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    53225 53225 Document Transcript

    • DRAFT FOR CONSULTATION Hypertension: clinical management of primary hypertension in adults NICE guideline Draft for consultation, February 2011If you wish to comment on this version of the guideline, please be aware thatall the supporting information and evidence is contained in the full version.Hypertension: NICE guideline DRAFT (February 2011) Page 1 of 39
    • DRAFT FOR CONSULTATIONContentsIntroduction ............................................................................................................... 4Person-centred care .................................................................................................. 5Key priorities for implementation ............................................................................... 61 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 .......................................... 182 Notes on the scope of the guidance................................................................. 193 Implementation ................................................................................................ 204 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 .................................................................................................... 225 Other versions of this guideline ........................................................................ 236 Related NICE guidance ................................................................................... 247 Updating the guideline ..................................................................................... 24Appendix A: The Guideline Development Groups, National Collaborating Centres andNICE project team ................................................................................................... 26Appendix B: The Guideline Review Panels ............................................................. 31Appendix C: The algorithms .................................................................................... 33Appendix D: Recommendations to be deleted ......................................................... 35Hypertension: NICE guideline DRAFT (February 2011) Page 2 of 39
    • DRAFT FOR CONSULTATIONThis guidance is a partial update of NICE clinical guideline 34 (published June2006) and will replace it. NICE clinical guideline 34 partially updated andreplaced NICE clinical guideline 18 (published August 2004).In this update new recommendations have been added on blood pressuremeasurement, 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] theevidence has not been updated. Yellow shading in these recommendationsindicates where wording changes have been made for the purposes ofclarification only.You are invited to comment on the new and updated recommendations in thisguideline only. These are marked as [2011] if the evidence has beenreviewed but no change has been made to the recommendation or[new 2011] if the evidence has been reviewed and the recommendation hasbeen added or updated.Appendix D contains recommendations from the 2006 guideline that NICEproposes deleting in the 2011 update. This is because the evidence has beenreviewed and the recommendation has been updated or because NICE hasupdated other relevant guidance and has replaced the originalrecommendations. Where there are replacement recommendations, detailsare provided. Where there is no replacement recommendation, an explanationfor the proposed deletion is given. You are invited to comment on the deletedrecommendations as part of the consultation on the 2011 update.The original NICE guideline and supporting documents are available fromwww.nice.org.uk/guidance/CG34Hypertension: NICE guideline DRAFT (February 2011) Page 3 of 39
    • DRAFT FOR CONSULTATION 1 Introduction 2 High blood pressure (hypertension) is one of the most important preventable 3 causes of premature morbidity and mortality in the UK. Hypertension is a 4 major risk factor for stroke (ischaemic and haemorrhagic), myocardial 5 infarction, heart failure, chronic kidney disease, cognitive decline and 6 premature death. Untreated hypertension is usually associated with a 7 progressive rise in blood pressure. The vascular and renal damage that this 8 may cause can culminate in a treatment-resistant state. 9 Blood pressure is normally distributed in the population and there is no natural10 cut-off point above which hypertension definitively exists and below which it11 does not. The risk associated with increasing blood pressure is continuous,12 with each 2 mmHg rise in systolic blood pressure associated with a 7%13 increased risk of mortality from ischaemic heart disease and a 10% increased14 risk of mortality from stroke. Hypertension is remarkably common in the UK15 and the prevalence is strongly influenced by age. In any individual person,16 systolic and/or diastolic blood pressures may be elevated. Diastolic pressure17 is more commonly elevated in younger people, that is, those younger than18 50 years. With ageing, systolic hypertension becomes a more significant19 problem, as a result of progressive stiffening and loss of compliance of larger20 arteries. At least one quarter of adults (and more than half of those older than21 60) have high blood pressure.22 The clinical management of hypertension is one of the most common23 interventions in primary care, accounting for approximately £1 billion in drug24 costs alone in 2006.25 The guideline will assume that prescribers will use a drug’s summary of26 product characteristics to inform decisions made with individual patients. Hypertension: NICE guideline DRAFT (February 2011) Page 4 of 39
    • DRAFT FOR CONSULTATION27 Person-centred care28 This guideline offers best practice advice on the care of adults with29 hypertension.30 Treatment and care should take into account people’s needs and preferences.31 People with hypertension should have the opportunity to make informed32 decisions about their care and treatment, in partnership with their healthcare33 professionals. If people do not have the capacity to make decisions,34 healthcare professionals should follow the Department of Health’s advice on35 consent (available from www.dh.gov.uk/consent) and the code of practice that36 accompanies the Mental Capacity Act (summary available from37 www.publicguardian.gov.uk). In Wales, healthcare professionals should follow38 advice on consent from the Welsh Assembly Government (available from39 www.wales.nhs.uk/consent).40 Good communication between healthcare professionals and people with41 hypertension is essential. It should be supported by evidence-based written42 information tailored to the person’s needs. Treatment and care, and the43 information people are given about it, should be culturally appropriate. It44 should also be accessible to people with additional needs such as physical,45 sensory or learning disabilities, and to people who do not speak or read46 English.47 If the person agrees, families and carers should have the opportunity to be48 involved in decisions about treatment and care.49 Families and carers should also be given the information and support50 they need.51 Hypertension: NICE guideline DRAFT (February 2011) Page 5 of 39
