nice guideline of hypertension

DRAFT FOR CONSULTATION

Hypertension: NICE guideline DRAFT (February 2011) of 39

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.



Contents

Introduction ............................................................................................................... 4

Person-centred care .................................................................................................. 5

Key priorities for implementation ............................................................................... 6

1 Guidance ........................................................................................................... 9

1.1 Measuring blood pressure ........................................................................... 9

1.2 Diagnosing hypertension ........................................................................... 10

1.3 Assessing cardiovascular risk ................................................................... 13

1.4 Lifestyle interventions ................................................................................ 13

1.5 Initiating and monitoring antihypertensive drug treatment, including blood

pressure targets .................................................................................................. 14

1.6 Choosing antihypertensive drug treatment ................................................ 15

1.7 Patient education and adherence to treatment .......................................... 18

2 Notes on the scope of the guidance................................................................. 19

3 Implementation ................................................................................................ 20

4 Research recommendations ............................................................................ 20

4.1 Out-of-office monitoring ............................................................................. 20

4.2 Intervention thresholds for people aged under 40 with hypertension ......... 21

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

hypertension ........................................................................................................ 21

4.4 Optimal systolic blood pressure ................................................................. 22

4.5 Step 4 treatment........................................................................................ 22

4.6 Automated blood pressure monitoring in people with

atrial fibrillation .................................................................................................... 22

5 Other versions of this guideline ........................................................................ 23

6 Related NICE guidance ................................................................................... 24

7 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



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

http://guidance.nice.org.uk/CG34



Introduction 1

High blood pressure (hypertension) is one of the most important preventable 2

causes of premature morbidity and mortality in the UK. Hypertension is a 3

major risk factor for stroke (ischaemic and haemorrhagic), myocardial 4

infarction, heart failure, chronic kidney disease, cognitive decline and 5

premature death. Untreated hypertension is usually associated with a 6

progressive rise in blood pressure. The vascular and renal damage that this 7

may cause can culminate in a treatment-resistant state. 8

Blood pressure is normally distributed in the population and there is no natural 9

cut-off point above which 'hypertension' definitively exists and below which it 10

does not. The risk associated with increasing blood pressure is continuous, 11

with each 2 mmHg rise in systolic blood pressure associated with a 7% 12

increased risk of mortality from ischaemic heart disease and a 10% increased 13

risk of mortality from stroke. Hypertension is remarkably common in the UK 14

and the prevalence is strongly influenced by age. In any individual person, 15

systolic and/or diastolic blood pressures may be elevated. Diastolic pressure 16

is more commonly elevated in younger people, that is, those younger than 17

50 years. With ageing, systolic hypertension becomes a more significant 18

problem, as a result of progressive stiffening and loss of compliance of larger 19

arteries. At least one quarter of adults (and more than half of those older than 20

60) have high blood pressure. 21

The clinical management of hypertension is one of the most common 22

interventions in primary care, accounting for approximately £1 billion in drug 23

costs alone in 2006. 24

The guideline will assume that prescribers will use a drug’s summary of 25

product characteristics to inform decisions made with individual patients. 26



Person-centred care 27

This guideline offers best practice advice on the care of adults with 28

hypertension. 29

Treatment and care should take into account people’s needs and preferences. 30

People with hypertension should have the opportunity to make informed 31

decisions about their care and treatment, in partnership with their healthcare 32

