Change in NICE guidelines for treatment of hypertension

Nicola Xiang, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP

NICE published new guidelines last month regarding the treatment of hypertension in the UK, developed in partnership with the British Hypertension Society

A summary of the vital points are as follows:

  1. For people aged over 80, a target blood pressure (BP) of lower than 150/90mmHg is recommended, relaxed from 140/90.
  2. Thiazides should no longer be one of the recommended first line drugs for over 55s and black people of African/Caribbean descent. Calcium channel blockers should be the preferred drug treatment for patients in these categories and angiotensin receptor inhibitors or angiotensin receptor blockers (if side effects such as cough persist) for the rest of the population.
  3. Second line treatment should be with thiazide-like diuretics e.g. chlortalidon in preference to conventional diuretics e.g. bendroflumothiazide.
  4. Ambulatory monitoring should be offered to all patients with BP over 140/90mmHg in the clinic, although for BP over 180/110mmHg, immediate treatment should be considered. Ambulatory monitoring involves taking 2 pressure readings/hour over the patient’s normal waking hours and taking the average of 14 readings.
  5. If ambulatory monitoring is not tolerated, offer home blood pressure monitoring (twice daily recordings for ideally 7 days).

The main controversy surrounds the use of ambulatory monitoring which has the potential to radically change the diagnosis of hypertension. Although there is evidence to suggest that ambulatory monitoring better identifies the patients who are likely to have cardiovascular events for treatment (1), its benefits compared to home blood pressure monitoring remain uncertain (2).

The BMJ suggest that due to the outstanding questions regarding ambulatory monitoring including summary readings and frequency of assessment (3), GP consortiums need to work with secondary care centres to develop this change in the diagnosis of hypertension.

References: 

(1) Verdecchia P. Prognostic Value of Ambulatory Blood Pressure : Current Evidence and Clinical Implications. Hypertension 2000 Mar;35(3):844 -851.

(2) Hodgkinson J, Mant J, Martin U, Guo B, Hobbs FDR, Deeks JJ, Heneghan C, Roberts N, McManus RJ. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review [Internet]. BMJ 2011 Jun;342Available from: http://www.bmj.com/content/342/bmj.d3621.abstract
doi: 10.1136/bmj.d3621

(3) Ritchie LD, Campbell NC, Murchie P. New NICE guidelines for hypertension [Internet]. BMJ 2011;343Available from: http://www.bmj.com/content/343/bmj.d5644.short
doi: 10.1136/bmj.d5644

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