1.2 Diagnosing hypertension ........................................................................... 10
1.3 Assessing cardiovascular risk ................................................................... 13
1.4 Lifestyle interventions ................................................................................ 13
1.5 Initiating and monitoring antihypertensive drug treatment, including blood
pressure targets .................................................................................................. 14
1.6 Choosing antihypertensive drug treatment ................................................ 15
1.7 Patient education and adherence to treatment .......................................... 18
2 Notes on the scope of the guidance................................................................. 19
3 Implementation ................................................................................................ 20
4 Research recommendations ............................................................................ 20
4.1 Out-of-office monitoring ............................................................................. 20
4.2 Intervention thresholds for people aged under 40 with hypertension ......... 21
4.3 Methods of assessing lifetime CV risk in people aged under 40 with
hypertension ........................................................................................................ 21
4.4 Optimal systolic blood pressure ................................................................. 22
4.5 Step 4 treatment........................................................................................ 22
4.6 Automated blood pressure monitoring in people with
atrial fibrillation .................................................................................................... 22
5 Other versions of this guideline ........................................................................ 23
6 Related NICE guidance ................................................................................... 24
7 Updating the guideline ..................................................................................... 24
Appendix A: The Guideline Development Groups, National Collaborating Centres and
NICE project team ................................................................................................... 26
Appendix B: The Guideline Review Panels ............................................................. 31
Appendix C: The algorithms .................................................................................... 33
Appendix D: Recommendations to be deleted ......................................................... 35
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This guidance is a partial update of NICE clinical guideline 34 (published June
2006) and will replace it. NICE clinical guideline 34 partially updated and
replaced NICE clinical guideline 18 (published August 2004).
In this update new recommendations have been added on blood pressure
measurement, the use of ambulatory and home blood pressure monitoring,
blood pressure targets and antihypertensive drug treatment.
Where recommendations are shaded in grey and end [2004] or [2006] the
evidence has not been updated. Yellow shading in these recommendations
indicates where wording changes have been made for the purposes of
clarification only.
You are invited to comment on the new and updated recommendations in this
guideline only. These are marked as [2011] if the evidence has been
reviewed but no change has been made to the recommendation or
[new 2011] if the evidence has been reviewed and the recommendation has
been added or updated.
Appendix D contains recommendations from the 2006 guideline that NICE
proposes deleting in the 2011 update. This is because the evidence has been
reviewed and the recommendation has been updated or because NICE has
updated other relevant guidance and has replaced the original
recommendations. Where there are replacement recommendations, details
are provided. Where there is no replacement recommendation, an explanation
for the proposed deletion is given. You are invited to comment on the deleted
recommendations as part of the consultation on the 2011 update.
The original NICE guideline and supporting documents are available from
www.nice.org.uk/guidance/CG34
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Introduction 1
High blood pressure (hypertension) is one of the most important preventable 2
causes of premature morbidity and mortality in the UK. Hypertension is a 3
major risk factor for stroke (ischaemic and haemorrhagic), myocardial 4
infarction, heart failure, chronic kidney disease, cognitive decline and 5
premature death. Untreated hypertension is usually associated with a 6
progressive rise in blood pressure. The vascular and renal damage that this 7
may cause can culminate in a treatment-resistant state. 8
Blood pressure is normally distributed in the population and there is no natural 9
cut-off point above which 'hypertension' definitively exists and below which it 10
does not. The risk associated with increasing blood pressure is continuous, 11
with each 2 mmHg rise in systolic blood pressure associated with a 7% 12
increased risk of mortality from ischaemic heart disease and a 10% increased 13
risk of mortality from stroke. Hypertension is remarkably common in the UK 14
and the prevalence is strongly influenced by age. In any individual person, 15
systolic and/or diastolic blood pressures may be elevated. Diastolic pressure 16
is more commonly elevated in younger people, that is, those younger than 17
50 years. With ageing, systolic hypertension becomes a more significant 18
problem, as a result of progressive stiffening and loss of compliance of larger 19
arteries. At least one quarter of adults (and more than half of those older than 20
60) have high blood pressure. 21
The clinical management of hypertension is one of the most common 22
interventions in primary care, accounting for approximately £1 billion in drug 23
costs alone in 2006. 24
The guideline will assume that prescribers will use a drug’s summary of 25
product characteristics to inform decisions made with individual patients. 26
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Person-centred care 27
This guideline offers best practice advice on the care of adults with 28
hypertension. 29
Treatment and care should take into account people’s needs and preferences. 30
People with hypertension should have the opportunity to make informed 31
decisions about their care and treatment, in partnership with their healthcare 32
professionals. If people do not have the capacity to make decisions, 33
healthcare professionals should follow the Department of Health’s advice on 34
consent (available from www.dh.gov.uk/consent) and the code of practice that 35
accompanies the Mental Capacity Act (summary available from 36
www.publicguardian.gov.uk). In Wales, healthcare professionals should follow 37
advice on consent from the Welsh Assembly Government (available from 38
www.wales.nhs.uk/consent). 39
Good communication between healthcare professionals and people with 40
hypertension is essential. It should be supported by evidence-based written 41
information tailored to the person’s needs. Treatment and care, and the 42
information people are given about it, should be culturally appropriate. It 43
should also be accessible to people with additional needs such as physical, 44