professionals. If people do not have the capacity to make decisions, 33

healthcare professionals should follow the Department of Health’s advice on 34

consent (available from www.dh.gov.uk/consent) and the code of practice that 35

accompanies the Mental Capacity Act (summary available from 36

www.publicguardian.gov.uk). In Wales, healthcare professionals should follow 37

advice on consent from the Welsh Assembly Government (available from 38

www.wales.nhs.uk/consent). 39

Good communication between healthcare professionals and people with 40

hypertension is essential. It should be supported by evidence-based written 41

information tailored to the person’s needs. Treatment and care, and the 42

information people are given about it, should be culturally appropriate. It 43

should also be accessible to people with additional needs such as physical, 44

sensory or learning disabilities, and to people who do not speak or read 45

English. 46

If the person agrees, families and carers should have the opportunity to be 47

involved in decisions about treatment and care. 48

Families and carers should also be given the information and support 49

they need. 50

51

http://www.dh.gov.uk/consent

http://www.publicguardian.gov.uk/

http://www.wales.nhs.uk/consent



Key priorities for implementation 52

The following recommendations have been identified as priorities for 53

implementation. 54

Diagnosing hypertension 55

If the first and second blood pressure measurements taken during a 56

consultation are 140/90 mmHg or higher, offer 24-hour ambulatory blood 57

pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new 58

2011] [1.2.2] 59

When using ABPM to confirm a diagnosis of hypertension, ensure that: 60

Blood pressure is measured for a total of 24 hours. 61

At least two measurements per hour are taken during the day (08:00 to 62

22:00). 63

At least one measurement per hour is taken during the night (22:00 to 64

08:00). 65

Use the average daytime blood pressure measurement, calculated using a 66

minimum of 14 daytime measurements, to confirm a diagnosis of 67

hypertension. [new 2011] [1.2.6] 68

When using home blood pressure monitoring (HBPM) to confirm a 69

diagnosis of hypertension, ensure that: 70

For each blood pressure measurement, two consecutive measurements 71

are taken, at least 1 minute apart and with the person seated (see 1.1.4). 72

Blood pressure measurements are taken twice daily, ideally in the 73

morning and evening. 74

Blood pressure measurement continues for at least 4 days, ideally for 75

7 days. 76

Discard the measurements taken on the first day and use the average 77

value of all the remaining measurements to confirm a diagnosis of 78

hypertension. [new 2011] [1.2.7] 79

80



Initiating and monitoring antihypertensive drug treatment, including 81

blood pressure targets 82

Initiating treatment 83

Offer antihypertensive drug treatment to people with stage 1 hypertension 84

who have: 85

target organ damage or 86

established cardiovascular disease or 87

renal disease or 88

diabetes or 89

a 10-year cardiovascular risk equivalent to 20% or greater. [new 2011] 90

91

Offer antihypertensive drug treatment to people with stage 2 hypertension. 92

[new 2011] [1.5.2] 93

For people younger than 40 years with stage 1 hypertension and no 94

evidence of target organ damage, cardiovascular (CV) disease, renal 95

disease or diabetes, consider seeking specialist evaluation of secondary 96

causes of hypertension and a more detailed assessment of potential target 97

organ damage. This is because 10-year CV risk assessments can 98

underestimate the lifetime risk of CV events in these people [new 2011] 99

[1.5.3] 100

Monitoring treatment and blood pressure targets 101

For people with a discrepancy of more than 20/10 mmHg between clinic 102

blood pressure measurements and ABPM or HBPM average 103

measurements, consider using daytime average ABPM or average HBPM 104

for monitoring the response to antihypertensive treatment. Aim for a target 105

ABPM or HBPM blood pressure of 135/85 mmHg or lower. [new 2011] 106

[1.5.6] 107



Choosing antihypertensive drug treatment 108

Offer people older than 80 years the same antihypertensive drug treatment 109

as people aged 55–80 years, taking into account any comorbidities. [new 110

2011] [1.6.4] 111

Step 1 treatment 112

Offer step 1 antihypertensive treatment with a calcium-channel blocker 113

(CCB) to people aged 55 years and older and to black people of African 114

and Caribbean descent of any age. If a CCB is not suitable, for example 115

because of oedema or intolerance, or if there is evidence of heart failure or 116

a high risk of heart failure, offer a thiazide-like diuretic. [new 2011] [1.6.8] 117

