DRAFT FOR CONSULTATION

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 1.2 1.3 1.4 1.5 Measuring blood pressure ........................................................................... 9 Diagnosing hypertension ........................................................................... 10 Assessing cardiovascular risk ................................................................... 13 Lifestyle interventions ................................................................................ 13 Initiating and monitoring antihypertensive drug treatment, including blood

pressure targets .................................................................................................. 14 1.6 1.7 2 3 4 Choosing antihypertensive drug treatment ................................................ 15 Patient education and adherence to treatment .......................................... 18

Notes on the scope of the guidance................................................................. 19 Implementation ................................................................................................ 20 Research recommendations ............................................................................ 20 4.1 4.2 4.3 Out-of-office monitoring ............................................................................. 20 Intervention thresholds for people aged under 40 with hypertension ......... 21 Methods of assessing lifetime CV risk in people aged under 40 with

hypertension ........................................................................................................ 21 4.4 4.5 4.6 Optimal systolic blood pressure................................................................. 22 Step 4 treatment........................................................................................ 22 Automated blood pressure monitoring in people with

atrial fibrillation .................................................................................................... 22 5 6 7 Other versions of this guideline ........................................................................ 23 Related NICE guidance ................................................................................... 24 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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DRAFT FOR CONSULTATION 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Introduction
High blood pressure (hypertension) is one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for stroke (ischaemic and haemorrhagic), myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension is usually associated with a progressive rise in blood pressure. The vascular and renal damage that this may cause can culminate in a treatment-resistant state. Blood pressure is normally distributed in the population and there is no natural cut-off point above which 'hypertension' definitively exists and below which it does not. The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke. Hypertension is remarkably common in the UK and the prevalence is strongly influenced by age. In any individual person, systolic and/or diastolic blood pressures may be elevated. Diastolic pressure is more commonly elevated in younger people, that is, those younger than 50 years. With ageing, systolic hypertension becomes a more significant problem, as a result of progressive stiffening and loss of compliance of larger arteries. At least one quarter of adults (and more than half of those older than 60) have high blood pressure. The clinical management of hypertension is one of the most common interventions in primary care, accounting for approximately 1 billion in drug costs alone in 2006. The guideline will assume that prescribers will use a drugs summary of product characteristics to inform decisions made with individual patients.

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27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51

Person-centred care
This guideline offers best practice advice on the care of adults with hypertension. Treatment and care should take into account peoples needs and preferences. People with hypertension should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If people do not have the capacity to make decisions, healthcare professionals should follow the Department of Healths advice on consent (available from www.dh.gov.uk/consent) and the code of practice that accompanies the Mental Capacity Act (summary available from www.publicguardian.gov.uk). In Wales, healthcare professionals should follow advice on consent from the Welsh Assembly Government (available from www.wales.nhs.uk/consent). Good communication between healthcare professionals and people with hypertension is essential. It should be supported by evidence-based written information tailored to the persons needs. Treatment and care, and the information people are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. If the person agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. Families and carers should also be given the information and support they need.

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DRAFT FOR CONSULTATION 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 Hypertension: NICE guideline DRAFT (February 2011) Page 6 of 39

Key priorities for implementation

The following recommendations have been identified as priorities for implementation. Diagnosing hypertension If the first and second blood pressure measurements taken during a consultation are 140/90 mmHg or higher, offer 24-hour ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new 2011] [1.2.2] When using ABPM to confirm a diagnosis of hypertension, ensure that: Blood pressure is measured for a total of 24 hours. At least two measurements per hour are taken during the day (08:00 to 22:00). At least one measurement per hour is taken during the night (22:00 to 08:00). Use the average daytime blood pressure measurement, calculated using a minimum of 14 daytime measurements, to confirm a diagnosis of hypertension. [new 2011] [1.2.6] When using home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension, ensure that: For each blood pressure measurement, two consecutive measurements are taken, at least 1 minute apart and with the person seated (see 1.1.4). Blood pressure measurements are taken twice daily, ideally in the morning and evening. Blood pressure measurement continues for at least 4 days, ideally for 7 days. Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. [new 2011] [1.2.7]

DRAFT FOR CONSULTATION 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 Offer antihypertensive drug treatment to people with stage 2 hypertension. [new 2011] [1.5.2] For people younger than 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular (CV) disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10-year CV risk assessments can underestimate the lifetime risk of CV events in these people [new 2011] [1.5.3] Monitoring treatment and blood pressure targets For people with a discrepancy of more than 20/10 mmHg between clinic blood pressure measurements and ABPM or HBPM average measurements, consider using daytime average ABPM or average HBPM for monitoring the response to antihypertensive treatment. Aim for a target ABPM or HBPM blood pressure of 135/85 mmHg or lower. [new 2011] [1.5.6] Initiating and monitoring antihypertensive drug treatment, including blood pressure targets Initiating treatment Offer antihypertensive drug treatment 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. [new 2011]

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DRAFT FOR CONSULTATION 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 Choosing antihypertensive drug treatment Offer people older than 80 years the same antihypertensive drug treatment as people aged 5580 years, taking into account any comorbidities. [new 2011] [1.6.4] Step 1 treatment Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged 55 years and older and to black people of African and 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. [new 2011] [1.6.8] If a diuretic is required, choose a thiazide-like diuretic, such as chlortalidone (12.5 mg25.0 mg once daily) or indapamide (2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.9] Step 4 treatment 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 estimated glomerular filtration rate is higher than 60 ml/min/1.73m2. If blood potassium levels are higher than 4.5 mmol/l, consider therapy with a higher-dose thiazide-like diuretic. [new 2011] [1.6.14]

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Guidance

The following guidance is based on the best available evidence. The full guideline (www.nice.org.uk/guidance/CGXXX) gives details of the methods and the evidence used to develop the guidance. Definitions In this guideline the following definitions are used. Stage 1 hypertension: initial clinic blood pressure 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure 135/85 mmHg or higher. Stage 2 hypertension: initial clinic blood pressure 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure 150/95 mmHg or higher. Severe hypertension: clinic blood pressure 180/110 mmHg or higher.

145 146 147 148 149 150 151 152 153 154 155 156 157

1.1
1.1.1

Measuring blood pressure

Healthcare professionals taking blood pressure measurements need adequate initial training and periodic review of their performance. [2004]

1.1.2

Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. [new 2011]

1.1.3

Healthcare providers must ensure that devices for measuring blood pressure are properly validated, maintained and regularly recalibrated according to manufacturers instructions. [2004]

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DRAFT FOR CONSULTATION 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 1.1.8 1.1.7 1.1.6 1.1.5 1.1.4 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. [new 2011] Use an ABPM device that is validated and is of an appropriate cuff size for the persons arm. [new 2011] 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. [new 2011] 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. [2004, amended 2011] If the systolic blood pressure falls by 20 mmHg or more when the person is standing: Review medication. Measure subsequent blood pressures with the person standing. Consider referral to specialist care if symptoms of postural hypotension persist. [2004, amended 2011]

1.2
1.2.1

Diagnosing hypertension
If blood pressure measured in the clinic is 140/90 mmHg or higher: Take a second measurement during the consultation.

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DRAFT FOR CONSULTATION 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 1.2.6 1.2.5 1.2.4 1.2.3 1.2.2 If the second measurement is substantially different from the first, take a third measurement. Use the lower of the last two measurements to diagnose hypertension. [new 2011] If the first and second blood pressure measurements taken during a consultation are both 140/90 mmHg or higher, offer 24-hour ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new 2011] If a person is unable to tolerate ABPM, home blood pressure monitoring (HBPM) is a suitable alternative to confirm the diagnosis of hypertension. [new 2011] If the person has severe hypertension and evidence of target organ damage, start antihypertensive drug treatment immediately; do not wait for the results of ABPM or HBPM. [new 2011]. When considering a diagnosis of hypertension, carry out appropriate investigations for target organ damage and a formal assessment of cardiovascular (CV) risk using a CV risk assessment tool, in line with Lipid modification (NICE clinical guideline 67). [new 2011] When using ABPM to confirm a diagnosis of hypertension, ensure that: blood pressure is measured for a total of 24 hours at least two measurements per hour are taken during the day (08:00 to 22:00) at least one measurement per hour is taken during the night (22:00 to 08:00). Use the average daytime blood pressure measurement, calculated using a minimum of 14 daytime measurements, to confirm a diagnosis of hypertension. [new 2011] Hypertension: NICE guideline DRAFT (February 2011) Page 11 of 39