sensory or learning disabilities, and to people who do not speak or read 45
English. 46
If the person agrees, families and carers should have the opportunity to be 47
involved in decisions about treatment and care. 48
Families and carers should also be given the information and support 49
they need. 50
51
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Key priorities for implementation 52
The following recommendations have been identified as priorities for 53
implementation. 54
Diagnosing hypertension 55
If the first and second blood pressure measurements taken during a 56
consultation are 140/90 mmHg or higher, offer 24-hour ambulatory blood 57
pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new 58
2011] [1.2.2] 59
When using ABPM to confirm a diagnosis of hypertension, ensure that: 60
Blood pressure is measured for a total of 24 hours. 61
At least two measurements per hour are taken during the day (08:00 to 62
22:00). 63
At least one measurement per hour is taken during the night (22:00 to 64
08:00). 65
Use the average daytime blood pressure measurement, calculated using a 66
minimum of 14 daytime measurements, to confirm a diagnosis of 67
hypertension. [new 2011] [1.2.6] 68
When using home blood pressure monitoring (HBPM) to confirm a 69
diagnosis of hypertension, ensure that: 70
For each blood pressure measurement, two consecutive measurements 71
are taken, at least 1 minute apart and with the person seated (see 1.1.4). 72
Blood pressure measurements are taken twice daily, ideally in the 73
morning and evening. 74
Blood pressure measurement continues for at least 4 days, ideally for 75
7 days. 76
Discard the measurements taken on the first day and use the average 77
value of all the remaining measurements to confirm a diagnosis of 78
hypertension. [new 2011] [1.2.7] 79
80
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Initiating and monitoring antihypertensive drug treatment, including 81
blood pressure targets 82
Initiating treatment 83
Offer antihypertensive drug treatment to people with stage 1 hypertension 84
who have: 85
target organ damage or 86
established cardiovascular disease or 87
renal disease or 88
diabetes or 89
a 10-year cardiovascular risk equivalent to 20% or greater. [new 2011] 90
91
Offer antihypertensive drug treatment to people with stage 2 hypertension. 92
[new 2011] [1.5.2] 93
For people younger than 40 years with stage 1 hypertension and no 94
evidence of target organ damage, cardiovascular (CV) disease, renal 95
disease or diabetes, consider seeking specialist evaluation of secondary 96
causes of hypertension and a more detailed assessment of potential target 97
organ damage. This is because 10-year CV risk assessments can 98
underestimate the lifetime risk of CV events in these people [new 2011] 99
[1.5.3] 100
Monitoring treatment and blood pressure targets 101
For people with a discrepancy of more than 20/10 mmHg between clinic 102
blood pressure measurements and ABPM or HBPM average 103
measurements, consider using daytime average ABPM or average HBPM 104
for monitoring the response to antihypertensive treatment. Aim for a target 105
ABPM or HBPM blood pressure of 135/85 mmHg or lower. [new 2011] 106
[1.5.6] 107
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Choosing antihypertensive drug treatment 108
Offer people older than 80 years the same antihypertensive drug treatment 109
as people aged 55–80 years, taking into account any comorbidities. [new 110
2011] [1.6.4] 111
Step 1 treatment 112
Offer step 1 antihypertensive treatment with a calcium-channel blocker 113
(CCB) to people aged 55 years and older and to black people of African 114
and Caribbean descent of any age. If a CCB is not suitable, for example 115
because of oedema or intolerance, or if there is evidence of heart failure or 116
a high risk of heart failure, offer a thiazide-like diuretic. [new 2011] [1.6.8] 117
If a diuretic is required, choose a thiazide-like diuretic, such as 118
chlortalidone (12.5 mg–25.0 mg once daily) or indapamide (2.5 mg once 119
daily) in preference to a conventional thiazide diuretic such as 120
bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.9] 121
Step 4 treatment 122
For treatment of resistant hypertension at step 4, consider further diuretic 123
therapy with low-dose spironolactone (25 mg once daily) if blood potassium 124
levels are lower than 4.5 mmol/l and estimated glomerular filtration rate is 125
higher than 60 ml/min/1.73m2. If blood potassium levels are higher than 126
4.5 mmol/l, consider therapy with a higher-dose thiazide-like diuretic. [new 127
2011] [1.6.14] 128
129
130
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1 Guidance 131
The following guidance is based on the best available evidence. The full 132
guideline (www.nice.org.uk/guidance/CGXXX) gives details of the methods 133
and the evidence used to develop the guidance. 134
Definitions 135
In this guideline the following definitions are used. 136
Stage 1 hypertension: initial clinic blood pressure 140/90 mmHg or higher 137
and subsequent ambulatory blood pressure monitoring (ABPM) daytime 138
average or home blood pressure monitoring (HBPM) average blood 139
pressure 135/85 mmHg or higher. 140
Stage 2 hypertension: initial clinic blood pressure 160/100 mmHg or 141
higher and subsequent ABPM daytime average or HBPM average blood 142
pressure 150/95 mmHg or higher. 143
Severe hypertension: clinic blood pressure 180/110 mmHg or higher. 144
1.1 Measuring blood pressure 145
1.1.1 Healthcare professionals taking blood pressure measurements 146
need adequate initial training and periodic review of their 147
performance. [2004] 148
1.1.2 Because automated devices may not measure blood pressure 149
accurately if there is pulse irregularity (for example, due to atrial 150
fibrillation), palpate the radial or brachial pulse before measuring 151
blood pressure. If pulse irregularity is present, measure blood 152
pressure manually using direct auscultation over the brachial 153
artery. [new 2011] 154
1.1.3 Healthcare providers must ensure that devices for measuring blood 155
pressure are properly validated, maintained and regularly 156
recalibrated according to manufacturers’ instructions. [2004] 157
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1.1.4 When measuring blood pressure in the clinic or in the home, 158
standardise the environment and provide a relaxed, temperate 159
setting, with the person quiet and seated, and their arm 160
outstretched and supported. [new 2011] 161
1.1.5 Use an ABPM device that is validated and is of an appropriate cuff 162
size for the person’s arm. [new 2011] 163
1.1.6 Measure blood pressure in both arms: 164
If the difference in readings between arms is more than 165
20 mmHg, repeat the measurements. 166
If the difference in readings between arms remains more than 167
20 mmHg on the second measurement, measure subsequent 168
blood pressure in the arm with the higher reading. [new 2011] 169
1.1.7 In people with symptoms of postural hypotension (falls or postural 170
dizziness): 171
Measure blood pressure with the person either supine or seated. 172
Measure blood pressure again with the person standing. [2004, 173
amended 2011] 174
1.1.8 If the systolic blood pressure falls by 20 mmHg or more when the 175
person is standing: 176
Review medication. 177
Measure subsequent blood pressures with the person standing. 178
Consider referral to specialist care if symptoms of postural 179
