NICE hypertension guideline 2011

Source: http://guidance.nice.org.uk/CG127
BMJ 2011;343:doi:10.1136/bmj.d4891 (Published 25 August 2011)


The recent updated guidance from the National Institute for Health and Clinical Excellence (NICE) on the management of hypertension in adults will have far reaching implications for day to day practice in the United Kingdom. The guidelines were developed in partnership with the British Hypertension Society and have 65 recommendations, 36 of which are new, with 12 listed as key priorities. Although these figures may seem daunting, closer scrutiny shows that most of the changes have evolved from previous guidelines and should be relatively straightforward to incorporate into clinical practice.
For the first time targets have been partially relaxed. Admittedly this applies only to people aged 80 or more, in whom a target blood pressure lower than 150/90 mm Hg is recommended. The previous target of 140/90 mm Hg is retained for everyone else, and this will continue to be a challenge in primary care. 3 However, the guidelines clearly state that individual needs and preferences must be taken into account. They acknowledge that a balance must be struck between achieving targets and the realities of adherence to treatment and possible distressing side effects — particularly symptoms of postural hypotension.

Hypertension is one of the most important preventable causes of death worldwide and one of the commonest conditions treated in primary care in the United Kingdom, where it affects more than a quarter of all adults and over half of those over the age of 65 years.

Recommendations

NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Diagnosing hypertension

If blood pressure measured in the clinic is 140/90 mm Hg or higher: 

• Take a second measurement during the consultation 
• If the second measurement is substantially different from the first, take a third measurement
• Record the lower of the last two measurements as the clinic blood pressure.

(Updated recommendation) [ Based on the experience and opinion of the Guideline Development Group (GDG)] 

• If the clinic blood pressure is 140/90 mm Hg or higher, use ambulatory blood pressure monitoring to confirm the diagnosis of hypertension. This strategy will improve the accuracy of the diagnosis compared with current practice 6 and was also shown to be cost effective—indeed, cost saving—for the NHS. (Updated recommendation).
• When using ambulatory blood pressure monitoring to confirm a diagnosis of hypertension, ensure that at least two measurements an hour are taken during the person’s usual waking hours.
• The first NICE hypertension guideline was issued in 2004 and updated in June 2006. The new, simple, 16-page document lists "key priorities," provides a care "pathway," and encompasses different ways to measure and diagnose hypertension, assess risk and target-organ damage, use lifestyle and drug interventions, and educate patients.

What are the novel elements of this update?

• For one, the update recommends the same antihypertensive drug treatment in people over aged 80 as in people aged 55 through 80, a change from previous guidance that urged caution in older subjects, out of concerns that adverse effects might offset benefits.
• Second, the NICE reviewers reexamined advice for subjects over age 55 and recommend the use of a calcium-channel blocker (CCB) as first-line therapy, with thiazidelike diuretics reserved for patients with edema, CCB intolerance, or evidence of heart failure or at high risk of heart failure.
• And in a departure from previous recommendations, the new update recommends physicians use a thiazidelike diuretic, such as chlorthalidone or indapamide, in patients starting on or switching diuretics. These drugs should be used "in preference to" what is more commonly the first-line diuretic in the UK, bendroflumethiazide, or the most common in the US, hydrochlorothiazide