    • DRAFT FOR CONSULTATION52 Key priorities for implementation53 The following recommendations have been identified as priorities for54 implementation.55 Diagnosing hypertension56 If the first and second blood pressure measurements taken during a57 consultation are 140/90 mmHg or higher, offer 24-hour ambulatory blood58 pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new59 2011] [1.2.2]60 When using ABPM to confirm a diagnosis of hypertension, ensure that:61 Blood pressure is measured for a total of 24 hours.62 At least two measurements per hour are taken during the day (08:00 to63 22:00).64 At least one measurement per hour is taken during the night (22:00 to65 08:00).66 Use the average daytime blood pressure measurement, calculated using a67 minimum of 14 daytime measurements, to confirm a diagnosis of68 hypertension. [new 2011] [1.2.6]69 When using home blood pressure monitoring (HBPM) to confirm a70 diagnosis of hypertension, ensure that:71 For each blood pressure measurement, two consecutive measurements72 are taken, at least 1 minute apart and with the person seated (see 1.1.4).73 Blood pressure measurements are taken twice daily, ideally in the74 morning and evening.75 Blood pressure measurement continues for at least 4 days, ideally for76 7 days.77 Discard the measurements taken on the first day and use the average78 value of all the remaining measurements to confirm a diagnosis of79 hypertension. [new 2011] [1.2.7]80 Hypertension: NICE guideline DRAFT (February 2011) Page 6 of 39
    • DRAFT FOR CONSULTATION 81 Initiating and monitoring antihypertensive drug treatment, including 82 blood pressure targets 83 Initiating treatment 84 Offer antihypertensive drug treatment to people with stage 1 hypertension 85 who have: 86 target organ damage or 87 established cardiovascular disease or 88 renal disease or 89 diabetes or 90 a 10-year cardiovascular risk equivalent to 20% or greater. [new 2011] 91 92 Offer antihypertensive drug treatment to people with stage 2 hypertension. 93 [new 2011] [1.5.2] 94 For people younger than 40 years with stage 1 hypertension and no 95 evidence of target organ damage, cardiovascular (CV) disease, renal 96 disease or diabetes, consider seeking specialist evaluation of secondary 97 causes of hypertension and a more detailed assessment of potential target 98 organ damage. This is because 10-year CV risk assessments can 99 underestimate the lifetime risk of CV events in these people [new 2011]100 [1.5.3]101 Monitoring treatment and blood pressure targets102 For people with a discrepancy of more than 20/10 mmHg between clinic103 blood pressure measurements and ABPM or HBPM average104 measurements, consider using daytime average ABPM or average HBPM105 for monitoring the response to antihypertensive treatment. Aim for a target106 ABPM or HBPM blood pressure of 135/85 mmHg or lower. [new 2011]107 [1.5.6] Hypertension: NICE guideline DRAFT (February 2011) Page 7 of 39
    • DRAFT FOR CONSULTATION108 Choosing antihypertensive drug treatment109 Offer people older than 80 years the same antihypertensive drug treatment110 as people aged 55–80 years, taking into account any comorbidities. [new111 2011] [1.6.4]112 Step 1 treatment113 Offer step 1 antihypertensive treatment with a calcium-channel blocker114 (CCB) to people aged 55 years and older and to black people of African115 and Caribbean descent of any age. If a CCB is not suitable, for example116 because of oedema or intolerance, or if there is evidence of heart failure or117 a high risk of heart failure, offer a thiazide-like diuretic. [new 2011] [1.6.8]118 If a diuretic is required, choose a thiazide-like diuretic, such as119 chlortalidone (12.5 mg–25.0 mg once daily) or indapamide (2.5 mg once120 daily) in preference to a conventional thiazide diuretic such as121 bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.9]122 Step 4 treatment123 For treatment of resistant hypertension at step 4, consider further diuretic124 therapy with low-dose spironolactone (25 mg once daily) if blood potassium125 levels are lower than 4.5 mmol/l and estimated glomerular filtration rate is126 higher than 60 ml/min/1.73m2. If blood potassium levels are higher than127 4.5 mmol/l, consider therapy with a higher-dose thiazide-like diuretic. [new128 2011] [1.6.14]129130 Hypertension: NICE guideline DRAFT (February 2011) Page 8 of 39
    • DRAFT FOR CONSULTATION131 1 Guidance132 The following guidance is based on the best available evidence. The full133 guideline (www.nice.org.uk/guidance/CGXXX) gives details of the methods134 and the evidence used to develop the guidance.135 Definitions136 In this guideline the following definitions are used.137 Stage 1 hypertension: initial clinic blood pressure 140/90 mmHg or higher138 and subsequent ambulatory blood pressure monitoring (ABPM) daytime139 average or home blood pressure monitoring (HBPM) average blood140 pressure 135/85 mmHg or higher.141 Stage 2 hypertension: initial clinic blood pressure 160/100 mmHg or142 higher and subsequent ABPM daytime average or HBPM average blood143 pressure 150/95 mmHg or higher.144 Severe hypertension: clinic blood pressure 180/110 mmHg or higher.145 1.1 Measuring blood pressure146 1.1.1 Healthcare professionals taking blood pressure measurements147 need adequate initial training and periodic review of their148 performance. [2004]149 1.1.2 Because automated devices may not measure blood pressure150 accurately if there is pulse irregularity (for example, due to atrial151 fibrillation), palpate the radial or brachial pulse before measuring152 blood pressure. If pulse irregularity is present, measure blood153 pressure manually using direct auscultation over the brachial154 artery. [new 2011]155 1.1.3 Healthcare providers must ensure that devices for measuring blood156 pressure are properly validated, maintained and regularly157 recalibrated according to manufacturers’ instructions. [2004] Hypertension: NICE guideline DRAFT (February 2011) Page 9 of 39
    • DRAFT FOR CONSULTATION158 1.1.4 When measuring blood pressure in the clinic or in the home,159 standardise the environment and provide a relaxed, temperate160 setting, with the person quiet and seated, and their arm161 outstretched and supported. [new 2011]162 1.1.5 Use an ABPM device that is validated and is of an appropriate cuff163 size for the person’s arm. [new 2011]164 1.1.6 Measure blood pressure in both arms:165 If the difference in readings between arms is more than166 20 mmHg, repeat the measurements.167 If the difference in readings between arms remains more than168 20 mmHg on the second measurement, measure subsequent169 blood pressure in the arm with the higher reading. [new 2011]170 1.1.7 In people with symptoms of postural hypotension (falls or postural171 dizziness):172 Measure blood pressure with the person either supine or seated.173 Measure blood pressure again with the person standing. [2004,174 amended 2011]175 1.1.8 If the systolic blood pressure falls by 20 mmHg or more when the176 person is standing:177 Review medication.178 Measure subsequent blood pressures with the person standing.179 Consider referral to specialist care if symptoms of postural180 hypotension persist. [2004, amended 2011]181 1.2 Diagnosing hypertension182 1.2.1 If blood pressure measured in the clinic is 140/90 mmHg or higher:183 Take a second measurement during the consultation. Hypertension: NICE guideline DRAFT (February 2011) Page 10 of 39
    • DRAFT FOR CONSULTATION184 If the second measurement is substantially different from the185 first, take a third measurement.186 Use the lower of the last two measurements to diagnose187 hypertension. [new 2011]188 1.2.2 If the first and second blood pressure measurements taken during189 a consultation are both 140/90 mmHg or higher, offer 24-hour190 ambulatory blood pressure monitoring (ABPM) to confirm the191 diagnosis of hypertension. [new 2011]192 1.2.3 If a person is unable to tolerate ABPM, home blood pressure193 monitoring (HBPM) is a suitable alternative to confirm the diagnosis194 of hypertension. [new 2011]195 1.2.4 If the person has severe hypertension and evidence of target organ196 damage, start antihypertensive drug treatment immediately; do not197 wait for the results of ABPM or HBPM. [new 2011].198 1.2.5 When considering a diagnosis of hypertension, carry out199 appropriate investigations for target organ damage and a formal200 assessment of cardiovascular (CV) risk using a CV risk201 assessment tool, in line with ‘Lipid modification’ (NICE clinical202 guideline 67). [new 2011]203 1.2.6 When using ABPM to confirm a diagnosis of hypertension,204 ensure that:205 blood pressure is measured for a total of 24 hours206 at least two measurements per hour are taken during the day207 (08:00 to 22:00)208 at least one measurement per hour is taken during the night209 (22:00 to 08:00).210 Use the average daytime blood pressure measurement, calculated211 using a minimum of 14 daytime measurements, to confirm a212 diagnosis of hypertension. [new 2011] Hypertension: NICE guideline DRAFT (February 2011) Page 11 of 39
    • DRAFT FOR CONSULTATION213 1.2.7 When using home blood pressure monitoring (HBPM) to confirm a214 diagnosis of hypertension,215 ensure that:216 For each blood pressure measurement, two consecutive217 measurements are taken, at least 1 minute apart and with the218 person seated (see 1.1.4).219 Blood pressure measurements are taken twice daily, ideally in220 the morning and evening.221 Blood pressure measurement continues for at least 4 days,222 ideally for 7 days.223 Discard the measurements taken on the first day and use the224 average value of all the remaining measurements to confirm a225 diagnosis of hypertension. [new 2011]226 1.2.8 Immediately refer people with the following signs for specialist care:227 accelerated hypertension (blood pressure usually higher than228 180/110 mmHg with signs of papilloedema and/or retinal229 haemorrhage)230 suspected phaeochromocytoma (labile or postural hypotension,231 headache, palpitations, pallor and diaphoresis). [2004,232 amended 2011]233 1.2.9 Consider the need for specialist investigations in people with signs234 and symptoms suggesting a secondary cause of hypertension.235 [2004, amended 2011] Hypertension: NICE guideline DRAFT (February 2011) Page 12 of 39
    • DRAFT FOR CONSULTATION236 1.3 Assessing cardiovascular risk237 1.3.1 Use a formal estimation of cardiovascular risk to discuss prognosis238 and healthcare options with people with hypertension, both for239 raised blood pressure and other modifiable risk factors. [2004]240 1.3.2 Estimate cardiovascular risk in line with recommendations 1.1.7,241 1.1.8, 1.1.10, 1.1.11, 1.1.13, 1.1.21 and 1.1.22 in ‘Lipid242 modification’ (NICE clinical guideline 67). [new 2011]243 1.3.3 For all people with hypertension:244 Test for the presence of protein in the urine by sending a urine245 sample for estimation of the albumin:creatinine ratio.246 Take a blood sample to measure plasma glucose, electrolytes,247 creatinine, estimated glomerular filtration rate, serum total248 cholesterol and HDL cholesterol.249 Arrange for a 12-lead electrocardiograph to be performed.250 [2004, amended 2011]251 1.4 Lifestyle interventions252 1.4.1 Ascertain people’s diet and exercise patterns because a healthy253 diet and regular exercise can reduce blood pressure. Offer254 appropriate guidance and written or audiovisual materials to255 promote lifestyle changes. [2004]256 1.4.2 Relaxation therapies can reduce blood pressure and people may257 wish to pursue these as part of their treatment. However, routine258 provision by primary care teams is not currently recommended.259 [2004]260 1.4.3 Ascertain people’s alcohol consumption and encourage a reduced261 intake if they drink excessively, because this can reduce blood262 pressure and has broader health benefits. [2004] Hypertension: NICE guideline DRAFT (February 2011) Page 13 of 39
    • DRAFT FOR CONSULTATION263 1.4.4 Discourage excessive consumption of coffee and other caffeine-264 rich products. [2004]265 1.4.5 Encourage people to keep their dietary sodium intake low, either by266 reducing or substituting sodium salt, as this can reduce blood267 pressure. [2004]268 1.4.6 Do not offer calcium, magnesium or potassium supplements as a269 method for reducing blood pressure. [2004]270 1.4.7 Offer advice and help to smokers to stop smoking. [2004]271 1.4.8 A common aspect of studies for motivating lifestyle change is the272 use of group working. Inform people about local initiatives by, for273 example, healthcare teams or patient organisations that provide274 support and promote healthy lifestyle change. [2004]275 1.5 Initiating and monitoring antihypertensive drug276 treatment, including blood pressure targets277 Initiating treatment278 1.5.1 Offer antihypertensive drug treatment to people with stage 1279 hypertension who have:280 target organ damage or281 established cardiovascular disease or282 renal disease or283 diabetes or284 a 10-year cardiovascular risk equivalent to 20% or greater.285 [new 2011]286 1.5.2 Offer antihypertensive drug treatment to people with stage 2287 hypertension. [new 2011]288 1.5.3 For people younger than 40 years with stage 1 hypertension and289 no evidence of target organ damage, cardiovascular disease, renal290 disease or diabetes, consider seeking specialist evaluation of Hypertension: NICE guideline DRAFT (February 2011) Page 14 of 39
    • DRAFT FOR CONSULTATION291 secondary causes of hypertension and a more detailed assessment292 of potential target organ damage. This is because 10-year293 cardiovascular risk assessments can underestimate the lifetime risk294 of cardiovascular events in these people. [new 2011]295 Monitoring treatment and blood pressure targets296 1.5.4 Use clinic blood pressure measurement to monitor the response to297 antihypertensive treatment. [new 2011]298 1.5.5 For people identified as having a ‘white-coat effect’, that is, a299 consistent alerting response or clinic hypertension, consider HBPM300 as an adjunct to clinic blood pressure measurement for monitoring301 the response to antihypertensive treatment with lifestyle302 modification or drugs. [new 2011]303 1.5.6 For people with a discrepancy of more than 20/10 mmHg between304 clinic blood pressure measurements and ABPM or HBPM average305 measurements, consider using daytime average ABPM or average306 HBPM for monitoring the response to antihypertensive treatment.307 Aim for a target daytime average ABPM or average HBPM blood308 pressure below 135/85 mmHg. [new 2011]309 1.5.7 Aim for a target clinic blood pressure below 140/90 mmHg in310 people aged under 80 years with treated hypertension. [new 2011]311 1.5.8 Aim for a target clinic blood pressure below 150/90 mmHg in312 people aged over 80 years with treated hypertension. [new 2011]313 1.6 Choosing antihypertensive drug treatment314 1.6.1 Where possible, recommend treatment with drugs taken only once315 a day. [2004]316 1.6.2 Prescribe non-proprietary drugs where these are appropriate and317 minimise cost. [2004] Hypertension: NICE guideline DRAFT (February 2011) Page 15 of 39
    • DRAFT FOR CONSULTATION318 1.6.3 Offer people with isolated systolic hypertension (systolic319 BP 160 mmHg or more) the same treatment as people with both320 raised systolic and diastolic blood pressure. [2004]321 1.6.4 Offer people older than 80 years the same antihypertensive drug322 treatment as people aged 55–80 years, taking into account any323 comorbidities. [new 2011]324 1.6.5 Offer antihypertensive drug treatment to women in line with325 recommendations 1.2.1.1, 1.2.1.2, 1.9.1.1 and 1.9.1.2 in326 ‘Hypertension in pregnancy’ (NICE clinical guideline 107). [new327 2011]328 Step 1 treatment329 1.6.6 Offer step 1 antihypertensive treatment with an angiotensin-330 converting enzyme (ACE) inhibitor or a low-cost angiotensin-II331 receptor blocker (ARB) to people aged under 55 years. If an ACE332 inhibitor is not tolerated, offer an ARB. [new 2011]333 1.6.7 Do not combine an ACE inhibitor with an ARB to treat334 hypertension. [new 2011]335 1.6.8 Offer step 1 antihypertensive treatment with a calcium-channel336 blocker (CCB) to people aged 55 years and older and to black337 people of African or Caribbean descent of any age. If a CCB is not338 suitable, for example because of oedema or intolerance, or if there339 is evidence of heart failure or a high risk of heart failure, offer a340 thiazide-like diuretic. [new 2011]341 1.6.9 If a diuretic is required, choose a thiazide-like diuretic, such as342 chlortalidone (12.5 mg–25.0 mg once daily) or indapamide (2.5 mg343 once daily) in preference to a conventional thiazide diuretic such as344 bendroflumethiazide or hydrochlorothiazide. [new 2011] Hypertension: NICE guideline DRAFT (February 2011) Page 16 of 39
    • DRAFT FOR CONSULTATION345 1.6.10 Beta-blockers are not a preferred initial therapy for hypertension.346 However, beta-blockers may be considered in younger people,347 particularly:348 those with an intolerance or contraindication to ACE inhibitors349 and angiotensin-II receptor antagonists or350 women of child-bearing potential or351 people with evidence of increased sympathetic drive.352 In these circumstances, if therapy is initiated with a beta-blocker353 and a second drug is required, add a calcium-channel blocker354 rather than a thiazide-type diuretic to reduce the person’s risk of355 developing diabetes. [2006]356 Step 2 treatment357 1.6.11 If step 2 antihypertensive treatment is required, offer a CCB in358 combination with either an ACE Inhibitor or a low-cost ARB. If a359 CCB is not suitable, for example because of oedema or360 intolerance, or if there is evidence of heart failure or a high risk of361 heart failure, offer a thiazide-like diuretic [new 2011]362 Step 3 treatment363 1.6.12 If treatment with three drugs is required, the combination of ACE364 inhibitor (or angiotensin-II receptor blocker), calcium-channel365 blocker and thiazide-like diuretic should be used. [2006]366 Step 4 treatment367 1.6.13 Regard clinic blood pressure that remains higher than368 140/90 mmHg with the optimal or best tolerated doses of an ACE369 inhibitor or an ARB plus a CCB plus a diuretic as resistant370 hypertension and consider adding a fourth antihypertensive drug371 and/or seeking expert advice. [new 2011]372 1.6.14 For treatment of resistant hypertension at step 4, consider further373 diuretic therapy with low-dose spironolactone (25 mg once daily) if374 blood potassium levels are lower than 4.5 mmol/l and estimated Hypertension: NICE guideline DRAFT (February 2011) Page 17 of 39
    • DRAFT FOR CONSULTATION375 glomerular filtration rate is higher than 60 ml/min/1.73m2. If blood376 potassium levels are higher than 4.5 mmol/l, consider higher-dose377 thiazide-like diuretic treatment. [new 2011]378 1.6.15 When using further diuretic therapy for resistant hypertension at379 step 4, monitor blood sodium and potassium and renal function380 within 1 month and repeat as required thereafter. [new 2011]381 1.6.16 If further diuretic therapy for resistant hypertension at step 4 is not382 tolerated, contraindicated or ineffective, consider an alpha- or beta-383 blocker. [new 2011]384 1.6.17 If blood pressure remains uncontrolled with the optimal or385 maximum tolerated doses of four drugs seek expert advice if it has386 not yet been obtained. [2011]387 1.7 Patient education and adherence to treatment388 1.7.1 Provide appropriate guidance and materials about the benefits of389 drugs and the unwanted side effects sometimes experienced in390 order to help people make informed choices. [2004]391 1.7.2 People vary in their attitudes to their hypertension and their392 experience of treatment. It may be helpful to provide details of393 patient organisations that provide useful forums to share views and394 information. [2004]395 1.7.3 Provide an annual review of care to monitor blood pressure,396 provide people with support and discuss their lifestyle, symptoms397 and medication. [2004]398 1.7.4 Because evidence supporting interventions to increase adherence399 is inconclusive, only use interventions to overcome practical400 problems associated with non-adherence if a specific need is401 identified. Target the intervention to the need. Interventions might402 include:403 suggesting that patients record their medicine-taking Hypertension: NICE guideline DRAFT (February 2011) Page 18 of 39
    • DRAFT FOR CONSULTATION404 encouraging patients to monitor their condition405 simplifying the dosing regimen406 using alternative packaging for the medicine407 using a multi-compartment medicines system. (This408 recommendation is taken from ‘Medicines adherence’, NICE409 clinical guideline 76). [new 2011]410 2 Notes on the scope of the guidance411 NICE guidelines are developed in accordance with a scope that defines what412 the guideline will and will not cover. The scope of this guideline is available413 from www.nice.org.uk/[NICE to add details].414 Groups that will be covered415 Adults with hypertension (18 years and older). Particular consideration will416 be given to the needs of black people of African and Caribbean descent417 and minority ethnic groups where these differ from the needs of the general418 population.419 People aged 80 years or older.420 Groups that will not be covered421 People with diabetes.422 Children and young people (younger than 18 years).423 Pregnant women.424 Secondary causes of hypertension (for example, Conns adenoma,425 phaeochromocytoma and renovascular hypertension).426 People with accelerated hypertension (that is, severe acute hypertension427 associated grade III retinopathy and encephalopathy).428 People with acute hypertension or high blood pressure in emergency care429 settings.430 Hypertension: NICE guideline DRAFT (February 2011) Page 19 of 39
    • DRAFT FOR CONSULTATION 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 publications@nice.org.uk and quote reference N1739).431432 3 Implementation433 NICE has developed tools to help organisations implement this guidance (see434 www.nice.org.uk/guidance/CG[XX]).435 4 Research recommendations436 The Guideline Development Group has made the following recommendations437 for research, based on its review of evidence, to improve NICE guidance and438 patient care in the future.439 4.1 Out-of-office monitoring440 In adults with primary hypertension, does the use of out-of-office monitoring441 (HBPM or ABPM) improve response to treatment?442 Why this is important443 There is likely to be increasing use of home and ambulatory blood pressure444 monitoring for the diagnosis of hypertension as a consequence of this445 guideline update. There are, however, very little data regarding the utility of446 HBPM or ABPM as means of monitoring blood pressure control or as Hypertension: NICE guideline DRAFT (February 2011) Page 20 of 39
    • DRAFT FOR CONSULTATION447 indicators of clinical outcome in treated hypertension, compared with clinic448 blood pressure monitoring. Studies should incorporate HBPM and/or ABPM to449 monitor blood pressure responses to treatment and their usefulness as450 indicators of clinical outcomes.451 4.2 Intervention thresholds for people aged under 40 with452 hypertension453 In people aged under 40 with hypertension, what are the appropriate454 thresholds for intervention?455 Why this is important456 There is genuine uncertainty about how to assess the impact of blood457 pressure treatment in younger people (aged under 40) with stage 1458 hypertension, and no overt target organ damage or CVD. In particular,459 whether those with untreated hypertension are more likely to develop target460 organ damage and, if so, whether such damage is reversible. Target organ461 damage and CVD as surrogate or intermediate disease markers are the only462 indicators that are likely to be feasible in younger people because traditional463 clinical outcomes are unlikely to occur in sufficient numbers over the time464 scale of a typical clinical trial. The data will be important to inform treatment465 decisions for younger people with stage 1 hypertension who do not have overt466 target organ damage.467 4.3 Methods of assessing lifetime CV risk in people aged468 under 40 with hypertension469 In people aged under 40 with hypertension, what is the most accurate method470 of assessing the lifetime risk of cardiovascular events and the impact of471 therapeutic intervention on this risk?472 Why this is important473 Current short-term (over 10 years) risk estimates are likely to substantially474 underestimate the lifetime cardiovascular risk of younger people (aged under475 40) with hypertension, because short-term risk assessment is powerfully476 influenced by age. Nevertheless, the lifetime risk associated with untreated Hypertension: NICE guideline DRAFT (February 2011) Page 21 of 39
    • DRAFT FOR CONSULTATION477 stage 1 hypertension in this age group could be substantial. Lifetime risk478 assessments may be a better way to inform treatment decisions and evaluate479 the cost effectiveness of earlier intervention with pharmacological therapy.480 4.4 Optimal systolic blood pressure481 In people with treated hypertension, what is the optimal systolic blood482 pressure?483 Why this is important484 Data on optimal blood pressure treatment targets, particularly for systolic485 blood pressure, are inadequate. Current guidance is largely based on the486 blood pressure targets adopted in clinical trials but there have been no large487 trials that have randomised people with hypertension to different systolic blood488 pressure targets and that have had sufficient power to examine clinical489 outcomes.490 4.5 Step 4 treatment491 In adults with hypertension, which drug treatment (diuretic therapy versus492 other step 4 treatments) is the most clinically and cost effective for step 4493 treatment?494 Why this is important495 Although this guideline provides recommendations on the use of further496 diuretic therapy for treatment at step 4 (resistant hypertension), they are497 largely based on post-hoc observational data from clinical trials. More data are498 needed to compare further diuretic therapies, for example a potassium-499 sparing diuretic with a higher-dose thiazide-like diuretic, and to compare500 diuretic therapy with alternative treatment options at step 4 to define whether501 further diuretic therapy is the best option.502 4.6 Automated blood pressure monitoring in people with503 atrial fibrillation504 Which automated blood pressure monitors are suitable for people with505 hypertension and atrial fibrillation? Hypertension: NICE guideline DRAFT (February 2011) Page 22 of 39
    • DRAFT FOR CONSULTATION506 Why this is important507 Atrial fibrillation may prevent accurate blood pressure measurement with508 automated devices. It would be valuable to know if this can be overcome.509 5 Other versions of this guideline510 5.1 Full guideline511 The full guideline, ‘Hypertension: the clinical management of primary512 hypertension in adults’ contains details of the methods and evidence used to513 develop the guideline. It is published by the National Clinical Guideline Centre,514 and is available from our website515 (www.nice.org.uk/guidance/CG[XX]/Guidance). Note: these details will516 apply to the published full guideline.517 5.2 Quick reference guide518 A quick reference guide for healthcare professionals is available from519 www.nice.org.uk/guidance/CG[XX]/QuickRefGuide520 For printed copies, phone NICE publications on 0845 003 7783 or email521 publications@nice.org.uk (quote reference number N[XXXX]). Note: these522 details will apply when the guideline is published.523 5.3 ‘Understanding NICE guidance’524 A summary for patients and carers (‘Understanding NICE guidance’) is525 available from www.nice.org.uk/guidance/CG[XX]/PublicInfo526 For printed copies, phone NICE publications on 0845 003 7783 or email527 publications@nice.org.uk (quote reference number N[XXXX]). Note: these528 details will apply when the guideline is published.529 We encourage NHS and voluntary sector organisations to use text from this530 booklet in their own information about primary hypertension.. Hypertension: NICE guideline DRAFT (February 2011) Page 23 of 39