hypotension persist. [2004, amended 2011] 180
1.2 Diagnosing hypertension 181
1.2.1 If blood pressure measured in the clinic is 140/90 mmHg or higher: 182
Take a second measurement during the consultation. 183
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If the second measurement is substantially different from the 184
first, take a third measurement. 185
Use the lower of the last two measurements to diagnose 186
hypertension. [new 2011] 187
1.2.2 If the first and second blood pressure measurements taken during 188
a consultation are both 140/90 mmHg or higher, offer 24-hour 189
ambulatory blood pressure monitoring (ABPM) to confirm the 190
diagnosis of hypertension. [new 2011] 191
1.2.3 If a person is unable to tolerate ABPM, home blood pressure 192
monitoring (HBPM) is a suitable alternative to confirm the diagnosis 193
of hypertension. [new 2011] 194
1.2.4 If the person has severe hypertension and evidence of target organ 195
damage, start antihypertensive drug treatment immediately; do not 196
wait for the results of ABPM or HBPM. [new 2011]. 197
1.2.5 When considering a diagnosis of hypertension, carry out 198
appropriate investigations for target organ damage and a formal 199
assessment of cardiovascular (CV) risk using a CV risk 200
assessment tool, in line with ‘Lipid modification’ (NICE clinical 201
guideline 67). [new 2011] 202
1.2.6 When using ABPM to confirm a diagnosis of hypertension, 203
ensure that: 204
blood pressure is measured for a total of 24 hours 205
at least two measurements per hour are taken during the day 206
(08:00 to 22:00) 207
at least one measurement per hour is taken during the night 208
(22:00 to 08:00). 209
Use the average daytime blood pressure measurement, calculated 210
using a minimum of 14 daytime measurements, to confirm a 211
diagnosis of hypertension. [new 2011] 212
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1.2.7 When using home blood pressure monitoring (HBPM) to confirm a 213
diagnosis of hypertension, 214
ensure that: 215
For each blood pressure measurement, two consecutive 216
measurements are taken, at least 1 minute apart and with the 217
person seated (see 1.1.4). 218
Blood pressure measurements are taken twice daily, ideally in 219
the morning and evening. 220
Blood pressure measurement continues for at least 4 days, 221
ideally for 7 days. 222
Discard the measurements taken on the first day and use the 223
average value of all the remaining measurements to confirm a 224
diagnosis of hypertension. [new 2011] 225
1.2.8 Immediately refer people with the following signs for specialist care: 226
accelerated hypertension (blood pressure usually higher than 227
180/110 mmHg with signs of papilloedema and/or retinal 228
haemorrhage) 229
suspected phaeochromocytoma (labile or postural hypotension, 230
headache, palpitations, pallor and diaphoresis). [2004, 231
amended 2011] 232
1.2.9 Consider the need for specialist investigations in people with signs 233
and symptoms suggesting a secondary cause of hypertension. 234
[2004, amended 2011] 235
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1.3 Assessing cardiovascular risk 236
1.3.1 Use a formal estimation of cardiovascular risk to discuss prognosis 237
and healthcare options with people with hypertension, both for 238
raised blood pressure and other modifiable risk factors. [2004] 239
1.3.2 Estimate cardiovascular risk in line with recommendations 1.1.7, 240
1.1.8, 1.1.10, 1.1.11, 1.1.13, 1.1.21 and 1.1.22 in ‘Lipid 241
modification’ (NICE clinical guideline 67). [new 2011] 242
1.3.3 For all people with hypertension: 243
Test for the presence of protein in the urine by sending a urine 244
sample for estimation of the albumin:creatinine ratio. 245
Take a blood sample to measure plasma glucose, electrolytes, 246
creatinine, estimated glomerular filtration rate, serum total 247
cholesterol and HDL cholesterol. 248
Arrange for a 12-lead electrocardiograph to be performed. 249
[2004, amended 2011] 250
1.4 Lifestyle interventions 251
1.4.1 Ascertain people’s diet and exercise patterns because a healthy 252
diet and regular exercise can reduce blood pressure. Offer 253
appropriate guidance and written or audiovisual materials to 254
promote lifestyle changes. [2004] 255
1.4.2 Relaxation therapies can reduce blood pressure and people may 256
wish to pursue these as part of their treatment. However, routine 257
provision by primary care teams is not currently recommended. 258
[2004] 259
1.4.3 Ascertain people’s alcohol consumption and encourage a reduced 260
intake if they drink excessively, because this can reduce blood 261
pressure and has broader health benefits. [2004] 262
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1.4.4 Discourage excessive consumption of coffee and other caffeine-263
rich products. [2004] 264
1.4.5 Encourage people to keep their dietary sodium intake low, either by 265
reducing or substituting sodium salt, as this can reduce blood 266
pressure. [2004] 267
1.4.6 Do not offer calcium, magnesium or potassium supplements as a 268
method for reducing blood pressure. [2004] 269
1.4.7 Offer advice and help to smokers to stop smoking. [2004] 270
1.4.8 A common aspect of studies for motivating lifestyle change is the 271
use of group working. Inform people about local initiatives by, for 272
example, healthcare teams or patient organisations that provide 273
support and promote healthy lifestyle change. [2004] 274
1.5 Initiating and monitoring antihypertensive drug 275
treatment, including blood pressure targets 276
Initiating treatment 277
1.5.1 Offer antihypertensive drug treatment to people with stage 1 278
hypertension who have: 279
target organ damage or 280
established cardiovascular disease or 281
renal disease or 282
diabetes or 283
a 10-year cardiovascular risk equivalent to 20% or greater. 284
[new 2011] 285
1.5.2 Offer antihypertensive drug treatment to people with stage 2 286
hypertension. [new 2011] 287
1.5.3 For people younger than 40 years with stage 1 hypertension and 288
no evidence of target organ damage, cardiovascular disease, renal 289
disease or diabetes, consider seeking specialist evaluation of 290
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secondary causes of hypertension and a more detailed assessment 291
of potential target organ damage. This is because 10-year 292
cardiovascular risk assessments can underestimate the lifetime risk 293
of cardiovascular events in these people. [new 2011] 294
Monitoring treatment and blood pressure targets 295
1.5.4 Use clinic blood pressure measurement to monitor the response to 296
antihypertensive treatment. [new 2011] 297
1.5.5 For people identified as having a ‘white-coat effect’, that is, a 298
consistent alerting response or clinic hypertension, consider HBPM 299
as an adjunct to clinic blood pressure measurement for monitoring 300
the response to antihypertensive treatment with lifestyle 301
modification or drugs. [new 2011] 302
1.5.6 For people with a discrepancy of more than 20/10 mmHg between 303
clinic blood pressure measurements and ABPM or HBPM average 304
measurements, consider using daytime average ABPM or average 305
HBPM for monitoring the response to antihypertensive treatment. 306
Aim for a target daytime average ABPM or average HBPM blood 307
pressure below 135/85 mmHg. [new 2011] 308
1.5.7 Aim for a target clinic blood pressure below 140/90 mmHg in 309
people aged under 80 years with treated hypertension. [new 2011] 310
