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The management of hypertension in primary care: updated guidance from NICE
Volume 17 Number 1
September 2006

Part 1 — Key points        

Estimating CVD risk
Measurement of blood pressure (BP)
Lifestyle advice
When to initiate drug treatment
Treatment targets
Which drugs to use
Treatment review

Hypertension is a major modifiable risk factor for cardiovascular disease (CVD). However, treating hypertension should not be viewed in isolation. Other interventions, such as statins and aspirin, should be considered, where appropriate, based on a person’s history of CVD or an assessment of their CVD risk.

Estimating CVD risk

• Health professionals should use a validated risk assessment tool, such as that produced by the Joint British Societies (JBS), as an aid for deciding when treatment is necessary. The latest version of the JBS chart is available in the BNF.

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Measurement of blood pressure (BP)

• Accurate measurement of BP needs good clinical technique using properly validated, maintained and regularly re-calibrated devices.
• Several BP measurements are usually required before hypertension is diagnosed. Patients with initial BP >140/90mmHg should be asked to return for at least two further visits. BP should be measured twice on each occasion under the best possible conditions.
• Patients with more severely raised BP should be re-evaluated more urgently.

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Lifestyle advice

• Lifestyle advice should be offered to all patients on an on-going basis. Support and guidance should be given to make appropriate changes in lifestyle and to maintain these changes in the long-term.

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When to initiate drug treatment

• Drug therapy should be offered to patients with persistent high BP of 160/100mmHg or more, and patients at raised CVD risk (10-year risk of CVD of 20% or more, or existing CVD or target organ damage) with persistent BP of >140/90mmHg.

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Treatment targets

• NICE guidance recommends a BP treatment target of <140/90mmHg for non-diabetic patients.
• Lower BP targets are recommended for those with diabetes in NICE diabetes guidelines (type 2 diabetes: <140/80mmHg, or <135/75mmHg if microalbuminuria or proteinuria is present; type 1 diabetes: <135/85mmHg, or <130/80mmHg with nephropathy).
• Patients who are at the highest baseline risk of CVD have the most to gain from lowering of BP.  Although it may not be possible to achieve target in all patients, any lowering of BP is beneficial. Aim to achieve the largest reduction possible towards the target, taking into account tolerability and concordance for each individual patient.

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Which drugs to use

• Where drug treatment is necessary for people newly diagnosed with hypertension, low-dose thiazide diuretics, calcium-channel blockers (CCBs), or angiotensin-converting enzyme inhibitors (ACEIs) can be considered as initial treatment choices. However, in some circumstances, there may be compelling reasons to choose a β-blocker (e.g. ischaemic heart disease).
• In general, there is no compelling evidence of any clinically significant, drug-specific effects to distinguish between drugs in terms of efficacy (within or between classes) when their BP lowering effect is taken into account. However, there may be some benefits for particular drug classes in specific patient groups. Choice should be based on individual patient factors, side-effect profiles, and costs.
• In June 2006, NICE updated its guidance on the drug treatment of hypertension. Recommendations were made following a systematic review of randomised controlled trial (RCT) data and a health economic analysis. In view of the limitations and uncertainties of the clinical evidence and economic analysis, many of the recommendations were based on pathophysiological grounds and expert opinion/consensus.
• The systematic review of RCTs found no difference between the classes of drug with regard to the risk of death or myocardial infarction. However, β-blockers were considered less effective than comparator drugs in reducing the risk of stroke. Thiazide diuretics and CCBs were considered the most likely drugs to confer benefits in cardiovascular outcomes, except possibly in younger patients.
• The economic analysis slightly favoured CCBs, with thiazide diuretics being the next most cost effective option for drug treatment. CCBs were associated with additional higher costs (NHS and social services) of about £12,000–£13,000 per quality adjusted life year (QALY) gained (i.e. a gain of one year of life in good health) compared with thiazide diuretics. This additional cost was considered affordable to the NHS, provided that the cost of CCBs was not more than £105 per year (£8 per 28 days).
• NICE recommends that diuretics or CCBs should be considered as equal first-line choices for people who are black (i.e. of African or Caribbean descent, not mixed race, Asian or Chinese) or aged 55 years or older. As the recommendations do not distinguish between thiazide diuretics or CCBs for these patients, prescribers may decide to use low-dose diuretics preferentially in view of their lower acquisition costs, unless there are good reasons to do otherwise.
• ACEIs are recommended for people aged less than 55 years. Where an ACEI is indicated but not tolerated (e.g. because of cough) an angiotensin-II receptor antagonist (AIIRA) is appropriate.
• Unless there are compelling reasons to do otherwise, β-blockers should not generally be used initially and they are best avoided in combination with thiazide diuretics because of the increased risk of developing diabetes. However, β-blockers are a suitable first-line alternative to ACEIs in younger people if ACEIs are contraindicated (e.g. in pregnancy) or not tolerated.
• Many patients will require more than one drug to achieve BP control. Where the first-line drug does not adequately control BP, NICE recommends that drugs should be added in a sequential manner according to the algorithm shown in Figure 1. Although not recommended by NICE, some patients may respond adequately if their first-line drug is switched to a drug of an alternative class.
• Where a combination of a diuretic, an ACEI and a CCB, is not effective in controlling BP, adding an α-blocker, using a high-dose or an additional diuretic, or adding a β-blocker can be considered. Referral to a specialist should also be considered at this stage.
• Treatment of patients with hypertension and diabetes was not considered in the development of the updated NICE guideline, and although not explicitly stated, the recommendations do not apply to patients with diabetes. In these people, a thiazide diuretic or an ACEI is an appropriate first-line choice, with a combination of these two drugs being used should BP control not be achieved. An ACEI should be used first-line where there is evidence of nephropathy.

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Treatment review

• Actively review patients' response to treatment. Any changes to treatment should respect patients' views.
• All patients should have an annual review of care.

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Figure 1. NICE algorithm for the drug treatment of patients with newly diagnosed hypertension1 Click here to return to Which drugs to use section
A = ACEI (AIIRA if intolerant), C = calcium channel blocker, D = thiazide diuretic † of African or Caribbean descent, and not mixed race, Asian or Chinese ‡ β-blockers are an alternative to A in patients younger than 55 years if A is not tolerated or is contraindicated (including women of childbearing potential)

Reference

1. National Institute for Health and Clinical Excellence. Hypertension: management of hypertension in adults in primary care (partial update of NICE clinical guideline 18). Clinical Guideline 34. June 2006. Accessed from www.nice.org.uk on 22/08/06

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