Hypertension NICE CG127 August 2011

Hypertension is not a disease it is a risk factor for cardiovasuclar disease (CVD)-it is a modifiable

risk factor

Key ChangesAmbulatory blood pressure is suggested as the

investigation of choice for all with suspected hypertension. Home readings are an alternative,. Clinic BP readings are no longer recommended for the diagnosis of hypertension,

Hypertension is now defined as stage 1 and stage 2. This affects who we treat.

The threshold blood pressure for offering drug therapy has changed, partly reflecting the move to ambulatory BP monitoring.

Diuretics have moved to third line drugs after ACE inhibitors and calcium channel blockers

The thiazide-like diuretic of choice is now indapamide or chlortalidone rather than bendroflumethiazide or hydrochlorothiazide. NICE say that those already established on bendroflumethiazide or hydrochlorothiazide need not be changed to chlortalidone or indapamide

Ambulatory BP readingsUse a device that records at least 2

measurements/hour during waking hours.

You need to have at least 14 readings to average.

In the past we added 10/5 to ABPM before making decisions – there is no need to do this now, since the decision flow charts are based on ABPM not clinic readings.

Home BP monitoring (HBPM)Take readings morning and evening for at least

4d, preferably 7d.

On each occasion take 2 readings≥1min apart, whilst seated.

Discard the first day's readings, and average the remaining readings.

Care pathway

CBPM ≥160/100 mmHg & ABPM/HBPM

≥ 150/95 mmHg

Stage 2 hypertension

Consider specialist referral

Offer antihypertensive drug treatment

Offer lifestyle interventions

If younger than 40 years

If target organ damage present or 10-year cardiovascular risk > 20%

Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

Offer patient education and interventions to support adherence to treatment

CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg

Stage 1 hypertension

Assessing CV risk and target organ damage: updated recommendations

Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension.

For all people with hypertension offer to:

–test urine for presence of protein–take blood to measure glucose, electrolytes, creatinine, eGFR and cholesterol–examine fundi for hypertensive retinopathy–arrange a 12-lead ECG.

Step 4

Summary of antihypertensive drug treatment

Aged over 55 years or black person of African or Caribbean family origin of any age

Aged under55 years

C2A

A + C2

A + C + D

Resistant hypertension

A + C + D + consider further diuretic3, 4 or alpha- or

beta-blocker5

Consider seeking expert advice

Step 1

Step 2

Step 3

KeyA – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic

See slide notes for details of footnotes 1-5

Drug therapyAim for drugs to be taken once a dayDo not use ACE inhibitors and Angiotensis

receptor antagonists together (no additional benefit and increased risk of s/e)

Treat women of child bearing age in line with NICE guidelines on hypertension in pregnancy

Treat isolated systolic BP in same way as if both were raised SBP>160

NICE prefer Chlortalidone 12.5mg-25mg daily or indapamide 1.5mg MR od or 2.5mg od

What are the cost differences?Based on drug tariff price (Dec 2010) monthly costs are:

Bendroflumethiazide (2.5mg)£0.79 for 28  

Chlortalidone (50mg) £1.77 for 28Indapamide ordinary release

2.5mg £1.27 for 28 £2.01 for 56 cheapest.Indapamide slow release 1.5mg £3.40 for 30

Monitoring drug treatment (1)

Use clinic blood pressure measurements to monitor response to treatment. Aim for target blood pressure below:

140/90 mmHg in people aged under 80150/90 mmHg in people aged 80 and over

Monitoring drug treatment (2)For people identified as having a ‘white-coat effect’ consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor response to treatment.

Aim for ABPM/HBPM target average of:below 135/85 mmHg in people aged under 80below 145/85 mmHg in people aged 80 and over.

White-coat effect: a discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.

Additional recommendationsLifestyle interventionsOffer guidance and advice about:

– diet (including sodium and caffeine intake) and exercise

– alcohol consumption

– smoking.

Patient education and adherenceProvide:

– information about benefits of drugs and side effects

– details of patient organisations

– an annual review of care.

SummaryAmbulatory blood pressure investigation of

choiceClinic BP readings no longer recommended

for diagnosis of hypertensionCan be used to monitor treatmentHypertension defined as stage 1 and 2Thresholds of treatments has changed

reflecting ambulatory BP monitoring

Diuretics have moved to 3rd line after ACE inhibitors and calcium channel blockers

Thiazide-like diuretic of choice is indapamide or chlortalidone

(no need to changed established)