    • DRAFT FOR CONSULTATION531 6 Related NICE guidance532 Chronic heart failure. NICE clinical guideline 108 (2010). Available from533 www.nice.org.uk/guidance/CG108534 Hypertension in pregnancy. NICE clinical guideline 107 (2010). Available535 from www.nice.org.uk/guidance/CG107536 Prevention of cardiovascular disease at population level. NICE public537 health guidance 25 (2010). Available from www.nice.org.uk/guidance/PH25538 Type 2 diabetes. NICE clinical guideline 87 (2009; updated March 2010539 and September 2010). Available from www.nice.org.uk/guidance/CG87540 Medicines adherence. NICE clinical guideline 76 (2009). Available from541 www.nice.org.uk/guidance/CG76542 Chronic kidney disease. NICE clinical guideline 73 (2008). Available from543 www.nice.org.uk/guidance/CG73544 Stroke. NICE clinical guideline 68 (2008). Available from545 www.nice.org.uk/guidance/CG68546 Lipid modification. NICE clinical guideline 67 (2008, reissued 2010).547 Available from www.nice.org.uk/guidance/CG67548 Continuous positive airway pressure for the treatment of obstructive sleep549 apnoea/hypopnoea syndrome. NICE technology appraisal guidance 139550 (2008). Available from www.nice.org.uk/guidance/TA139551 MI: secondary prevention. NICE clinical guideline 48 (2007). Available from552 www.nice.org.uk/guidance/CG48553 Obesity. NICE clinical guideline 43. Available from554 www.nice.org.uk/guidance/CG43555 Atrial fibrillation. NICE clinical guideline 36 (2006). Available from556 www.nice.org.uk/guidance/CG36557 7 Updating the guideline558 NICE clinical guidelines are updated so that recommendations take into559 account important new information. New evidence is checked 3 years after560 publication, and healthcare professionals and patients are asked for their561 views; we use this information to decide whether all or part of a guideline Hypertension: NICE guideline DRAFT (February 2011) Page 24 of 39
    • DRAFT FOR CONSULTATION562 needs updating. If important new evidence is published at other times, we563 may decide to do a more rapid update of some recommendations. Please see564 our website for information about updating the guideline.565 Hypertension: NICE guideline DRAFT (February 2011) Page 25 of 39
    • DRAFT FOR CONSULTATION566 Appendix A: The Guideline Development Groups,567 National Collaborating Centres and NICE project team568 Guideline Development Group (2011 update)569 Bryan Williams (Chair)570 Professor of Medicine, University of Leicester and University Hospitals of571 Leicester NHS Trust572 Helen Williams573 Consultant Pharmacist for Cardiovascular Disease, Southwark Health and574 Social Care575 Jane Northedge576 Patient and carer member577 John Crimmins578 General Practitioner, Vale of Glamorgan579 Mark Caulfield580 Professor of Clinical Pharmacology, Barts and the London School of Medicine581 Michaela Watts582 Hypertension Nurse Specialist, Addenbrooke’s Hospital, Cambridge583 Naomi Stetson584 Primary Care Nurse, Watling Medical Centre, London585 Richard McManus586 Professor of Primary Care Cardiovascular Research, University of587 Birmingham588 Shelley Mason589 Patient and carer member590 Terry McCormack591 General Practitioner, Spring Vale Medical Centre, North Yorkshire Hypertension: NICE guideline DRAFT (February 2011) Page 26 of 39
    • DRAFT FOR CONSULTATION592 National Clinical Guideline Centre (2011 update)593 Bernard Higgins594 Clinical Director595 Kate Lovibond596 Senior Health Economist597 Paul Miller598 Senior Information Scientist599 Rachel O’Mahony600 Senior Research Fellow601 Taryn Krause602 Senior Project Manager/Research Fellow603 NICE project team (2011 update)604 Phil Alderson605 Associate Director606 Sarah Dunsdon607 Guideline Commissioning Manager608 Andrew Gyton609 Guideline Coordinator610 Ruaraidh Hill611 Technical Lead612 Prashanth Kandaswamy613 Health Economist614 Judy McBride615 Editor Hypertension: NICE guideline DRAFT (February 2011) Page 27 of 39
    • DRAFT FOR CONSULTATION616 Guideline Development Group (2006 update)617 Dr Bernard Higgins (Chair)618 Consultant Respiratory Physician, Freeman Hospital; Director, National619 Collaborating Centre for Chronic Conditions620 Professor Morris Brown621 Professor of Medicine, Cambridge University and Addenbrooke’s Hospital;622 President, British Hypertension Society623 Dr Mark Davis624 General Practitioner, West Yorkshire; Primary Care Cardiovascular Society625 Professor Gary Ford626 Consultant Stroke Physician, University of Newcastle and Freeman Hospital;627 Royal College of Physicians628 Mr Colin Penney629 Patient and carer representative630 Ms Jan Procter-King631 Nurse Practitioner, West Yorkshire; Primary Care Cardiovascular Society632 Mrs Jean Thurston633 Patient and carer representative634 Professor Bryan Williams635 Clinical Adviser; Professor of Medicine, University of Leicester School of636 Medicine and University Hospitals Leicester NHS Trust637 National Collaborating Centre for Chronic Conditions638 (2006 update)639 Ms Lina Bakhshi640 Information Scientist641 Mr Rob Grant642 Senior Project Manager; Medical Statistician, Royal College of Physicians Hypertension: NICE guideline DRAFT (February 2011) Page 28 of 39
    • DRAFT FOR CONSULTATION643 Mr Mike Hughes644 Health Services Research Fellow in Guideline Development645 Dr Ian Lockhart646 Health Services Research Fellow in Guideline Development647 Mr Leo Nherera648 Health Economist; Health Economics Fellow, Queen Mary, University of649 London650 Guideline Development Group (2004 guideline)651 Ms Susan L Brent652 Acting Head of Prescribing Support, Northern and Yorkshire Regional Drug653 and Therapeutics Centre, Newcastle upon Tyne654 Dr Paul Creighton655 General Practitioner, Northumberland656 Dr William Cunningham657 General Practitioner, Northumberland658 Dr Heather Dickinson659 Technical Support, Newcastle upon Tyne660 Dr Julie Eccles (Group Leader)661 General Practitioner, Tyne and Wear662 Professor Gary Ford663 Professor of Pharmacology of Old Age and Consultant Physician, Newcastle664 upon Tyne665 Dr John Harley666 General Practitioner, Stockton on Tees667 Ms Suzanne Laing668 Nurse Practitioner, Tyne and Wear Hypertension: NICE guideline DRAFT (February 2011) Page 29 of 39
    • DRAFT FOR CONSULTATION669 Professor James Mason670 Methodologist and Technical Support, Newcastle upon Tyne671 Mr Colin Penney672 Patient Representative673 Dr Wendy Ross674 General Practitioner, Newcastle upon Tyne675 Mrs Jean Thurston676 Patient Representative677 Professor Bryan Williams678 Professor of Medicine and Director, Cardiovascular Research Unit, Leicester679 Hypertension: NICE guideline DRAFT (February 2011) Page 30 of 39
    • DRAFT FOR CONSULTATION680 Appendix B: The Guideline Review Panels681 The Guideline Review Panel is an independent panel that oversees the682 development of the guideline and takes responsibility for monitoring683 adherence to NICE guideline development processes. In particular, the panel684 ensures that stakeholder comments have been adequately considered and685 responded to. The panel includes members from the following perspectives:686 primary care, secondary care, lay, public health and industry.687 Guideline Review Panel (2011 update)688 NICE to add689 Guideline Review Panel (2006 update)690 Dr Peter Rutherford (Chair)691 Senior Lecturer in Nephrology, University of Wales College of Medicine692 Dr John Harley693 General Practitioner, North Tees PCT694 Dr Rob Higgins695 Consultant in Renal and General Medicine, University Hospitals Coventry and696 Warwickshire NHS Trust, Coventry697 Dr Kevork Hopayian698 General Practitioner, Suffolk699 Dr Robert Walker700 Clinical Director, West Cumbria Primary Care Trust701 Guideline Review Panel (2004 guideline)702 Professor Mike Drummond (Chair)703 Director, Centre for Health Economics (CHE), University of York704 Dr Kevork Hopayian705 General Practitioner, Suffolk Hypertension: NICE guideline DRAFT (February 2011) Page 31 of 39
    • DRAFT FOR CONSULTATION706 Mr Barry Stables707 Patient/Lay representative708 Dr Imogen Stephens709 Joint Director of Public Health, Western Sussex Primary Care Trust710 Dr Robert Walker711 Clinical Director, West Cumbria Primary Care Trust Hypertension: NICE guideline DRAFT (February 2011) Page 32 of 39
    • DRAFT FOR CONSULTATION Appendix C: The algorithms Diagnosis of hypertensionInitial clinic blood pressure Initial clinic blood pressure Initial clinic blood pressure <140/90 mmHg ≥140/90 mmHg ≥180/110 mmHg Arrange 24-hour ABPM (or HBPM) Blood pressure usually >180/110mmHg Assess* for target organ damage** and established CV (cardiovascular) disease (CVD)† Signs or symptoms of papilloedema and/or If target organ damage present and no CVD retinal haemorrhage or and person is younger than 40, estimate suspected 10-year CV risk‡. phaeochromotcytoma ABPM/HBPM ABPM/HBPM ABPM/HBPM Severe <135/85 mmHg ≥135/85 mmHg ≥ 150/90 mmHg hypertension Normotensive Stage 1 Stage 2+ Evidence of target Accelerated hypertension hypertension organ damage** hypertension Start Refer for No target organ Target antihypertensive drug specialist damage organ treatment care No established CVD damage immediately immediately 10-year CV risk <20% present 10-year CV *Assessment risk >20% eGFR Lipids Lower risk ECG Higher risk Test urine for protein and blood Changes to retina Person younger Person 40 or **Target organ damage than 40 older Chronic kidney disease Left ventricular hypertrophy ECG changes Retinal changes such as papilloedema or haemorrhages Consider Offer antihypertensive drug treatment/specialist treatment †Established CVD referral Heart disease Peripheral vascular disease Cerebrovascular disease (stroke, TIA) Diabetes Chronic kidney disease Review blood pressure at least every 12 months ‡10-year CV risk estimation See ‘Lipid modification’ (NICE clinical guideline 67) Hypertension: NICE guideline DRAFT (February 2011) Page 33 of 39
    • DRAFT FOR CONSULTATION Antihypertensive drug treatment Key People aged People aged ≥ 55 A = ACE inhibitor or angiotensin II < 55 years years and all black receptor blocker people of African or Caribbean descent C = calcium-channel blocker (CCB) D = thiazide-like diuretic C* = CCB preferred but considerStep 1 A C* thiazide-like diuretics in people with oedema or a high risk of heart failure Further diuretic** = consider low-dose spironolactone or higherStep 2 A + C* doses of a thiazide-like diureticStep 3 A+C+DStep 4 A + C + D + further diuretic** or alpha-blocker or(resistant beta-blockerhypertension) Consider seeking specialist advice. Hypertension: NICE guideline DRAFT (February 2011) Page 34 of 39
    • DRAFT FOR CONSULTATIONAppendix D: Recommendations to be deletedRecommendation CommentWhere possible, standarise the Replaced by:environment when measuring blood When measuring blood pressure in thepressure: provide a relaxed, temperate clinic or in the home, standardise thesetting, with the patient quiet and seated environment and provide a relaxed,and with their arm outstretched and temperate setting, with the person quietsupported. (Recommendation 1.1.3 in and seated, and their arm outstretched2006 guideline) and supported.If the first measurement exceeds Replaced by:140/90mmHg, if practical, take a second If blood pressure measured in the clinic isconfirmatory reading at the end of the higher than 140/90mmHg:consultation.(Recommendation 1.1.4 in Take a second measurement during the2006 guideline) consultation If the second measurement is substantially different from the first, take a third measurement.Measure blood pressure on both of the Replaced by:patient’s arms with the higher value Measure blood pressure in both arms:identifying the reference arm for future If the difference in readings betweenmeasurement. (Recommendation 1.1.5 arms is more than 20 mmHg, repeat thein 2006 guideline) 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 Replaced by:postural hypotension (falls or postural In people with symptoms of posturaldizziness) measure blood pressure while hypotension (falls or postural dizziness):patient is standing. In patients with Measure blood pressure with the personsymptoms or documented either supine or seated.psoturalhypotension (fall in systolic BPwhen standing of 20 mmHg or more) Measure blood pressure again with theconsider referral to a specialist. person standing.(Recommendation 1.1.6 in 2006guideline)To identify hypertension (persistent Replaced byraised blood pressure, above If the first and second blood pressure140/90 mmHg), ask the patient to return measurements taken during afor at least two subsequent clinics where consultation are both higher thanblood pressure is assessed from two 140/90 mmHg, offer 24-hour ambulatoryreadings under the best conditions blood pressure monitoring (ABPM) toavailable. (Recommendation 1.1.8 in confirm the diagnosis of hypertension.2006 guideline) Use an ABPM device that is validatedAnd and is of an appropriate cuff size for theMeasurements should normally be made person’s arm.at monthly intervals. However, patientsHypertension: NICE guideline DRAFT (February 2011) Page 35 of 39
    • DRAFT FOR CONSULTATIONwith more severe hypertension should bere-evaluated more urgently.(Recommendation 1.1.9 in 2006guideline)Refer immediately patients with Replaced by:accelerated (malignant) hypertension Immediately refer people with the(BP more than 180/110 mmHg with signs following signs for specialist care:of papilloedema and/or retinal Accelerated hypertension (bloodhaemorrhage) or suspected pressure usually higher than 180/110phaeochromocytoma (possible signs mmHg with signs of papilloedema and/orinclude labile or postural hypotension, retinal haemorrhage)headache, palpitations, pallor ordiaphoresis). (Recommendation 1.1.7 in Suspected phaeochromocytoma (labile2006 guideline) or postural hypotension, headache, palpitations, pallor and diaphoreses).Routine use of automated ambulatory The evidence for automated ambulatoryblood pressure monitoring or home blood pressure monitoring (ABPM) wasmonitoring devices in primary care is not reviewed in the 2011 update.currently recommended because theirvalue has not been adequatelyestablished; appropriate use in primarycare remains an issue for furtherresearch. (Recommendation 1.1.10 in2006 guideline)Consider the need for specialist We are now recommending ABPMinvestigation of patients with unusual routinely for diagnosis.signs and symptoms, or of those whosemanagement depends critically on theaccurate estimation of their bloodpressure. (Recommendation 1.1.11 in2006 guideline)If raised blood pressure persists and the This has been clarified in newpatient does not have established recommendations in the 2011 update.cardiovascular disease, discuss withthem the need to formally assess theircardiovascular risk. Tests may helpidentify diabetes, evidence ofhypertensive damage to the heart andkidneys, and secondary causes ofhypertension such as kidney disease.(Recommendation 1.3.1 in 2006guideline)Test for the presence of protein in the Replaced by:patient’s urine. Take a blood sample to Test for the presence of protein in theassess plasma glucose, electrolytes, urine by sending a urine sample forcreatinine, serum total cholesterol and estimation of the albumin:creatinine ratioHDL cholesterol. Arrange for a 12-lead (ACR). Take a blood sample to measureelectrocardiograph to be performed. plasma glucose, electrolytes, creatinine,(Recommendation 1.3.2 in 2006 eGFR, serum total cholesterol and HDLguideline) cholesterol. Arrange for a 12-lead electrocardiograph to be performed.Drug therapy reduced the risk of Replaced by:cardiovascular disease and death. Offer Offer antihypertensive drug treatmentHypertension: NICE guideline DRAFT (February 2011) Page 36 of 39