1.5.8 Aim for a target clinic blood pressure below 150/90 mmHg in 311
people aged over 80 years with treated hypertension. [new 2011] 312
1.6 Choosing antihypertensive drug treatment 313
1.6.1 Where possible, recommend treatment with drugs taken only once 314
a day. [2004] 315
1.6.2 Prescribe non-proprietary drugs where these are appropriate and 316
minimise cost. [2004] 317
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1.6.3 Offer people with isolated systolic hypertension (systolic 318
BP 160 mmHg or more) the same treatment as people with both 319
raised systolic and diastolic blood pressure. [2004] 320
1.6.4 Offer people older than 80 years the same antihypertensive drug 321
treatment as people aged 55–80 years, taking into account any 322
comorbidities. [new 2011] 323
1.6.5 Offer antihypertensive drug treatment to women in line with 324
recommendations 1.2.1.1, 1.2.1.2, 1.9.1.1 and 1.9.1.2 in 325
‘Hypertension in pregnancy’ (NICE clinical guideline 107). [new 326
2011] 327
Step 1 treatment 328
1.6.6 Offer step 1 antihypertensive treatment with an angiotensin-329
converting enzyme (ACE) inhibitor or a low-cost angiotensin-II 330
receptor blocker (ARB) to people aged under 55 years. If an ACE 331
inhibitor is not tolerated, offer an ARB. [new 2011] 332
1.6.7 Do not combine an ACE inhibitor with an ARB to treat 333
hypertension. [new 2011] 334
1.6.8 Offer step 1 antihypertensive treatment with a calcium-channel 335
blocker (CCB) to people aged 55 years and older and to black 336
people of African or Caribbean descent of any age. If a CCB is not 337
suitable, for example because of oedema or intolerance, or if there 338
is evidence of heart failure or a high risk of heart failure, offer a 339
thiazide-like diuretic. [new 2011] 340
1.6.9 If a diuretic is required, choose a thiazide-like diuretic, such as 341
chlortalidone (12.5 mg–25.0 mg once daily) or indapamide (2.5 mg 342
once daily) in preference to a conventional thiazide diuretic such as 343
bendroflumethiazide or hydrochlorothiazide. [new 2011] 344
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1.6.10 Beta-blockers are not a preferred initial therapy for hypertension. 345
However, beta-blockers may be considered in younger people, 346
particularly: 347
those with an intolerance or contraindication to ACE inhibitors 348
and angiotensin-II receptor antagonists or 349
women of child-bearing potential or 350
people with evidence of increased sympathetic drive. 351
In these circumstances, if therapy is initiated with a beta-blocker 352
and a second drug is required, add a calcium-channel blocker 353
rather than a thiazide-type diuretic to reduce the person’s risk of 354
developing diabetes. [2006] 355
Step 2 treatment 356
1.6.11 If step 2 antihypertensive treatment is required, offer a CCB in 357
combination with either an ACE Inhibitor or a low-cost ARB. If a 358
CCB is not suitable, for example because of oedema or 359
intolerance, or if there is evidence of heart failure or a high risk of 360
heart failure, offer a thiazide-like diuretic [new 2011] 361
Step 3 treatment 362
1.6.12 If treatment with three drugs is required, the combination of ACE 363
inhibitor (or angiotensin-II receptor blocker), calcium-channel 364
blocker and thiazide-like diuretic should be used. [2006] 365
Step 4 treatment 366
1.6.13 Regard clinic blood pressure that remains higher than 367
140/90 mmHg with the optimal or best tolerated doses of an ACE 368
inhibitor or an ARB plus a CCB plus a diuretic as resistant 369
hypertension and consider adding a fourth antihypertensive drug 370
and/or seeking expert advice. [new 2011] 371
1.6.14 For treatment of resistant hypertension at step 4, consider further 372
diuretic therapy with low-dose spironolactone (25 mg once daily) if 373
blood potassium levels are lower than 4.5 mmol/l and estimated 374
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glomerular filtration rate is higher than 60 ml/min/1.73m2. If blood 375
potassium levels are higher than 4.5 mmol/l, consider higher-dose 376
thiazide-like diuretic treatment. [new 2011] 377
1.6.15 When using further diuretic therapy for resistant hypertension at 378
step 4, monitor blood sodium and potassium and renal function 379
within 1 month and repeat as required thereafter. [new 2011] 380
1.6.16 If further diuretic therapy for resistant hypertension at step 4 is not 381
tolerated, contraindicated or ineffective, consider an alpha- or beta-382
blocker. [new 2011] 383
1.6.17 If blood pressure remains uncontrolled with the optimal or 384
maximum tolerated doses of four drugs seek expert advice if it has 385
not yet been obtained. [2011] 386
1.7 Patient education and adherence to treatment 387
1.7.1 Provide appropriate guidance and materials about the benefits of 388
drugs and the unwanted side effects sometimes experienced in 389
order to help people make informed choices. [2004] 390
1.7.2 People vary in their attitudes to their hypertension and their 391
experience of treatment. It may be helpful to provide details of 392
patient organisations that provide useful forums to share views and 393
information. [2004] 394
1.7.3 Provide an annual review of care to monitor blood pressure, 395
provide people with support and discuss their lifestyle, symptoms 396
and medication. [2004] 397
1.7.4 Because evidence supporting interventions to increase adherence 398
is inconclusive, only use interventions to overcome practical 399
problems associated with non-adherence if a specific need is 400
identified. Target the intervention to the need. Interventions might 401
include: 402
suggesting that patients record their medicine-taking 403
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encouraging patients to monitor their condition 404
simplifying the dosing regimen 405
using alternative packaging for the medicine 406
using a multi-compartment medicines system. (This 407
recommendation is taken from ‘Medicines adherence’, NICE 408
clinical guideline 76). [new 2011] 409
2 Notes on the scope of the guidance 410
NICE guidelines are developed in accordance with a scope that defines what 411
the guideline will and will not cover. The scope of this guideline is available 412
from www.nice.org.uk/[NICE to add details]. 413
Groups that will be covered 414
Adults with hypertension (18 years and older). Particular consideration will 415
be given to the needs of black people of African and Caribbean descent 416
and minority ethnic groups where these differ from the needs of the general 417
population. 418
People aged 80 years or older. 419
Groups that will not be covered 420
People with diabetes. 421
Children and young people (younger than 18 years). 422
Pregnant women. 423
Secondary causes of hypertension (for example, Conn's adenoma, 424
phaeochromocytoma and renovascular hypertension). 425
People with accelerated hypertension (that is, severe acute hypertension 426
associated grade III retinopathy and encephalopathy). 427
People with acute hypertension or high blood pressure in emergency care 428
settings. 429
430
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How this guideline was developed
NICE commissioned the National Clinical Guideline Centre to update this
guideline. The Centre established a Guideline Development Group (see
appendix A), which reviewed the evidence and updated the
recommendations. An independent Guideline Review Panel oversaw the
updating of the guideline (see appendix B).
There is more information about how NICE clinical guidelines are developed
on the NICE website (www.nice.org.uk/HowWeWork). A booklet, ‘How NICE
clinical guidelines are developed: an overview for stakeholders, the public and
the NHS’ (fourth edition, published 2009), is available from NICE publications
(phone 0845 003 7783 or email [email protected] and quote reference
N1739).
431
3 Implementation 432
NICE has developed tools to help organisations implement this guidance (see 433
www.nice.org.uk/guidance/CG[XX]). 434
4 Research recommendations 435
The Guideline Development Group has made the following recommendations 436
for research, based on its review of evidence, to improve NICE guidance and 437
patient care in the future. 438
4.1 Out-of-office monitoring 439
In adults with primary hypertension, does the use of out-of-office monitoring 440
(HBPM or ABPM) improve response to treatment? 441
Why this is important 442
There is likely to be increasing use of home and ambulatory blood pressure 443
monitoring for the diagnosis of hypertension as a consequence of this 444
guideline update. There are, however, very little data regarding the utility of 445
HBPM or ABPM as means of monitoring blood pressure control or as 446
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indicators of clinical outcome in treated hypertension, compared with clinic 447
blood pressure monitoring. Studies should incorporate HBPM and/or ABPM to 448
monitor blood pressure responses to treatment and their usefulness as 449
indicators of clinical outcomes. 450
4.2 Intervention thresholds for people aged under 40 with 451
hypertension 452
In people aged under 40 with hypertension, what are the appropriate 453
thresholds for intervention? 454
Why this is important 455
There is genuine uncertainty about how to assess the impact of blood 456
pressure treatment in younger people (aged under 40) with stage 1 457
hypertension, and no overt target organ damage or CVD. In particular, 458
whether those with untreated hypertension are more likely to develop target 459
organ damage and, if so, whether such damage is reversible. Target organ 460
damage and CVD as surrogate or intermediate disease markers are the only 461
indicators that are likely to be feasible in younger people because traditional 462
clinical outcomes are unlikely to occur in sufficient numbers over the time 463
scale of a typical clinical trial. The data will be important to inform treatment 464
decisions for younger people with stage 1 hypertension who do not have overt 465
target organ damage. 466
4.3 Methods of assessing lifetime CV risk in people aged 467
under 40 with hypertension 468
In people aged under 40 with hypertension, what is the most accurate method 469
of assessing the lifetime risk of cardiovascular events and the impact of 470
therapeutic intervention on this risk? 471
Why this is important 472
Current short-term (over 10 years) risk estimates are likely to substantially 473
underestimate the lifetime cardiovascular risk of younger people (aged under 474
40) with hypertension, because short-term risk assessment is powerfully 475
influenced by age. Nevertheless, the lifetime risk associated with untreated 476
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stage 1 hypertension in this age group could be substantial. Lifetime risk 477
assessments may be a better way to inform treatment decisions and evaluate 478
the cost effectiveness of earlier intervention with pharmacological therapy. 479
4.4 Optimal systolic blood pressure 480
In people with treated hypertension, what is the optimal systolic blood 481
pressure? 482
Why this is important 483
Data on optimal blood pressure treatment targets, particularly for systolic 484
blood pressure, are inadequate. Current guidance is largely based on the 485
blood pressure targets adopted in clinical trials but there have been no large 486
trials that have randomised people with hypertension to different systolic blood 487
pressure targets and that have had sufficient power to examine clinical 488
outcomes. 489
4.5 Step 4 treatment 490
In adults with hypertension, which drug treatment (diuretic therapy versus 491
other step 4 treatments) is the most clinically and cost effective for step 4 492
treatment? 493
Why this is important 494
Although this guideline provides recommendations on the use of further 495
diuretic therapy for treatment at step 4 (resistant hypertension), they are 496
largely based on post-hoc observational data from clinical trials. More data are 497
needed to compare further diuretic therapies, for example a potassium-498
sparing diuretic with a higher-dose thiazide-like diuretic, and to compare 499
diuretic therapy with alternative treatment options at step 4 to define whether 500
further diuretic therapy is the best option. 501
4.6 Automated blood pressure monitoring in people with 502
atrial fibrillation 503
Which automated blood pressure monitors are suitable for people with 504
hypertension and atrial fibrillation? 505
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Why this is important 506
Atrial fibrillation may prevent accurate blood pressure measurement with 507
automated devices. It would be valuable to know if this can be overcome. 508
5 Other versions of this guideline 509
5.1 Full guideline 510
The full guideline, ‘Hypertension: the clinical management of primary 511
hypertension in adults’ contains details of the methods and evidence used to 512
develop the guideline. It is published by the National Clinical Guideline Centre, 513
and is available from our website 514
(www.nice.org.uk/guidance/CG[XX]/Guidance). Note: these details will 515
apply to the published full guideline. 516
5.2 Quick reference guide 517
A quick reference guide for healthcare professionals is available from 518
www.nice.org.uk/guidance/CG[XX]/QuickRefGuide 519
For printed copies, phone NICE publications on 0845 003 7783 or email 520
[email protected] (quote reference number N[XXXX]). Note: these 521
details will apply when the guideline is published. 522
5.3 ‘Understanding NICE guidance’ 523
A summary for patients and carers (‘Understanding NICE guidance’) is 524
available from www.nice.org.uk/guidance/CG[XX]/PublicInfo 525
For printed copies, phone NICE publications on 0845 003 7783 or email 526
[email protected] (quote reference number N[XXXX]). Note: these 527
details will apply when the guideline is published. 528
We encourage NHS and voluntary sector organisations to use text from this 529
booklet in their own information about primary hypertension.. 530
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6 Related NICE guidance 531
Chronic heart failure. NICE clinical guideline 108 (2010). Available from 532
www.nice.org.uk/guidance/CG108 533
Hypertension in pregnancy. NICE clinical guideline 107 (2010). Available 534
from www.nice.org.uk/guidance/CG107 535
Prevention of cardiovascular disease at population level. NICE public 536
health guidance 25 (2010). Available from www.nice.org.uk/guidance/PH25 537
Type 2 diabetes. NICE clinical guideline 87 (2009; updated March 2010 538
and September 2010). Available from www.nice.org.uk/guidance/CG87 539
Medicines adherence. NICE clinical guideline 76 (2009). Available from 540
www.nice.org.uk/guidance/CG76 541
Chronic kidney disease. NICE clinical guideline 73 (2008). Available from 542
www.nice.org.uk/guidance/CG73 543
Stroke. NICE clinical guideline 68 (2008). Available from 544
www.nice.org.uk/guidance/CG68 545