DRAFT FOR CONSULTATION 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 1.2.9 1.2.8 1.2.7 When using home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension, ensure that: For each blood pressure measurement, two consecutive measurements are taken, at least 1 minute apart and with the person seated (see 1.1.4). Blood pressure measurements are taken twice daily, ideally in the morning and evening. Blood pressure measurement continues for at least 4 days, ideally for 7 days. Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. [new 2011] 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 diaphoresis). [2004, amended 2011] Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. [2004, amended 2011]

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DRAFT FOR CONSULTATION 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 1.4.3 1.4.2 1.3.3 1.3.2

1.3
1.3.1

Assessing cardiovascular risk

Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension, both for raised blood pressure and other modifiable risk factors. [2004] Estimate cardiovascular risk in line with recommendations 1.1.7, 1.1.8, 1.1.10, 1.1.11, 1.1.13, 1.1.21 and 1.1.22 in Lipid modification (NICE clinical guideline 67). [new 2011] For all people with hypertension: Test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio. Take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol. Arrange for a 12-lead electrocardiograph to be performed. [2004, amended 2011]

1.4
1.4.1

Lifestyle interventions
Ascertain peoples diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes. [2004] Relaxation therapies can reduce blood pressure and people may wish to pursue these as part of their treatment. However, routine provision by primary care teams is not currently recommended. [2004] Ascertain peoples alcohol consumption and encourage a reduced intake if they drink excessively, because this can reduce blood pressure and has broader health benefits. [2004]

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DRAFT FOR CONSULTATION 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 1.5.3 1.5.2 1.4.7 1.4.8 1.4.6 1.4.5 1.4.4 Discourage excessive consumption of coffee and other caffeinerich products. [2004] Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. [2004] Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. [2004] Offer advice and help to smokers to stop smoking. [2004] A common aspect of studies for motivating lifestyle change is the use of group working. Inform people about local initiatives by, for example, healthcare teams or patient organisations that provide support and promote healthy lifestyle change. [2004]

1.5

Initiating and monitoring antihypertensive drug treatment, including blood pressure targets

Initiating treatment 1.5.1 Offer antihypertensive drug treatment 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. [new 2011] Offer antihypertensive drug treatment to people with stage 2 hypertension. [new 2011] For people younger than 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation of Hypertension: NICE guideline DRAFT (February 2011) Page 14 of 39

DRAFT FOR CONSULTATION 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 1.6.2 1.5.8 1.5.7 1.5.6 1.5.5 secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people. [new 2011] Monitoring treatment and blood pressure targets 1.5.4 Use clinic blood pressure measurement to monitor the response to antihypertensive treatment. [new 2011] For people identified as having a white-coat effect, that is, a consistent alerting response or clinic hypertension, consider HBPM as an adjunct to clinic blood pressure measurement for monitoring the response to antihypertensive treatment with lifestyle modification or drugs. [new 2011] For people with a discrepancy of more than 20/10 mmHg between clinic blood pressure measurements and ABPM or HBPM average measurements, consider using daytime average ABPM or average HBPM for monitoring the response to antihypertensive treatment. Aim for a target daytime average ABPM or average HBPM blood pressure below 135/85 mmHg. [new 2011] Aim for a target clinic blood pressure below 140/90 mmHg in people aged under 80 years with treated hypertension. [new 2011] Aim for a target clinic blood pressure below 150/90 mmHg in people aged over 80 years with treated hypertension. [new 2011]