If a diuretic is required, choose a thiazide-like diuretic, such as 118

chlortalidone (12.5 mg–25.0 mg once daily) or indapamide (2.5 mg once 119

daily) in preference to a conventional thiazide diuretic such as 120

bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.9] 121


For treatment of resistant hypertension at step 4, consider further diuretic 123

therapy with low-dose spironolactone (25 mg once daily) if blood potassium 124

levels are lower than 4.5 mmol/l and estimated glomerular filtration rate is 125

higher than 60 ml/min/1.73m2. If blood potassium levels are higher than 126

4.5 mmol/l, consider therapy with a higher-dose thiazide-like diuretic. [new 127

2011] [1.6.14] 128

129

130



1 Guidance 131

The following guidance is based on the best available evidence. The full 132

guideline (www.nice.org.uk/guidance/CGXXX) gives details of the methods 133

and the evidence used to develop the guidance. 134

Definitions 135

In this guideline the following definitions are used. 136

Stage 1 hypertension: initial clinic blood pressure 140/90 mmHg or higher 137

and subsequent ambulatory blood pressure monitoring (ABPM) daytime 138

average or home blood pressure monitoring (HBPM) average blood 139

pressure 135/85 mmHg or higher. 140

Stage 2 hypertension: initial clinic blood pressure 160/100 mmHg or 141

higher and subsequent ABPM daytime average or HBPM average blood 142

pressure 150/95 mmHg or higher. 143

Severe hypertension: clinic blood pressure 180/110 mmHg or higher. 144

1.1 Measuring blood pressure 145

1.1.1 Healthcare professionals taking blood pressure measurements 146

need adequate initial training and periodic review of their 147

performance. [2004] 148

1.1.2 Because automated devices may not measure blood pressure 149

accurately if there is pulse irregularity (for example, due to atrial 150

fibrillation), palpate the radial or brachial pulse before measuring 151

blood pressure. If pulse irregularity is present, measure blood 152

pressure manually using direct auscultation over the brachial 153

artery. [new 2011] 154

1.1.3 Healthcare providers must ensure that devices for measuring blood 155

pressure are properly validated, maintained and regularly 156

recalibrated according to manufacturers’ instructions. [2004] 157



1.1.4 When measuring blood pressure in the clinic or in the home, 158

standardise the environment and provide a relaxed, temperate 159

setting, with the person quiet and seated, and their arm 160

outstretched and supported. [new 2011] 161

1.1.5 Use an ABPM device that is validated and is of an appropriate cuff 162

size for the person’s arm. [new 2011] 163

1.1.6 Measure blood pressure in both arms: 164

If the difference in readings between arms is more than 165

20 mmHg, repeat the measurements. 166

If the difference in readings between arms remains more than 167

20 mmHg on the second measurement, measure subsequent 168

blood pressure in the arm with the higher reading. [new 2011] 169

1.1.7 In people with symptoms of postural hypotension (falls or postural 170

dizziness): 171

Measure blood pressure with the person either supine or seated. 172

Measure blood pressure again with the person standing. [2004, 173

amended 2011] 174

1.1.8 If the systolic blood pressure falls by 20 mmHg or more when the 175

person is standing: 176

Review medication. 177

Measure subsequent blood pressures with the person standing. 178

Consider referral to specialist care if symptoms of postural 179

hypotension persist. [2004, amended 2011] 180

1.2 Diagnosing hypertension 181

1.2.1 If blood pressure measured in the clinic is 140/90 mmHg or higher: 182

Take a second measurement during the consultation. 183



If the second measurement is substantially different from the 184

first, take a third measurement. 185

Use the lower of the last two measurements to diagnose 186

hypertension. [new 2011] 187

1.2.2 If the first and second blood pressure measurements taken during 188

a consultation are both 140/90 mmHg or higher, offer 24-hour 189

ambulatory blood pressure monitoring (ABPM) to confirm the 190

diagnosis of hypertension. [new 2011] 191

1.2.3 If a person is unable to tolerate ABPM, home blood pressure 192

monitoring (HBPM) is a suitable alternative to confirm the diagnosis 193

of hypertension. [new 2011] 194

1.2.4 If the person has severe hypertension and evidence of target organ 195