Lipid modification. NICE clinical guideline 67 (2008, reissued 2010). 546
Available from www.nice.org.uk/guidance/CG67 547
Continuous positive airway pressure for the treatment of obstructive sleep 548
apnoea/hypopnoea syndrome. NICE technology appraisal guidance 139 549
(2008). Available from www.nice.org.uk/guidance/TA139 550
MI: secondary prevention. NICE clinical guideline 48 (2007). Available from 551
www.nice.org.uk/guidance/CG48 552
Obesity. NICE clinical guideline 43. Available from 553
www.nice.org.uk/guidance/CG43 554
Atrial fibrillation. NICE clinical guideline 36 (2006). Available from 555
www.nice.org.uk/guidance/CG36 556
7 Updating the guideline 557
NICE clinical guidelines are updated so that recommendations take into 558
account important new information. New evidence is checked 3 years after 559
publication, and healthcare professionals and patients are asked for their 560
views; we use this information to decide whether all or part of a guideline 561
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needs updating. If important new evidence is published at other times, we 562
may decide to do a more rapid update of some recommendations. Please see 563
our website for information about updating the guideline. 564
565
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Appendix A: The Guideline Development Groups, 566
National Collaborating Centres and NICE project team 567
Guideline Development Group (2011 update) 568
Bryan Williams (Chair) 569
Professor of Medicine, University of Leicester and University Hospitals of 570
Leicester NHS Trust 571
Helen Williams 572
Consultant Pharmacist for Cardiovascular Disease, Southwark Health and 573
Social Care 574
Jane Northedge 575
Patient and carer member 576
John Crimmins 577
General Practitioner, Vale of Glamorgan 578
Mark Caulfield 579
Professor of Clinical Pharmacology, Barts and the London School of Medicine 580
Michaela Watts 581
Hypertension Nurse Specialist, Addenbrooke’s Hospital, Cambridge 582
Naomi Stetson 583
Primary Care Nurse, Watling Medical Centre, London 584
Richard McManus 585
Professor of Primary Care Cardiovascular Research, University of 586
Birmingham 587
Shelley Mason 588
Patient and carer member 589
Terry McCormack 590
General Practitioner, Spring Vale Medical Centre, North Yorkshire 591
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National Clinical Guideline Centre (2011 update) 592
Bernard Higgins 593
Clinical Director 594
Kate Lovibond 595
Senior Health Economist 596
Paul Miller 597
Senior Information Scientist 598
Rachel O’Mahony 599
Senior Research Fellow 600
Taryn Krause 601
Senior Project Manager/Research Fellow 602
NICE project team (2011 update) 603
Phil Alderson 604
Associate Director 605
Sarah Dunsdon 606
Guideline Commissioning Manager 607
Andrew Gyton 608
Guideline Coordinator 609
Ruaraidh Hill 610
Technical Lead 611
Prashanth Kandaswamy 612
Health Economist 613
Judy McBride 614
Editor 615
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Guideline Development Group (2006 update) 616
Dr Bernard Higgins (Chair) 617
Consultant Respiratory Physician, Freeman Hospital; Director, National 618
Collaborating Centre for Chronic Conditions 619
Professor Morris Brown 620
Professor of Medicine, Cambridge University and Addenbrooke’s Hospital; 621
President, British Hypertension Society 622
Dr Mark Davis 623
General Practitioner, West Yorkshire; Primary Care Cardiovascular Society 624
Professor Gary Ford 625
Consultant Stroke Physician, University of Newcastle and Freeman Hospital; 626
Royal College of Physicians 627
Mr Colin Penney 628
Patient and carer representative 629
Ms Jan Procter-King 630
Nurse Practitioner, West Yorkshire; Primary Care Cardiovascular Society 631
Mrs Jean Thurston 632
Patient and carer representative 633
Professor Bryan Williams 634
Clinical Adviser; Professor of Medicine, University of Leicester School of 635
Medicine and University Hospitals Leicester NHS Trust 636
National Collaborating Centre for Chronic Conditions 637
(2006 update) 638
Ms Lina Bakhshi 639
Information Scientist 640
Mr Rob Grant 641
Senior Project Manager; Medical Statistician, Royal College of Physicians 642
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Mr Mike Hughes 643
Health Services Research Fellow in Guideline Development 644
Dr Ian Lockhart 645
Health Services Research Fellow in Guideline Development 646
Mr Leo Nherera 647
Health Economist; Health Economics Fellow, Queen Mary, University of 648
London 649
Guideline Development Group (2004 guideline) 650
Ms Susan L Brent 651
Acting Head of Prescribing Support, Northern and Yorkshire Regional Drug 652
and Therapeutics Centre, Newcastle upon Tyne 653
Dr Paul Creighton 654
General Practitioner, Northumberland 655
Dr William Cunningham 656
General Practitioner, Northumberland 657
Dr Heather Dickinson 658
Technical Support, Newcastle upon Tyne 659
Dr Julie Eccles (Group Leader) 660
General Practitioner, Tyne and Wear 661
Professor Gary Ford 662
Professor of Pharmacology of Old Age and Consultant Physician, Newcastle 663
upon Tyne 664
Dr John Harley 665
General Practitioner, Stockton on Tees 666
Ms Suzanne Laing 667
Nurse Practitioner, Tyne and Wear 668
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Professor James Mason 669
Methodologist and Technical Support, Newcastle upon Tyne 670
Mr Colin Penney 671
Patient Representative 672
Dr Wendy Ross 673
General Practitioner, Newcastle upon Tyne 674
Mrs Jean Thurston 675
Patient Representative 676
Professor Bryan Williams 677
Professor of Medicine and Director, Cardiovascular Research Unit, Leicester 678
679
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Appendix B: The Guideline Review Panels 680
The Guideline Review Panel is an independent panel that oversees the 681
development of the guideline and takes responsibility for monitoring 682
adherence to NICE guideline development processes. In particular, the panel 683
ensures that stakeholder comments have been adequately considered and 684
responded to. The panel includes members from the following perspectives: 685
primary care, secondary care, lay, public health and industry. 686
Guideline Review Panel (2011 update) 687
NICE to add 688
Guideline Review Panel (2006 update) 689
Dr Peter Rutherford (Chair) 690
Senior Lecturer in Nephrology, University of Wales College of Medicine 691
Dr John Harley 692
General Practitioner, North Tees PCT 693
Dr Rob Higgins 694
Consultant in Renal and General Medicine, University Hospitals Coventry and 695
Warwickshire NHS Trust, Coventry 696
Dr Kevork Hopayian 697
General Practitioner, Suffolk 698
Dr Robert Walker 699
Clinical Director, West Cumbria Primary Care Trust 700
Guideline Review Panel (2004 guideline) 701
Professor Mike Drummond (Chair) 702
Director, Centre for Health Economics (CHE), University of York 703
Dr Kevork Hopayian 704
General Practitioner, Suffolk 705
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Mr Barry Stables 706
Patient/Lay representative 707
Dr Imogen Stephens 708
Joint Director of Public Health, Western Sussex Primary Care Trust 709
Dr Robert Walker 710
Clinical Director, West Cumbria Primary Care Trust 711
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Appendix C: The algorithms
Diagnosis of hypertension
Initial clinic blood pressure ≥140/90 mmHg
Arrange 24-hour ABPM (or HBPM)
Assess* for target organ damage** and established CV (cardiovascular) disease (CVD)†
If target organ damage present and no CVD and person is younger than 40, estimate 10-year CV risk‡.
Initial clinic blood pressure ≥180/110 mmHg
No target organ damage
No established CVD
10-year CV risk <20%
Initial clinic blood pressure <140/90 mmHg
Blood pressure usually >180/110mmHg
Signs or symptoms of papilloedema and/or retinal haemorrhage or suspected phaeochromotcytoma
Refer for specialist
care immediately
Evidence of target organ damage**
ABPM/HBPM <135/85 mmHg
ABPM/HBPM ≥135/85 mmHg
ABPM/HBPM ≥ 150/90 mmHg
Target organ damage present
10-year CV risk >20%
Person younger than 40
Consider treatment/specialist
referral
Offer antihypertensive drug treatment
Review blood pressure at least every 12 months
*Assessment
eGFR
Lipids
ECG
Test urine for protein and blood
Changes to retina
**Target organ damage
Chronic kidney disease
Left ventricular hypertrophy
ECG changes
Retinal changes such as papilloedema or haemorrhages
†Established CVD
Heart disease
Peripheral vascular disease
Cerebrovascular disease (stroke, TIA)
Diabetes
Chronic kidney disease
‡10-year CV risk estimation
See ‘Lipid modification’ (NICE clinical guideline 67)
Person 40 or older
Normotensive Stage 2+
hypertension
Stage 1
hypertension
Higher risk
Lower risk
Severe hypertension
Accelerated hypertension
Start antihypertensive drug
treatment immediately
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Antihypertensive drug treatment
Step 1
Step 2
Step 3
Step 4 (resistant
hypertension)
People aged
< 55 years
People aged ≥ 55 years and all black people of African or Caribbean descent
A C*
A + C + D
A + C*
A + C + D + further diuretic** or alpha-blocker or beta-blocker
Consider seeking specialist advice.
Key A = ACE inhibitor or angiotensin II receptor blocker C = calcium-channel blocker (CCB) D = thiazide-like diuretic C* = CCB preferred but consider thiazide-like diuretics in people with oedema or a high risk of heart failure Further diuretic** = consider low-dose spironolactone or higher doses of a thiazide-like diuretic
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Appendix D: Recommendations to be deleted
Recommendation Comment
Where possible, standarise the environment when measuring blood pressure: provide a relaxed, temperate setting, with the patient quiet and seated and with their arm outstretched and supported. (Recommendation 1.1.3 in 2006 guideline)
Replaced by:
When measuring blood pressure in the clinic or in the home, standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported.
If the first measurement exceeds 140/90mmHg, if practical, take a second confirmatory reading at the end of the consultation.(Recommendation 1.1.4 in 2006 guideline)
Replaced by:
If blood pressure measured in the clinic is higher than 140/90mmHg:
Take a second measurement during the consultation
If the second measurement is substantially different from the first, take a third measurement.
Measure blood pressure on both of the patient’s arms with the higher value identifying the reference arm for future measurement. (Recommendation 1.1.5 in 2006 guideline)
Replaced by:
Measure blood pressure in both arms:
If the difference in readings between arms is more than 20 mmHg, repeat the measurements.
If the difference in readings between arms remains more than 20 mmHg on the second measurement, measure subsequent blood pressure in the arm with the higher reading.
1.1.6 In patients with symptoms of postural hypotension (falls or postural dizziness) measure blood pressure while patient is standing. In patients with symptoms or documented psoturalhypotension (fall in systolic BP when standing of 20 mmHg or more) consider referral to a specialist. (Recommendation 1.1.6 in 2006 guideline)
Replaced by:
In people with symptoms of postural hypotension (falls or postural dizziness):
Measure blood pressure with the person either supine or seated.
Measure blood pressure again with the person standing.
To identify hypertension (persistent raised blood pressure, above 140/90 mmHg), ask the patient to return for at least two subsequent clinics where blood pressure is assessed from two readings under the best conditions available. (Recommendation 1.1.8 in 2006 guideline)
And
Measurements should normally be made at monthly intervals. However, patients
Replaced by
If the first and second blood pressure measurements taken during a consultation are both higher than 140/90 mmHg, offer 24-hour ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.
Use an ABPM device that is validated and is of an appropriate cuff size for the person’s arm.
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with more severe hypertension should be re-evaluated more urgently. (Recommendation 1.1.9 in 2006 guideline)
Refer immediately patients with accelerated (malignant) hypertension (BP more than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage) or suspected phaeochromocytoma (possible signs include labile or postural hypotension, headache, palpitations, pallor or diaphoresis). (Recommendation 1.1.7 in 2006 guideline)
Replaced by:
Immediately refer people with the following signs for specialist care:
Accelerated hypertension (blood pressure usually higher than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage)
Suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor and diaphoreses).
Routine use of automated ambulatory blood pressure monitoring or home monitoring devices in primary care is not currently recommended because their value has not been adequately established; appropriate use in primary care remains an issue for further research. (Recommendation 1.1.10 in 2006 guideline)
The evidence for automated ambulatory blood pressure monitoring (ABPM) was reviewed in the 2011 update.
Consider the need for specialist investigation of patients with unusual signs and symptoms, or of those whose management depends critically on the accurate estimation of their blood pressure. (Recommendation 1.1.11 in 2006 guideline)
We are now recommending ABPM routinely for diagnosis.
If raised blood pressure persists and the patient does not have established cardiovascular disease, discuss with them the need to formally assess their cardiovascular risk. Tests may help identify diabetes, evidence of hypertensive damage to the heart and kidneys, and secondary causes of hypertension such as kidney disease. (Recommendation 1.3.1 in 2006 guideline)
This has been clarified in new recommendations in the 2011 update.
