New NICE guidelines reduce treatment threshold for high BP to 10% from 20% of CVD risk

According to the guideline, patients with hypertension aged under 80 with an estimated 10-year risk of cardiovascular disease of 10% or more should be offered blood pressure-lowering drugs. This represents a large reduction in the treatment threshold for hypertension, which was previously set at a 20% risk of cardiovascular disease.

It continues to use a blood pressure reading of 140/90mmHg and above as the level used to define hypertension.

The change would have a “significant impact on practice” with many more people becoming eligible for treatment, meaning more time and resources needed to start and monitor patients on antihypertensive drugs, said NICE.

It includes recommendations on measuring blood pressure, diagnosing hypertension, assessing cardiovascular risk and target organ damage, treating and monitoring hypertension and identifying who to refer for same-day specialist review.

Measuring blood pressure

• 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. Use an appropriate cuff size for the person's arm.

Diagnosing hypertension

• When considering a diagnosis of hypertension, measure blood pressure in both arms:
  
  
  
  • If the difference in readings between arms is more than 15 mmHg, repeat the measurements.
  
  
  • If the difference in readings between arms remains more than 15 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading.
  
  
  
  


• If blood pressure measured in the clinic is 140/90 mmHg 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 2 measurements as the clinic blood pressure.
  
  
  
  


• If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.


• If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension.


• While waiting for confirmation of a diagnosis of hypertension, carry out:
  
  
  
  • investigations for target organ damage, followed by
  
  
  • a formal assessment of cardiovascular risk using a cardiovascular risk assessment tool.
  
  
  
  


• Confirm the diagnosis of hypertension in people with a:
  
  
  
  • clinic blood pressure of 140/90 mmHg or higher and
  
  
  • ABPM daytime average or HBPM average of 135/85 mmHg 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 glycated haemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol
  
  
  • examine the fundi for the presence of hypertensive retinopathy
  
  
  • arrange for a 12-lead electrocardiograph to be performed.
  
  
  
  

Treating and monitoring hypertension

Lifestyle interventions

• Ask about people's alcohol consumption and encourage a reduced intake if they drink excessively because this can reduce blood pressure and has broader health benefits.

Starting antihypertensive drug treatment

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


• Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:
  
  
  
  • target organ damage
  
  
  • established cardiovascular disease
  
  
  • renal disease
  
  
  • diabetes
  
  
  • the estimated 10-year risk of cardiovascular disease of 10% or more.
  
  
  
  


• Discuss with the person their individual cardiovascular disease risk and their preferences for treatment, including no treatment, and explain the risks and benefits 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.


• Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. Bear in mind that 10-year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease.


• Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with a clinic blood pressure of over 150/90 mmHg. 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 benefit and risks.

Monitoring treatment and blood pressure targets

• Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension.


• Measure standing as well as seated blood pressure in people with hypertension and:
  
  
  
  • with type 2 diabetes or
  
  
  • with symptoms of postural hypotension or
  
  
  • aged 80 and over.
  
  
  
  


• In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure.


• Advise people with hypertension who choose to self-monitor their blood pressure to use HBPM.


• Consider ABPM or HBPM, in addition to clinic blood pressure measurements, for people with hypertension identified as having a white-coat effect or masked hypertension. Be aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurements.


• For people who choose to use HBPM, provide:
  
  
  
  • training and advice on using home blood pressure monitors
  
  
  • information about what to do if they are not achieving their target blood pressure.
  
  
  
  


• Be aware that the corresponding measurements for HBPM are 5 mmHg lower than for clinic measurements.


• Reduce clinic blood pressure to below 140/90 mmHg and maintain that level in adults with hypertension aged under 80.


• Reduce clinic blood pressure to below 150/90 mmHg and maintain that level in adults with hypertension aged 80 and over.


• When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person's usual waking hours. Reduce and maintain blood pressure at the following levels:
  
  
  
  • below 135/85 mmHg for adults aged under 80
  
  
  • below 145/85 mmHg for adults aged 80 and over.
  