    • DRAFT FOR CONSULTATIONdrug therapy to: to:people with stage 1 hypertension whoPatients with persistent high blood have:pressure of 160/100 mmHg or more target organ damage orPatients at raised cardiovascular disease established cardiovascularor target organ damage) with persistent disease orblood pressure of more than 140/90 renal disease ormmHg. (recommendation 1.4.1) 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 Replaced by:or black patients of any age, the first Offer step 1 antihypertensive treatmentchoice for initial therapy should either be with a calcium-channel blocker (CCB) toa calcium channel blocker or a thiazide- people aged 55 years and older and totype diuretic. For this recommendation, black people of African or Caribbeanblack patients are considered to be those descent of any age. If a CCB is notof African or Caribbean descent, not suitable, for example because of oedemamixed-race, Asian or Chinese. or intolerance, or if there is evidence of(Recommendation 1.4.4 in 2006 heart failure, or a high risk of heartguideline) failure, offer a thiazide-like diuretic.In hypertensive patients younger than 55, Replaced by:the first choice for initial therapy should Offer step 1 antihypertensive treatmentbe an angiotensin-converting enzyme with an angiotensin-converting enzyme(ACE) inhibitor (or an angiotensive-II (ACE) inhibitor or a low-cost angiotensin-receptor antagonist if an ACE inhibitor is II receptor blocker (ARB) to people agednot tolerated). (Recommedation1.4.5 in 55 years and younger. If an ACE inhibitor2006 guideline) is not tolerated, offer an ARB.If blood pressure remains uncontrolled Replaced by:on adequate doses of three drugs, Regard clinic blood pressure thatconsider adding a fourth and/or seeking remains higher than 140/90 mmHg withexpert advice. (Recommendation 1.4.8 in the optimal or best tolerated doses of an2006 guideline) 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 Replaced by:following should be considered: For treatment of resistant hypertension at A higher dose of a thiazide-type step 4, consider further diuretic therapy diuretic or the addition of another with low-dose spironolactone (25 mg diuretic (careful monitoring is once daily.) if blood potassium levels are recommended) or lower than 4.5 mmol/l and eGFR is Beta-blockers or higher than 60. If blood potassium levels are higher than 4.5 mmol/l, considerHypertension: NICE guideline DRAFT (February 2011) Page 37 of 39
    • DRAFT FOR CONSULTATION Selective alpha-blockers. higher-dose thiazide-like diuretic (recommendation 1.4.9 in 2006 treatment. guideline) 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 Replaced by:if necessary, to achieve a target of Aim for a target clinic blood pressure140/90 mmHg, or until further treatment below 140/90 mmHg in people agedis inappropriate or declined. Titrate drug under 80 years with treated hypertension.doses as described in the ‘British Andnational formulary’ noting any cautionsand contraindications. (Recommendation Aim for a target clinic blood pressure1.4.3 in 2006 guideline) below 150/90 mmHg in people aged over 80 years with treated hypertension.If initial therapy was with a calcium- Replaced by:channel blocker or a thiazide-type If step 2 antihypertensive treatment isdiuretic and a second drug is required, required offer a calcium channel blockeradd an ACE inhibitor (or an angiotensin-II in combination with either an ACEreceptor antagonist if an ACE inhibitor is Inhibitor or a low-cost angiotensin-IInot tolerated). If therapy was initiated receptor blocker. If a calcium channelwith an ACE inhibitor (or angiotensin-II blocker is not suitable, for examplereceptor antagonist), add a calcium- because of oedema or intolerance, or ifchannel blocker or a thiazide-type there is evidence of heart failure or a highdiuretic. (Recommendation 1.4.6 in 2006 risk of heart failure, offer a thiazide-likeguideline) diureticIn patients whose blood pressure is not This algorithm has been superseded incontrolled (that is, above 140/90 mmHg) the 2011 guidance.despite a treatment regimen that includesa beta-blockers, treatment should berevised according to the treatmentalgorithm on page 45 (recommendation1.4.12 in 2006 guideline)In patients whose blood pressure is well This recommendation was relevant incontrolled (that is, 140/90mmHg or 2006, as many people were taking beta-below) with a regimen that includes a blockers for hypertension.beta-blocker, long term managementshould be considered as part of their Since the 2006 guideline, it has beenroutine review. In these patients there is well accepted that beta blockers shouldno absolute need to replace the beta- not be used as a first -line treatment forblocker with an alternative agent. hypertension.(Recommendation 1.4.13 in 2006guideline)Hypertension: NICE guideline DRAFT (February 2011) Page 38 of 39
    • DRAFT FOR CONSULTATION Therefore there are far fewer people taking beta-blockers for hypertension. When a beta-blockers is withdrawn, the As above – the 2006 guideline dose should be stepped down gradually. recommended that beta-blockers should Beta-blockers should not be withdrawn in not be used as a first line treatment for patients who have compelling indications hypertension. for beta-blockade, for example those who have symptomatic angina or who have had a myocardial infarction. (Recommendation 1.4.14 in 2006 guideline) Offer patients over 80 years of age the Replaced by: same treatment as other patients over Offer people older than 80 years the 55, taking into account of any same antihypertensive treatment as comorbidity and their existing burden of people aged 55-80 years, taking into drug use. (Recommendation 1.4.16 in account any comorbidities. 2006 guideline) The aim of medication is to reduce blood This recommendation doesn’t add any pressure to 140/90 mmHg or below. value – it is a redundant recommendation However, patients not achieving this so therefore has been removed. 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) Patients may become motivated to make This has been superseded by NICE lifestyle changes and want to reduce or guidance on lifestyle. 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)712 Hypertension: NICE guideline DRAFT (February 2011) Page 39 of 39