Test for the presence of protein in the patient’s urine. Take a blood sample to assess plasma glucose, electrolytes, creatinine, serum total cholesterol and HDL cholesterol. Arrange for a 12-lead electrocardiograph to be performed. (Recommendation 1.3.2 in 2006 guideline)
Replaced by:
Test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio (ACR). Take a blood sample to measure plasma glucose, electrolytes, creatinine, eGFR, serum total cholesterol and HDL cholesterol. Arrange for a 12-lead electrocardiograph to be performed.
Drug therapy reduced the risk of cardiovascular disease and death. Offer
Replaced by:
Offer antihypertensive drug treatment
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drug therapy to:
Patients with persistent high blood pressure of 160/100 mmHg or more
Patients at raised cardiovascular disease or target organ damage) with persistent blood pressure of more than 140/90 mmHg. (recommendation 1.4.1)
to:people with stage 1 hypertension who have:
target organ damage or
established cardiovascular disease or
renal disease or
diabetes or
a 10-year cardiovascular risk equivalent to 20% or greater.
And
Offer antihypertensive drug treatment to people with stage 2 hypertension.
In hypertensive patients aged 55 or older or black patients of any age, the first choice for initial therapy should either be a calcium channel blocker or a thiazide-type diuretic. For this recommendation, black patients are considered to be those of African or Caribbean descent, not mixed-race, Asian or Chinese. (Recommendation 1.4.4 in 2006 guideline)
Replaced by:
Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged 55 years and older and to black people of African or Caribbean descent of any age. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure, or a high risk of heart failure, offer a thiazide-like diuretic.
In hypertensive patients younger than 55, the first choice for initial therapy should be an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensive-II receptor antagonist if an ACE inhibitor is not tolerated). (Recommedation1.4.5 in 2006 guideline)
Replaced by:
Offer step 1 antihypertensive treatment with an angiotensin-converting enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB) to people aged 55 years and younger. If an ACE inhibitor is not tolerated, offer an ARB.
If blood pressure remains uncontrolled on adequate doses of three drugs, consider adding a fourth and/or seeking expert advice. (Recommendation 1.4.8 in 2006 guideline)
Replaced by:
Regard clinic blood pressure that remains higher than 140/90 mmHg with the optimal or best tolerated doses of an ACE inhibitor or an angiotensin-II receptor blocker plus a calcium channel blocker plus a diuretic) as resistant hypertension and consider adding a fourth antihypertensive drug and/or seeking expert advice.
If a fourth drug is required, one of the following should be considered:
A higher dose of a thiazide-type diuretic or the addition of another diuretic (careful monitoring is recommended) or
Beta-blockers or
Replaced by:
For treatment of resistant hypertension at step 4, consider further diuretic therapy with low-dose spironolactone (25 mg once daily.) if blood potassium levels are lower than 4.5 mmol/l and eGFR is higher than 60. If blood potassium levels are higher than 4.5 mmol/l, consider
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Selective alpha-blockers. (recommendation 1.4.9 in 2006 guideline)
higher-dose thiazide-like diuretic treatment.
And
When using further diuretic therapy for resistant hypertension at step 4, monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter.
And
If further diuretic therapy for resistant hypertension at step 4 is not tolerated, contraindicated or ineffective, consider an alpha or beta-blocker.
Offer drug therapy, adding different drugs if necessary, to achieve a target of 140/90 mmHg, or until further treatment is inappropriate or declined. Titrate drug doses as described in the ‘British national formulary’ noting any cautions and contraindications. (Recommendation 1.4.3 in 2006 guideline)
Replaced by:
Aim for a target clinic blood pressure below 140/90 mmHg in people aged under 80 years with treated hypertension.
And
Aim for a target clinic blood pressure below 150/90 mmHg in people aged over 80 years with treated hypertension.
If initial therapy was with a calcium-channel blocker or a thiazide-type diuretic and a second drug is required, add an ACE inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated). If therapy was initiated with an ACE inhibitor (or angiotensin-II receptor antagonist), add a calcium-channel blocker or a thiazide-type diuretic. (Recommendation 1.4.6 in 2006 guideline)
Replaced by:
If step 2 antihypertensive treatment is required offer a calcium channel blocker in combination with either an ACE Inhibitor or a low-cost angiotensin-II receptor blocker. If a calcium channel blocker is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic
In patients whose blood pressure is not controlled (that is, above 140/90 mmHg) despite a treatment regimen that includes a beta-blockers, treatment should be revised according to the treatment algorithm on page 45 (recommendation 1.4.12 in 2006 guideline)
This algorithm has been superseded in the 2011 guidance.
In patients whose blood pressure is well controlled (that is, 140/90mmHg or below) with a regimen that includes a beta-blocker, long term management should be considered as part of their routine review. In these patients there is no absolute need to replace the beta-blocker with an alternative agent. (Recommendation 1.4.13 in 2006 guideline)
This recommendation was relevant in 2006, as many people were taking beta-blockers for hypertension.
Since the 2006 guideline, it has been well accepted that beta blockers should not be used as a first -line treatment for hypertension.
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Therefore there are far fewer people taking beta-blockers for hypertension.
When a beta-blockers is withdrawn, the dose should be stepped down gradually. Beta-blockers should not be withdrawn in patients who have compelling indications for beta-blockade, for example those who have symptomatic angina or who have had a myocardial infarction. (Recommendation 1.4.14 in 2006 guideline)
As above – the 2006 guideline recommended that beta-blockers should not be used as a first line treatment for hypertension.
Offer patients over 80 years of age the same treatment as other patients over 55, taking into account of any comorbidity and their existing burden of drug use. (Recommendation 1.4.16 in 2006 guideline)
Replaced by:
Offer people older than 80 years the same antihypertensive treatment as people aged 55-80 years, taking into account any comorbidities.
The aim of medication is to reduce blood pressure to 140/90 mmHg or below. However, patients not achieving this target, or for whom further treatment is inappropriate or declined, will still receive worthwhile benefit from the drug(s) if these lower blood pressure. (Recommendation 1.5.1 in 2006 guideline)
This recommendation doesn’t add any value – it is a redundant recommendation so therefore has been removed.
Patients may become motivated to make lifestyle changes and want to reduce or stop using antihypertensive drugs. If at low cardiovascular risk and with well controlled blood pressure, these patients should be offered a trial reduction or withdrawal of therapy with appropriate lifestyle guidance and ongoing review. (Recommendation 1.5.2 in 2006 guideline)
This has been superseded by NICE guidance on lifestyle.
712