  
  
  


• Use clinical judgement for people with frailty or multimorbidity.

Choosing antihypertensive drug treatment (for people with or without type 2 diabetes)

• Offer antihypertensive drug treatment to women of childbearing potential with diagnosed hypertension in line with the recommendations in this guideline.


• When choosing antihypertensive drug treatment for adults of black African or African–Caribbean family origin, consider an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor.

Step 1 treatment

• Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:
  
  
  
  • have type 2 diabetes and are of any age or family origin (see also recommendation 1.4.29 for adults of black African or African–Caribbean family origin) or
  
  
  • are aged under 55 but not of black African or African–Caribbean family origin.
  
  
  
  


• If an ACE inhibitor is not tolerated, for example, because of cough, offer an ARB to treat hypertension.


• Do not combine an ACE inhibitor with an ARB to treat hypertension.


• Offer a calcium-channel blocker (CCB) to adults starting step 1 antihypertensive treatment who:
  
  
  
  • are aged 55 or over and do not have type 2 diabetes or
  
  
  • are of black African or African–Caribbean family origin and do not have type 2 diabetes (of any age).
  
  
  
  


• If a CCB is not tolerated, for example, because of oedema, offer a thiazide-like diuretic to treat hypertension.


• If there is evidence of heart failure, offer a thiazide-like diuretic and follow NICE's guideline on chronic heart failure.


• If starting or changing diuretic treatment for hypertension, offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.


• For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment.

Step 2 treatment

• Before considering next step treatment for hypertension discuss with the person if they are taking their medicine as prescribed and support adherence in line with NICE's guideline on medicines adherence.


• If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step 1 treatment:
  
  
  
  • a CCB or
  
  
  • a thiazide-like diuretic.
  
  
  
  


• If hypertension is not controlled in adults taking step 1 treatment of a CCB, offer the choice of 1 of the following drugs in addition to step 1 treatment:
  
  
  
  • an ACE inhibitor or
  
  
  • an ARB or
  
  
  • a thiazide-like diuretic.
  
  
  
  


• If hypertension is not controlled in adults of black African or African–Caribbean family origin who do not have type 2 diabetes taking step 1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step 1 treatment.

Step 3 treatment

• Before considering next step treatment for hypertension:
  
  
  
  • review the person's medications to ensure they are being taken at the optimal tolerated doses and
  
  
  • discuss adherence
  
  
  
  


• If hypertension is not controlled in adults taking 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 in adults taking the optimal tolerated doses of an ACE inhibitor or an ARB plus a CCB and a thiazide-like diuretic, regard them as having resistant hypertension.


• Before considering further treatment for a person with resistant hypertension:
  
  
  
  • Confirm elevated clinic blood pressure measurements using ambulatory or home blood pressure recordings.
  
  
  • Assess for postural hypotension.
  
  
  • Discuss adherence.
  
  
  
  


• For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice.


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


• When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium and potassium and renal function within 1 month of starting treatment and repeat as needed thereafter.


• Consider an alpha-blocker or beta-blocker for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4.5 mmol/l.


• If blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4 drugs, seek specialist advice.

Identifying who to refer for same-day specialist review

• If a person has severe hypertension (clinic blood pressure of 180/120 mmHg or higher), but no symptoms or signs indicating same-day referral, carry out investigations for target organ damage as soon as possible:
  
  
  
  • If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
  
  
  • If no target organ damage is identified, repeat clinic blood pressure measurement within 7 days.
  
  
  
  


• Refer people for specialist assessment, carried out on the same day if they have a clinic blood pressure of 180/120 mmHg and higher with:
  
  
  
  • signs of retinal haemorrhage or papilloedema (accelerated hypertension) or
  
  
  • life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury.
  
  
  
  


• Refer people for specialist assessment, carried out on the same day if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis)