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March 2019

Hypertension – draft guidance


This guideline covers identifying and treating primary hypertension in people aged 18 and over, including people with type 2 diabetes. It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively.


In the biggest change to NICE’s previous guidance published in 2011, the level of a person’s cardiovascular disease risk at which treatment for high blood pressure can be started has been halved from 20% to 10%.

The draft guideline1 recommends that blood pressure lowering drugs should be offered to people aged under 80 with a diagnosis of stage 1 hypertension who have a 10% or greater risk of developing cardiovascular disease within the next 10 years.  

It is estimated that around 450,000 men and 270,000 women would fall into this category. However, it is likely that the impact of the new recommendations will in fact be lower as some estimates suggest half of people in this category are already receiving treatment.

The draft guideline also considered new studies suggesting people with blood pressure below the level at which high blood pressure is usually diagnosed (140/90mmHg) might also benefit from medication. It also looked at what the effect would be of lowering the blood pressure target for people on treatment.

In 2015 high blood pressure affected more than 1 in 4 adults (31% of men; 26% of women) – around 13.5 million people – and contributed to 75,000 deaths in England. The clinical management of hypertension accounts for 12% of visits to primary care and up to £2.1 billion of healthcare expenditure.

Over the last decade progress has been made to improve the diagnosis and management of hypertension: the average blood pressure in England has fallen by about 3 mmHg systolic and the proportion of adults with untreated high blood pressure has decreased. However, the Public Health England Blood Pressure Action Plan (Tackling high blood pressure: from evidence into action, 2015)2 called for further measures to reduce average blood pressure by a further  5 mmHg through improved prevention, detection and management.

The draft guideline supports the direction of the NHS Long Term Plan and CVD ambitions to improve outcomes in cardiovascular disease, including preventing strokes and heart attacks, through better detection and treatment of high blood pressure.

Since the publication of the 2011 guideline, new studies have been published in key areas, in particular the optimal method and threshold for diagnosis, managing BP in lower risk populations and reducing BP to lower targets. The updated guideline make new recommendations in these areas, based on the evidence, that aim to improve care and reduce variation in practice.



NEW FOR 2019

Diagnosis

When taking blood pressure measurements, whether in the clinic or the person’s home, use an appropriate cuff size for the person’s arm.

Measure BP in both arms, and repeat the measurements if the difference in readings is more than 15mmHg. If the difference in readings between arms remains more than 15mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading.

If BP measured in the clinic is 140/90mmHg or higher, take a second measurement during the consultation. If the second is substantially different from the first, take a third measurement: record the lower of the last two measurements as the clinic BP.

If clinic BP is between 140/90mmHg and 180.110mmHG, offer ambulatory BP monitoring (ABPM) to confirm the diagnosis of hypertension, or home BP monitoring if the person is unable to tolerate ABPM.

While waiting for confirmation of a diagnosis of hypertension, carry out investigations for target organ damage*, followed by formal assessment of cardiovascular risk assessment using a cardiovascular risk assessment tool, e.g. QRISK2 (version 3 now available).4

*Target organ damage: damage to organs such as heart, brain, kidney and eyes. Examples include left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy, increased urine albumin: creatinine ratio

Confirm a diagnosis of hypertension in people with a:

  • Clinic BP of 140.90mmHg or higher and
  • ABPM daytime average or HBPM average of 135/85mmHg or higher

Assessing cardiovascular risk and target organ damage

For all people with hypertension, offer to:

  • Test for the presence of protein in the urine by sending a urine sample for estimation of the albumin: creatinine ratio and test for haematuria using a reagent strip
  • Take a blood sample to measure HbA1c, electrolytes, creatinine, estimated glomerular filtration rate (eGFR), total cholesterol and HDL-cholesterol
  • Examine the fundi for the presence of hypertensive retinopathy
  • Arrange for a 12-lead electrocardiograph (ECG) to be performed

Treating and monitoring hypertension

Discuss with the person their preferences for treatment before starting antihypertensive drug treatment. Continue to offer lifestyle advice and support them to make lifestyle changes whether or not they choose to start antihypertensive drug treatment. While relaxation therapies may reduce BP, there is no evidence of direct benefit to people with hypertension, such as improving quality of life or reducing cardiovascular events. It is not the intention of the guideline to stop people trying relaxation therapies but to make them aware that there is less evidence of benefit for relaxation compared with lifestyle interventions – taking regular exercise and maintaining a healthy weight – or pharmacological treatment.

Offer antihypertensive drug treatment in addition to lifestyle advice to adult aged under 80 with persistent stage 1 hypertension who have one or more of the following

  • Established cardiovascular disease
  • Renal disease
  • Diabetes
  • An estimated 10-year risk of cardiovascular disease of 10% or more

The guideline committee decided to lower the treatment threshold to 10% risk in people aged under 80 with stage 1 hypertension, and include the option to consider treatment below the 10% threshold. This will mean that more people will now be eligible for treatment, but not by as much as might be assumed as 2018 data show that around 50% with stage 1 hypertension and risk below 20% are already receiving BP lowering drugs.

Offer antihypertensive drug treatment to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people with frailty or multimorbidity.

Consider antihypertensive drug treatment in addition to lifestyle advice for younger adults with stage 1 hypertension and estimated 10-year risk below 10%. Bear in mind that 10-year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease.

Consider starting antihypertensive drug treatment for people aged over 80 with stage 1 hypertension. Use clinical judgement for people with frailty or multimorbidity.

For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long term balance of treatment benefits and risks.

Use clinic BP measurements to monitor response to lifestyle changes or drug treatment, and HPBM for adults who choose to self-monitor their BP.