damage, start antihypertensive drug treatment immediately; do not 196

wait for the results of ABPM or HBPM. [new 2011]. 197

1.2.5 When considering a diagnosis of hypertension, carry out 198

appropriate investigations for target organ damage and a formal 199

assessment of cardiovascular (CV) risk using a CV risk 200

assessment tool, in line with ‘Lipid modification’ (NICE clinical 201

guideline 67). [new 2011] 202

1.2.6 When using ABPM to confirm a diagnosis of hypertension, 203

ensure that: 204

blood pressure is measured for a total of 24 hours 205

at least two measurements per hour are taken during the day 206

(08:00 to 22:00) 207

at least one measurement per hour is taken during the night 208

(22:00 to 08:00). 209

Use the average daytime blood pressure measurement, calculated 210

using a minimum of 14 daytime measurements, to confirm a 211





1.2.7 When using home blood pressure monitoring (HBPM) to confirm a 213

diagnosis of hypertension, 214

ensure that: 215

For each blood pressure measurement, two consecutive 216

measurements are taken, at least 1 minute apart and with the 217

person seated (see 1.1.4). 218

Blood pressure measurements are taken twice daily, ideally in 219

the morning and evening. 220

Blood pressure measurement continues for at least 4 days, 221

ideally for 7 days. 222

Discard the measurements taken on the first day and use the 223

average value of all the remaining measurements to confirm a 224


1.2.8 Immediately refer people with the following signs for specialist care: 226

accelerated hypertension (blood pressure usually higher than 227

180/110 mmHg with signs of papilloedema and/or retinal 228

haemorrhage) 229

suspected phaeochromocytoma (labile or postural hypotension, 230

headache, palpitations, pallor and diaphoresis). [2004, 231

amended 2011] 232

1.2.9 Consider the need for specialist investigations in people with signs 233

and symptoms suggesting a secondary cause of hypertension. 234

[2004, amended 2011] 235



1.3 Assessing cardiovascular risk 236

1.3.1 Use a formal estimation of cardiovascular risk to discuss prognosis 237

and healthcare options with people with hypertension, both for 238

raised blood pressure and other modifiable risk factors. [2004] 239

1.3.2 Estimate cardiovascular risk in line with recommendations 1.1.7, 240

1.1.8, 1.1.10, 1.1.11, 1.1.13, 1.1.21 and 1.1.22 in ‘Lipid 241

modification’ (NICE clinical guideline 67). [new 2011] 242

1.3.3 For all people with hypertension: 243

Test for the presence of protein in the urine by sending a urine 244

sample for estimation of the albumin:creatinine ratio. 245

Take a blood sample to measure plasma glucose, electrolytes, 246

creatinine, estimated glomerular filtration rate, serum total 247

cholesterol and HDL cholesterol. 248

Arrange for a 12-lead electrocardiograph to be performed. 249

[2004, amended 2011] 250

1.4 Lifestyle interventions 251

1.4.1 Ascertain people’s diet and exercise patterns because a healthy 252

diet and regular exercise can reduce blood pressure. Offer 253

appropriate guidance and written or audiovisual materials to 254

promote lifestyle changes. [2004] 255

1.4.2 Relaxation therapies can reduce blood pressure and people may 256

wish to pursue these as part of their treatment. However, routine 257

provision by primary care teams is not currently recommended. 258

[2004] 259

1.4.3 Ascertain people’s alcohol consumption and encourage a reduced 260

intake if they drink excessively, because this can reduce blood 261

pressure and has broader health benefits. [2004] 262





1.4.4 Discourage excessive consumption of coffee and other caffeine-263

rich products. [2004] 264

1.4.5 Encourage people to keep their dietary sodium intake low, either by 265

reducing or substituting sodium salt, as this can reduce blood 266

pressure. [2004] 267

1.4.6 Do not offer calcium, magnesium or potassium supplements as a 268

method for reducing blood pressure. [2004] 269

1.4.7 Offer advice and help to smokers to stop smoking. [2004] 270

1.4.8 A common aspect of studies for motivating lifestyle change is the 271

use of group working. Inform people about local initiatives by, for 272

example, healthcare teams or patient organisations that provide 273

support and promote healthy lifestyle change. [2004] 274

1.5 Initiating and monitoring antihypertensive drug 275

treatment, including blood pressure targets 276

Initiating treatment 277

1.5.1 Offer antihypertensive drug treatment to people with stage 1 278

hypertension who have: 279

target organ damage or 280

established cardiovascular disease or 281

renal disease or 282

diabetes or 283

a 10-year cardiovascular risk equivalent to 20% or greater. 284

[new 2011] 285

1.5.2 Offer antihypertensive drug treatment to people with stage 2 286


1.5.3 For people younger than 40 years with stage 1 hypertension and 288

no evidence of target organ damage, cardiovascular disease, renal 289

disease or diabetes, consider seeking specialist evaluation of 290



secondary causes of hypertension and a more detailed assessment 291

of potential target organ damage. This is because 10-year 292

cardiovascular risk assessments can underestimate the lifetime risk 293

of cardiovascular events in these people. [new 2011] 294

Monitoring treatment and blood pressure targets 295

1.5.4 Use clinic blood pressure measurement to monitor the response to 296

antihypertensive treatment. [new 2011] 297

1.5.5 For people identified as having a ‘white-coat effect’, that is, a 298

consistent alerting response or clinic hypertension, consider HBPM 299

as an adjunct to clinic blood pressure measurement for monitoring 300

the response to antihypertensive treatment with lifestyle 301

modification or drugs. [new 2011] 302

1.5.6 For people with a discrepancy of more than 20/10 mmHg between 303

clinic blood pressure measurements and ABPM or HBPM average 304

measurements, consider using daytime average ABPM or average 305

HBPM for monitoring the response to antihypertensive treatment. 306

Aim for a target daytime average ABPM or average HBPM blood 307

pressure below 135/85 mmHg. [new 2011] 308

1.5.7 Aim for a target clinic blood pressure below 140/90 mmHg in 309

people aged under 80 years with treated hypertension. [new 2011] 310

1.5.8 Aim for a target clinic blood pressure below 150/90 mmHg in 311

people aged over 80 years with treated hypertension. [new 2011] 312

1.6 Choosing antihypertensive drug treatment 313

1.6.1 Where possible, recommend treatment with drugs taken only once 314

a day. [2004] 315

1.6.2 Prescribe non-proprietary drugs where these are appropriate and 316

minimise cost. [2004] 317



1.6.3 Offer people with isolated systolic hypertension (systolic 318

BP 160 mmHg or more) the same treatment as people with both 319

raised systolic and diastolic blood pressure. [2004] 320

1.6.4 Offer people older than 80 years the same antihypertensive drug 321

treatment as people aged 55–80 years, taking into account any 322

comorbidities. [new 2011] 323

1.6.5 Offer antihypertensive drug treatment to women in line with 324

recommendations 1.2.1.1, 1.2.1.2, 1.9.1.1 and 1.9.1.2 in 325

‘Hypertension in pregnancy’ (NICE clinical guideline 107). [new 326

2011] 327


1.6.6 Offer step 1 antihypertensive treatment with an angiotensin-329

converting enzyme (ACE) inhibitor or a low-cost angiotensin-II 330

receptor blocker (ARB) to people aged under 55 years. If an ACE 331

inhibitor is not tolerated, offer an ARB. [new 2011] 332

1.6.7 Do not combine an ACE inhibitor with an ARB to treat 333


1.6.8 Offer step 1 antihypertensive treatment with a calcium-channel 335

blocker (CCB) to people aged 55 years and older and to black 336

people of African or Caribbean descent of any age. If a CCB is not 337

suitable, for example because of oedema or intolerance, or if there 338

is evidence of heart failure or a high risk of heart failure, offer a 339

thiazide-like diuretic. [new 2011] 340

1.6.9 If a diuretic is required, choose a thiazide-like diuretic, such as 341

chlortalidone (12.5 mg–25.0 mg once daily) or indapamide (2.5 mg 342

once daily) in preference to a conventional thiazide diuretic such as 343

bendroflumethiazide or hydrochlorothiazide. [new 2011] 344




1.6.10 Beta-blockers are not a preferred initial therapy for hypertension. 345

However, beta-blockers may be considered in younger people, 346

particularly: 347

those with an intolerance or contraindication to ACE inhibitors 348

and angiotensin-II receptor antagonists or 349

women of child-bearing potential or 350

people with evidence of increased sympathetic drive. 351

In these circumstances, if therapy is initiated with a beta-blocker 352

and a second drug is required, add a calcium-channel blocker 353

rather than a thiazide-type diuretic to reduce the person’s risk of 354