1.6
1.6.1

Choosing antihypertensive drug treatment

Where possible, recommend treatment with drugs taken only once a day. [2004] Prescribe non-proprietary drugs where these are appropriate and minimise cost. [2004]

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DRAFT FOR CONSULTATION 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 1.6.9 1.6.8 1.6.7 1.6.5 1.6.4 1.6.3 Offer people with isolated systolic hypertension (systolic BP 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure. [2004] Offer people older than 80 years the same antihypertensive drug treatment as people aged 5580 years, taking into account any comorbidities. [new 2011] Offer antihypertensive drug treatment to women in line with recommendations 1.2.1.1, 1.2.1.2, 1.9.1.1 and 1.9.1.2 in Hypertension in pregnancy (NICE clinical guideline 107). [new 2011] Step 1 treatment 1.6.6 Offer step 1 antihypertensive treatment with an angiotensinconverting enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB) to people aged under 55 years. If an ACE inhibitor is not tolerated, offer an ARB. [new 2011] Do not combine an ACE inhibitor with an ARB to treat hypertension. [new 2011] 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. [new 2011] If a diuretic is required, choose a thiazide-like diuretic, such as chlortalidone (12.5 mg25.0 mg once daily) or indapamide (2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [new 2011]

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DRAFT FOR CONSULTATION 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 1.6.14 1.6.10 Beta-blockers are not a preferred initial therapy for hypertension. However, beta-blockers may be considered in younger people, particularly: those with an intolerance or contraindication to ACE inhibitors and angiotensin-II receptor antagonists or women of child-bearing potential or people with evidence of increased sympathetic drive. In these circumstances, if therapy is initiated with a beta-blocker and a second drug is required, add a calcium-channel blocker rather than a thiazide-type diuretic to reduce the persons risk of developing diabetes. [2006] Step 2 treatment 1.6.11 If step 2 antihypertensive treatment is required, offer a CCB in combination with either an ACE Inhibitor or a low-cost ARB. 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 [new 2011] Step 3 treatment 1.6.12 If treatment with three drugs is required, the combination of ACE inhibitor (or angiotensin-II receptor blocker), calcium-channel blocker and thiazide-like diuretic should be used. [2006] Step 4 treatment 1.6.13 Regard clinic blood pressure that remains higher than 140/90 mmHg with the optimal or best tolerated doses of an ACE inhibitor or an ARB plus a CCB plus a diuretic as resistant hypertension and consider adding a fourth antihypertensive drug and/or seeking expert advice. [new 2011] 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 estimated Hypertension: NICE guideline DRAFT (February 2011) Page 17 of 39

DRAFT FOR CONSULTATION 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 1.7.4 1.7.3 1.7.2 1.6.17 1.6.16 1.6.15 glomerular filtration rate is higher than 60 ml/min/1.73m2. If blood potassium levels are higher than 4.5 mmol/l, consider higher-dose thiazide-like diuretic treatment. [new 2011] 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. [new 2011] If further diuretic therapy for resistant hypertension at step 4 is not tolerated, contraindicated or ineffective, consider an alpha- or betablocker. [new 2011] If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs seek expert advice if it has not yet been obtained. [2011]

1.7
1.7.1

Patient education and adherence to treatment

Provide appropriate guidance and materials about the benefits of drugs and the unwanted side effects sometimes experienced in order to help people make informed choices. [2004] People vary in their attitudes to their hypertension and their experience of treatment. It may be helpful to provide details of patient organisations that provide useful forums to share views and information. [2004] Provide an annual review of care to monitor blood pressure, provide people with support and discuss their lifestyle, symptoms and medication. [2004] Because evidence supporting interventions to increase adherence is inconclusive, only use interventions to overcome practical problems associated with non-adherence if a specific need is identified. Target the intervention to the need. Interventions might include: suggesting that patients record their medicine-taking

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DRAFT FOR CONSULTATION 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 encouraging patients to monitor their condition simplifying the dosing regimen using alternative packaging for the medicine using a multi-compartment medicines system. (This recommendation is taken from Medicines adherence, NICE clinical guideline 76). [new 2011]

Notes on the scope of the guidance

NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover. The scope of this guideline is available from www.nice.org.uk/[NICE to add details]. Groups that will be covered Adults with hypertension (18 years and older). Particular consideration will be given to the needs of black people of African and Caribbean descent and minority ethnic groups where these differ from the needs of the general population. People aged 80 years or older. Groups that will not be covered People with diabetes. Children and young people (younger than 18 years). Pregnant women. Secondary causes of hypertension (for example, Conn's adenoma, phaeochromocytoma and renovascular hypertension). People with accelerated hypertension (that is, severe acute hypertension associated grade III retinopathy and encephalopathy). People with acute hypertension or high blood pressure in emergency care settings.

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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). 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446

Implementation

NICE has developed tools to help organisations implement this guidance (see www.nice.org.uk/guidance/CG[XX]).

Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

4.1

Out-of-office monitoring

In adults with primary hypertension, does the use of out-of-office monitoring (HBPM or ABPM) improve response to treatment? Why this is important There is likely to be increasing use of home and ambulatory blood pressure monitoring for the diagnosis of hypertension as a consequence of this guideline update. There are, however, very little data regarding the utility of HBPM or ABPM as means of monitoring blood pressure control or as Hypertension: NICE guideline DRAFT (February 2011) Page 20 of 39

DRAFT FOR CONSULTATION 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 indicators of clinical outcome in treated hypertension, compared with clinic blood pressure monitoring. Studies should incorporate HBPM and/or ABPM to monitor blood pressure responses to treatment and their usefulness as indicators of clinical outcomes.

4.2

Intervention thresholds for people aged under 40 with hypertension

In people aged under 40 with hypertension, what are the appropriate thresholds for intervention? Why this is important There is genuine uncertainty about how to assess the impact of blood pressure treatment in younger people (aged under 40) with stage 1 hypertension, and no overt target organ damage or CVD. In particular, whether those with untreated hypertension are more likely to develop target organ damage and, if so, whether such damage is reversible. Target organ damage and CVD as surrogate or intermediate disease markers are the only indicators that are likely to be feasible in younger people because traditional clinical outcomes are unlikely to occur in sufficient numbers over the time scale of a typical clinical trial. The data will be important to inform treatment decisions for younger people with stage 1 hypertension who do not have overt target organ damage.

4.3

Methods of assessing lifetime CV risk in people aged under 40 with hypertension

In people aged under 40 with hypertension, what is the most accurate method of assessing the lifetime risk of cardiovascular events and the impact of therapeutic intervention on this risk? Why this is important Current short-term (over 10 years) risk estimates are likely to substantially underestimate the lifetime cardiovascular risk of younger people (aged under 40) with hypertension, because short-term risk assessment is powerfully influenced by age. Nevertheless, the lifetime risk associated with untreated

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DRAFT FOR CONSULTATION 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 stage 1 hypertension in this age group could be substantial. Lifetime risk assessments may be a better way to inform treatment decisions and evaluate the cost effectiveness of earlier intervention with pharmacological therapy.

4.4
pressure?

Optimal systolic blood pressure

In people with treated hypertension, what is the optimal systolic blood

Why this is important Data on optimal blood pressure treatment targets, particularly for systolic blood pressure, are inadequate. Current guidance is largely based on the blood pressure targets adopted in clinical trials but there have been no large trials that have randomised people with hypertension to different systolic blood pressure targets and that have had sufficient power to examine clinical outcomes.

4.5

Step 4 treatment

In adults with hypertension, which drug treatment (diuretic therapy versus other step 4 treatments) is the most clinically and cost effective for step 4 treatment? Why this is important Although this guideline provides recommendations on the use of further diuretic therapy for treatment at step 4 (resistant hypertension), they are largely based on post-hoc observational data from clinical trials. More data are needed to compare further diuretic therapies, for example a potassiumsparing diuretic with a higher-dose thiazide-like diuretic, and to compare diuretic therapy with alternative treatment options at step 4 to define whether further diuretic therapy is the best option.

4.6

Automated blood pressure monitoring in people with atrial fibrillation

Which automated blood pressure monitors are suitable for people with hypertension and atrial fibrillation?

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DRAFT FOR CONSULTATION 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 Why this is important Atrial fibrillation may prevent accurate blood pressure measurement with automated devices. It would be valuable to know if this can be overcome.

5
5.1

Other versions of this guideline

Full guideline

The full guideline, Hypertension: the clinical management of primary hypertension in adults contains details of the methods and evidence used to develop the guideline. It is published by the National Clinical Guideline Centre, and is available from our website (www.nice.org.uk/guidance/CG[XX]/Guidance). Note: these details will apply to the published full guideline.

5.2

Quick reference guide

A quick reference guide for healthcare professionals is available from www.nice.org.uk/guidance/CG[XX]/QuickRefGuide For printed copies, phone NICE publications on 0845 003 7783 or email publications@nice.org.uk (quote reference number N[XXXX]). Note: these details will apply when the guideline is published.

5.3

Understanding NICE guidance

A summary for patients and carers (Understanding NICE guidance) is available from www.nice.org.uk/guidance/CG[XX]/PublicInfo For printed copies, phone NICE publications on 0845 003 7783 or email publications@nice.org.uk (quote reference number N[XXXX]). Note: these details will apply when the guideline is published. We encourage NHS and voluntary sector organisations to use text from this booklet in their own information about primary hypertension..

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DRAFT FOR CONSULTATION 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561

Related NICE guidance

Chronic heart failure. NICE clinical guideline 108 (2010). Available from www.nice.org.uk/guidance/CG108 Hypertension in pregnancy. NICE clinical guideline 107 (2010). Available from www.nice.org.uk/guidance/CG107 Prevention of cardiovascular disease at population level. NICE public health guidance 25 (2010). Available from www.nice.org.uk/guidance/PH25 Type 2 diabetes. NICE clinical guideline 87 (2009; updated March 2010 and September 2010). Available from www.nice.org.uk/guidance/CG87 Medicines adherence. NICE clinical guideline 76 (2009). Available from www.nice.org.uk/guidance/CG76 Chronic kidney disease. NICE clinical guideline 73 (2008). Available from www.nice.org.uk/guidance/CG73 Stroke. NICE clinical guideline 68 (2008). Available from www.nice.org.uk/guidance/CG68 Lipid modification. NICE clinical guideline 67 (2008, reissued 2010). Available from www.nice.org.uk/guidance/CG67 Continuous positive airway pressure for the treatment of obstructive sleep apnoea/hypopnoea syndrome. NICE technology appraisal guidance 139 (2008). Available from www.nice.org.uk/guidance/TA139 MI: secondary prevention. NICE clinical guideline 48 (2007). Available from www.nice.org.uk/guidance/CG48 Obesity. NICE clinical guideline 43. Available from www.nice.org.uk/guidance/CG43 Atrial fibrillation. NICE clinical guideline 36 (2006). Available from www.nice.org.uk/guidance/CG36

Updating the guideline

NICE clinical guidelines are updated so that recommendations take into account important new information. New evidence is checked 3 years after publication, and healthcare professionals and patients are asked for their 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 CONSULTATION 562 563 564 565 needs updating. If important new evidence is published at other times, we may decide to do a more rapid update of some recommendations. Please see our website for information about updating the guideline.

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DRAFT FOR CONSULTATION 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591

Appendix A: The Guideline Development Groups, National Collaborating Centres and NICE project team
Guideline Development Group (2011 update)
Bryan Williams (Chair) Professor of Medicine, University of Leicester and University Hospitals of Leicester NHS Trust Helen Williams Consultant Pharmacist for Cardiovascular Disease, Southwark Health and Social Care Jane Northedge Patient and carer member John Crimmins General Practitioner, Vale of Glamorgan Mark Caulfield Professor of Clinical Pharmacology, Barts and the London School of Medicine Michaela Watts Hypertension Nurse Specialist, Addenbrookes Hospital, Cambridge Naomi Stetson Primary Care Nurse, Watling Medical Centre, London Richard McManus Professor of Primary Care Cardiovascular Research, University of Birmingham Shelley Mason Patient and carer member Terry McCormack General Practitioner, Spring Vale Medical Centre, North Yorkshire

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DRAFT FOR CONSULTATION 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615

National Clinical Guideline Centre (2011 update)

Bernard Higgins Clinical Director Kate Lovibond Senior Health Economist Paul Miller Senior Information Scientist Rachel OMahony Senior Research Fellow Taryn Krause Senior Project Manager/Research Fellow

NICE project team (2011 update)

Phil Alderson Associate Director Sarah Dunsdon Guideline Commissioning Manager Andrew Gyton Guideline Coordinator Ruaraidh Hill Technical Lead Prashanth Kandaswamy Health Economist Judy McBride Editor

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DRAFT FOR CONSULTATION 616 617 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642

Guideline Development Group (2006 update)

Dr Bernard Higgins (Chair) Consultant Respiratory Physician, Freeman Hospital; Director, National Collaborating Centre for Chronic Conditions Professor Morris Brown Professor of Medicine, Cambridge University and Addenbrookes Hospital; President, British Hypertension Society Dr Mark Davis General Practitioner, West Yorkshire; Primary Care Cardiovascular Society Professor Gary Ford Consultant Stroke Physician, University of Newcastle and Freeman Hospital; Royal College of Physicians Mr Colin Penney Patient and carer representative Ms Jan Procter-King Nurse Practitioner, West Yorkshire; Primary Care Cardiovascular Society Mrs Jean Thurston Patient and carer representative Professor Bryan Williams Clinical Adviser; Professor of Medicine, University of Leicester School of Medicine and University Hospitals Leicester NHS Trust

National Collaborating Centre for Chronic Conditions (2006 update)

Ms Lina Bakhshi Information Scientist Mr Rob Grant Senior Project Manager; Medical Statistician, Royal College of Physicians

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DRAFT FOR CONSULTATION 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 Mr Mike Hughes Health Services Research Fellow in Guideline Development Dr Ian Lockhart Health Services Research Fellow in Guideline Development Mr Leo Nherera Health Economist; Health Economics Fellow, Queen Mary, University of London

Guideline Development Group (2004 guideline)

Ms Susan L Brent Acting Head of Prescribing Support, Northern and Yorkshire Regional Drug and Therapeutics Centre, Newcastle upon Tyne Dr Paul Creighton General Practitioner, Northumberland Dr William Cunningham General Practitioner, Northumberland Dr Heather Dickinson Technical Support, Newcastle upon Tyne Dr Julie Eccles (Group Leader) General Practitioner, Tyne and Wear Professor Gary Ford Professor of Pharmacology of Old Age and Consultant Physician, Newcastle upon Tyne Dr John Harley General Practitioner, Stockton on Tees Ms Suzanne Laing Nurse Practitioner, Tyne and Wear

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DRAFT FOR CONSULTATION 669 670 671 672 673 674 675 676 677 678 679 Professor James Mason
Methodologist and Technical Support, Newcastle upon Tyne

Mr Colin Penney Patient Representative Dr Wendy Ross

General Practitioner, Newcastle upon Tyne

Mrs Jean Thurston

Patient Representative

Professor Bryan Williams

Professor of Medicine and Director, Cardiovascular Research Unit, Leicester

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DRAFT FOR CONSULTATION 680 681 682 683 684 685 686 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705

Appendix B: The Guideline Review Panels

The Guideline Review Panel is an independent panel that oversees the development of the guideline and takes responsibility for monitoring adherence to NICE guideline development processes. In particular, the panel ensures that stakeholder comments have been adequately considered and responded to. The panel includes members from the following perspectives: primary care, secondary care, lay, public health and industry.