Consider ABPM or HBPM for adults with white coat effect or masked hypertension, in which clinic and non-clinic BP results are conflicting. Remember that the corresponding measurements for ABPM and HBPM are 5mmHg lower than clinic measurements.

BP targets

Reduce clinic BP to below 140/90mmHg and maintain that level in people aged under 80, including those with type 2 diabetes.

Previously the BP target for people with type 2 diabetes was 130/80mmHg (in the presence of target organ damage), but a review suggests there is insufficient evidence to recommend a different BP target for this group.

For people aged 80 and over, reduce and maintain BP to below 150/90mmHg. Use clinical judgement for people with frailty or multimorbidity.

In people with a significant postural drop or symptoms of postural hypotension, treat to a BP target based on standing BP measurement.

Whereas earlier versions of the guideline recommended treating to target, the new recommendations place more emphasis on maintaining BP consistently below the BP targets. This could result in higher use of BP lowering drugs and an increase in consultations, but benefits in reducing mortality and cardiovascular events.

Choosing antihypertensive drug treatment

Recommendations in this section relating to people with type 2 diabetes will replace those on blood pressure management in the NICE guideline of type 2 diabetes (NG28).

Step 1 treatment

Offer an ACE inhibitor or ARB to adults, who:

  • Have type 2 diabetes (of any age or family origin), or
  • Are aged under 55 but not of African or Caribbean family origin

Offer a calcium-channel blocker (CCB) to adults who:

  • Are aged 55 or over and do not have type 2 diabetes, or
  • Are of African or Caribbean family origin and do not have type 2 diabetes.

If an ACE inhibitor is not tolerated, e.g. because of cough, offer an ARB.

Do not combine an ACE inhibitor with an ARB.

If CCB is not tolerated, e.g. because of oedema, offer a thiazide-like diuretic.

If there is evidence of heart failure, offer a thiazide-like diuretic e.g. indapamide or chlorthalidone in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. Adults already being treated with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled BP, continue current treatment.

The guideline committee concluded that there was insufficient evidence to recommend initial dual therapy at step 1. The recommendation for considering beta-blockers for certain patient groups has been withdrawn as first, they are seldom used in current practice at step 1, and secondly, there is no established relationship between beta-blocker use and reduction in cardiovascular events.

Step 2 treatment

If hypertension is not controlled on step 1 treatment of an ACE inhibitor or ARB offer the choice of one of the following drugs:

  • A CCB or
  • A thiazide-like diuretic

If hypertension is not controlled on step 1 treatment with a CCB, offer the choice of one of the following:

  • An ACE inhibitor, or
  • An ARB, or
  • A thiazide-like diuretic

In adults of African and Caribbean family origin, without type 2 diabetes, whose hypertension is not controlled on step 1 treatment, consider an ARB in preference to an ACE inhibitor.

There is no evidence for the best sequence for step 2 and step 3 BP lowering treatment, so any of these treatments can be offered based on an individualised approach informed by risks and benefits of each treatment and the patient’s preference.

Step 3 treatment

Before considering next step treatment

  • Review medications to ensure they are being taken at optimal tolerated doses and
  • Discuss adherence

If hypertension is not controlled on step 2 treatment, offer a combination of:

  • An ACE inhibitor or ARB, and
  • A CCB, and
  • A thiazide-like diuretic

Step 4 treatment

If hypertension is not controlled on three step 3 drugs, regard the person as having resistant hypertension. Before considering further treatment:

  • Confirm elevated clinic BP measurements using ABPM or HBPM
  • Assess for postural hypotension
  • Discuss adherence

For people with confirmed resistant hypertension, consider adding a fourth drug (see above) or seek expert advice.

Consider further diuretic therapy with low-dose spironolactone for adults with resistant hypertension requiring step 4 treatment who have a blood potassium level of 4.5mmol/l or less. Use particular caution in people with reduced eGFR as they have an increased risk of hyperkalaemia.

Monitor blood sodium and potassium levels and renal function within 1 month of starting treatment.

Consider an alpha-blocker or beta-blocker for adults with resistant hypertension who have a blood potassium level >4.5mmol/l.

If BP remains uncontrolled in people with resistant hypertension on optimal tolerated doses of four drugs, seek expert advice.

The guideline committee considered there was insufficient evidence to retain the 2011 recommendation to use high-dose thiazide diuretics as a potential step 4 treatment in people with high blood potassium levels. The recommendations for considering alpha- and beta-blockers have been retained, based on significant clinical experience of safe and effective use, and because adding a further drug is likely to have a greater effect on BP that increasing the thiazide diuretic dose.

When to refer for same-day specialist review

  • If there is evidence of accelerated hypertension – clinic BP 180/120mmHg or higher with signs of retinal haemorrhage or papilloedema or
  • Suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor, abdominal pain and.or diaphoresis) or
  • Life-threating symptoms such as new onset confusion, chest pain, signs of heart failure, or acute renal impairment.

The emergency symptoms above may lead to more referrals to hospital, but people with these symptoms would benefit from urgent treatment because accelerated hypertension can be fatal if untreated.


1. NICE. Hypertension in adults. NICE guideline, draft for consultation. March 2019. https://www.nice.org.uk/guidance/GID-NG10054/documents/draft-guideline

2. Public Health England. Blood Pressure Action Plan. Tackling high blood pressure: from evidence into action, 2015. https://www.gov.uk/government/publications/high-blood-pressure-action-plan

3. NHS England. NHS Long Term Plan https://www.gov.uk/government/publications/health-matters-preventing-cardiovascular-disease/health-matters-preventing-cardiovascular-disease

4. QRISK®3. https://qrisk.org

NICE, March 2019
The full guideline is expected in August 2019, when this version will be updated 


 

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