developing diabetes. [2006] 355


1.6.11 If step 2 antihypertensive treatment is required, offer a CCB in 357

combination with either an ACE Inhibitor or a low-cost ARB. If a 358

CCB is not suitable, for example because of oedema or 359

intolerance, or if there is evidence of heart failure or a high risk of 360

heart failure, offer a thiazide-like diuretic [new 2011] 361


1.6.12 If treatment with three drugs is required, the combination of ACE 363

inhibitor (or angiotensin-II receptor blocker), calcium-channel 364

blocker and thiazide-like diuretic should be used. [2006] 365


1.6.13 Regard clinic blood pressure that remains higher than 367

140/90 mmHg with the optimal or best tolerated doses of an ACE 368

inhibitor or an ARB plus a CCB plus a diuretic as resistant 369

hypertension and consider adding a fourth antihypertensive drug 370

and/or seeking expert advice. [new 2011] 371

1.6.14 For treatment of resistant hypertension at step 4, consider further 372

diuretic therapy with low-dose spironolactone (25 mg once daily) if 373

blood potassium levels are lower than 4.5 mmol/l and estimated 374



glomerular filtration rate is higher than 60 ml/min/1.73m2. If blood 375

potassium levels are higher than 4.5 mmol/l, consider higher-dose 376

thiazide-like diuretic treatment. [new 2011] 377

1.6.15 When using further diuretic therapy for resistant hypertension at 378

step 4, monitor blood sodium and potassium and renal function 379

within 1 month and repeat as required thereafter. [new 2011] 380

1.6.16 If further diuretic therapy for resistant hypertension at step 4 is not 381

tolerated, contraindicated or ineffective, consider an alpha- or beta-382

blocker. [new 2011] 383

1.6.17 If blood pressure remains uncontrolled with the optimal or 384

maximum tolerated doses of four drugs seek expert advice if it has 385

not yet been obtained. [2011] 386

1.7 Patient education and adherence to treatment 387

1.7.1 Provide appropriate guidance and materials about the benefits of 388

drugs and the unwanted side effects sometimes experienced in 389

order to help people make informed choices. [2004] 390

1.7.2 People vary in their attitudes to their hypertension and their 391

experience of treatment. It may be helpful to provide details of 392

patient organisations that provide useful forums to share views and 393

information. [2004] 394

1.7.3 Provide an annual review of care to monitor blood pressure, 395

provide people with support and discuss their lifestyle, symptoms 396

and medication. [2004] 397

1.7.4 Because evidence supporting interventions to increase adherence 398

is inconclusive, only use interventions to overcome practical 399

problems associated with non-adherence if a specific need is 400

identified. Target the intervention to the need. Interventions might 401

include: 402

suggesting that patients record their medicine-taking 403



encouraging patients to monitor their condition 404

simplifying the dosing regimen 405

using alternative packaging for the medicine 406

using a multi-compartment medicines system. (This 407

recommendation is taken from ‘Medicines adherence’, NICE 408

clinical guideline 76). [new 2011] 409

2 Notes on the scope of the guidance 410

NICE guidelines are developed in accordance with a scope that defines what 411

the guideline will and will not cover. The scope of this guideline is available 412

from www.nice.org.uk/[NICE to add details]. 413

Groups that will be covered 414

Adults with hypertension (18 years and older). Particular consideration will 415

be given to the needs of black people of African and Caribbean descent 416

and minority ethnic groups where these differ from the needs of the general 417

population. 418

People aged 80 years or older. 419

Groups that will not be covered 420

People with diabetes. 421

Children and young people (younger than 18 years). 422

Pregnant women. 423

Secondary causes of hypertension (for example, Conn's adenoma, 424

phaeochromocytoma and renovascular hypertension). 425

People with accelerated hypertension (that is, severe acute hypertension 426

associated grade III retinopathy and encephalopathy). 427

People with acute hypertension or high blood pressure in emergency care 428

settings. 429

430


http://www.nice.org.uk/XX



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 [email protected] and quote reference

N1739).