Guideline Review Panel (2011 update)

NICE to add

Guideline Review Panel (2006 update)

Dr Peter Rutherford (Chair)
Senior Lecturer in Nephrology, University of Wales College of Medicine

Dr John Harley
General Practitioner, North Tees PCT

Dr Rob Higgins
Consultant in Renal and General Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry

Dr Kevork Hopayian
General Practitioner, Suffolk

Dr Robert Walker
Clinical Director, West Cumbria Primary Care Trust

Guideline Review Panel (2004 guideline)

Professor Mike Drummond (Chair)
Director, Centre for Health Economics (CHE), University of York

Dr Kevork Hopayian
General Practitioner, Suffolk

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DRAFT FOR CONSULTATION 706 707 708 709 710 711 Mr Barry Stables
Patient/Lay representative

Dr Imogen Stephens
Joint Director of Public Health, Western Sussex Primary Care Trust

Dr Robert Walker
Clinical Director, West Cumbria Primary Care Trust

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Appendix C: The algorithms

Diagnosis of hypertension
Initial clinic blood pressure <140/90 mmHg Initial clinic blood pressure 140/90 mmHg Initial clinic blood pressure 180/110 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.

Blood pressure usually >180/110mmHg Signs or symptoms of papilloedema and/or retinal haemorrhage or suspected phaeochromotcytoma

ABPM/HBPM <135/85 mmHg

ABPM/HBPM 135/85 mmHg

ABPM/HBPM 150/90 mmHg

Severe hypertension

Normotensive

Stage 1 hypertension

Stage 2+ hypertension

Evidence of target organ damage**

Accelerated hypertension

No target organ damage No established CVD 10-year CV risk <20%

Target organ damage present 10-year CV risk >20%

Start antihypertensive drug treatment immediately

Refer for specialist care immediately

Lower risk Higher risk Person younger than 40 Person 40 or older

*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

Consider treatment/specialist referral

Offer antihypertensive drug treatment

Review blood pressure at least every 12 months

guideline 67)

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Antihypertensive drug treatment

Key

People aged < 55 years

People aged 55 years and all black people of African or Caribbean descent

A = ACE inhibitor or angiotensin II receptor blocker C = calcium-channel blocker (CCB) D = thiazide-like diuretic

Step 1

C*

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

Step 2

A + C*

Step 3

A+C+D

Step 4 (resistant hypertension)

A + C + D + further diuretic** or alpha-blocker or beta-blocker Consider seeking specialist advice.

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Appendix D: Recommendations to be deleted

Recommendation
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) 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)

Comment
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. 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. 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. 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.

Measure blood pressure on both of the patients arms with the higher value identifying the reference arm for future measurement. (Recommendation 1.1.5 in 2006 guideline)

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) 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 persons 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) 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) 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) 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) Test for the presence of protein in the patients 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) Drug therapy reduced the risk of cardiovascular disease and death. Offer

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). The evidence for automated ambulatory blood pressure monitoring (ABPM) was reviewed in the 2011 update.

We are now recommending ABPM routinely for diagnosis.

This has been clarified in new recommendations in the 2011 update.

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. 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. 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. Replaced by: Offer step 1 antihypertensive treatment with an angiotensin-converting enzyme (ACE) inhibitor or a low-cost angiotensinII receptor blocker (ARB) to people aged 55 years and younger. If an ACE inhibitor is not tolerated, offer an ARB. 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. 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

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 thiazidetype 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) 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) 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)

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

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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. 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. 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 This algorithm has been superseded in the 2011 guidance.

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)

If initial therapy was with a calciumchannel 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 calciumchannel blocker or a thiazide-type diuretic. (Recommendation 1.4.6 in 2006 guideline) 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) 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 betablocker with an alternative agent. (Recommendation 1.4.13 in 2006 guideline)

This recommendation was relevant in 2006, as many people were taking betablockers 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) 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) 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) 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) As above the 2006 guideline recommended that beta-blockers should not be used as a first line treatment for hypertension.

Replaced by: Offer people older than 80 years the same antihypertensive treatment as people aged 55-80 years, taking into account any comorbidities. This recommendation doesnt add any value it is a redundant recommendation so therefore has been removed.

This has been superseded by NICE guidance on lifestyle.

712

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