431

3 Implementation 432

NICE has developed tools to help organisations implement this guidance (see 433

www.nice.org.uk/guidance/CG[XX]). 434

4 Research recommendations 435

The Guideline Development Group has made the following recommendations 436

for research, based on its review of evidence, to improve NICE guidance and 437

patient care in the future. 438

4.1 Out-of-office monitoring 439

In adults with primary hypertension, does the use of out-of-office monitoring 440

(HBPM or ABPM) improve response to treatment? 441

Why this is important 442

There is likely to be increasing use of home and ambulatory blood pressure 443

monitoring for the diagnosis of hypertension as a consequence of this 444

guideline update. There are, however, very little data regarding the utility of 445

HBPM or ABPM as means of monitoring blood pressure control or as 446

http://www.nice.org.uk/howwework

http://www.nice.org.uk/guidance/CGXX



indicators of clinical outcome in treated hypertension, compared with clinic 447

blood pressure monitoring. Studies should incorporate HBPM and/or ABPM to 448

monitor blood pressure responses to treatment and their usefulness as 449

indicators of clinical outcomes. 450

4.2 Intervention thresholds for people aged under 40 with 451

hypertension 452

In people aged under 40 with hypertension, what are the appropriate 453

thresholds for intervention? 454


There is genuine uncertainty about how to assess the impact of blood 456

pressure treatment in younger people (aged under 40) with stage 1 457

hypertension, and no overt target organ damage or CVD. In particular, 458

whether those with untreated hypertension are more likely to develop target 459

organ damage and, if so, whether such damage is reversible. Target organ 460

damage and CVD as surrogate or intermediate disease markers are the only 461

indicators that are likely to be feasible in younger people because traditional 462

clinical outcomes are unlikely to occur in sufficient numbers over the time 463

scale of a typical clinical trial. The data will be important to inform treatment 464

decisions for younger people with stage 1 hypertension who do not have overt 465

target organ damage. 466

4.3 Methods of assessing lifetime CV risk in people aged 467

under 40 with hypertension 468

In people aged under 40 with hypertension, what is the most accurate method 469

of assessing the lifetime risk of cardiovascular events and the impact of 470

therapeutic intervention on this risk? 471


Current short-term (over 10 years) risk estimates are likely to substantially 473

underestimate the lifetime cardiovascular risk of younger people (aged under 474

40) with hypertension, because short-term risk assessment is powerfully 475

influenced by age. Nevertheless, the lifetime risk associated with untreated 476



stage 1 hypertension in this age group could be substantial. Lifetime risk 477

assessments may be a better way to inform treatment decisions and evaluate 478

the cost effectiveness of earlier intervention with pharmacological therapy. 479

4.4 Optimal systolic blood pressure 480

In people with treated hypertension, what is the optimal systolic blood 481

pressure? 482


Data on optimal blood pressure treatment targets, particularly for systolic 484

blood pressure, are inadequate. Current guidance is largely based on the 485

blood pressure targets adopted in clinical trials but there have been no large 486

trials that have randomised people with hypertension to different systolic blood 487

pressure targets and that have had sufficient power to examine clinical 488

outcomes. 489

4.5 Step 4 treatment 490

In adults with hypertension, which drug treatment (diuretic therapy versus 491

other step 4 treatments) is the most clinically and cost effective for step 4 492

treatment? 493


Although this guideline provides recommendations on the use of further 495

diuretic therapy for treatment at step 4 (resistant hypertension), they are 496

largely based on post-hoc observational data from clinical trials. More data are 497

needed to compare further diuretic therapies, for example a potassium-498

sparing diuretic with a higher-dose thiazide-like diuretic, and to compare 499

diuretic therapy with alternative treatment options at step 4 to define whether 500

further diuretic therapy is the best option. 501

4.6 Automated blood pressure monitoring in people with 502

atrial fibrillation 503

Which automated blood pressure monitors are suitable for people with 504

hypertension and atrial fibrillation? 505




Atrial fibrillation may prevent accurate blood pressure measurement with 507

automated devices. It would be valuable to know if this can be overcome. 508

5 Other versions of this guideline 509

5.1 Full guideline 510

The full guideline, ‘Hypertension: the clinical management of primary 511

hypertension in adults’ contains details of the methods and evidence used to 512

develop the guideline. It is published by the National Clinical Guideline Centre, 513

and is available from our website 514

(www.nice.org.uk/guidance/CG[XX]/Guidance). Note: these details will 515

apply to the published full guideline. 516

5.2 Quick reference guide 517

A quick reference guide for healthcare professionals is available from 518

www.nice.org.uk/guidance/CG[XX]/QuickRefGuide 519

For printed copies, phone NICE publications on 0845 003 7783 or email 520

[email protected] (quote reference number N[XXXX]). Note: these 521

details will apply when the guideline is published. 522

5.3 ‘Understanding NICE guidance’ 523

A summary for patients and carers (‘Understanding NICE guidance’) is 524

available from www.nice.org.uk/guidance/CG[XX]/PublicInfo 525

For printed copies, phone NICE publications on 0845 003 7783 or email 526

[email protected] (quote reference number N[XXXX]). Note: these 527

details will apply when the guideline is published. 528

We encourage NHS and voluntary sector organisations to use text from this 529

booklet in their own information about primary hypertension.. 530

http://www.nice.org.uk/guidance/CG%5bXX%5d/Guidance

http://www.nice.org.uk/guidance/CGXX/QuickRefGuide

http://www.nice.org.uk/guidance/CGXX/PublicInfo



6 Related NICE guidance 531

Chronic heart failure. NICE clinical guideline 108 (2010). Available from 532

www.nice.org.uk/guidance/CG108 533

Hypertension in pregnancy. NICE clinical guideline 107 (2010). Available 534

from www.nice.org.uk/guidance/CG107 535

Prevention of cardiovascular disease at population level. NICE public 536

health guidance 25 (2010). Available from www.nice.org.uk/guidance/PH25 537

Type 2 diabetes. NICE clinical guideline 87 (2009; updated March 2010 538

and September 2010). Available from www.nice.org.uk/guidance/CG87 539

Medicines adherence. NICE clinical guideline 76 (2009). Available from 540


Chronic kidney disease. NICE clinical guideline 73 (2008). Available from 542


Stroke. NICE clinical guideline 68 (2008). Available from 544


Lipid modification. NICE clinical guideline 67 (2008, reissued 2010). 546

Available from www.nice.org.uk/guidance/CG67 547

Continuous positive airway pressure for the treatment of obstructive sleep 548

apnoea/hypopnoea syndrome. NICE technology appraisal guidance 139 549

(2008). Available from www.nice.org.uk/guidance/TA139 550

MI: secondary prevention. NICE clinical guideline 48 (2007). Available from 551


Obesity. NICE clinical guideline 43. Available from 553


Atrial fibrillation. NICE clinical guideline 36 (2006). Available from 555


7 Updating the guideline 557

NICE clinical guidelines are updated so that recommendations take into 558

account important new information. New evidence is checked 3 years after 559

publication, and healthcare professionals and patients are asked for their 560

views; we use this information to decide whether all or part of a guideline 561

http://www.nice.org.uk/guidance/CG108


http://guidance.nice.org.uk/PH25






http://guidance.nice.org.uk/TA139






needs updating. If important new evidence is published at other times, we 562

may decide to do a more rapid update of some recommendations. Please see 563

our website for information about updating the guideline. 564

565



Appendix A: The Guideline Development Groups, 566

National Collaborating Centres and NICE project team 567

Guideline Development Group (2011 update) 568

Bryan Williams (Chair) 569

Professor of Medicine, University of Leicester and University Hospitals of 570

Leicester NHS Trust 571

Helen Williams 572

Consultant Pharmacist for Cardiovascular Disease, Southwark Health and 573

Social Care 574

Jane Northedge 575

Patient and carer member 576

John Crimmins 577

General Practitioner, Vale of Glamorgan 578

Mark Caulfield 579

Professor of Clinical Pharmacology, Barts and the London School of Medicine 580

Michaela Watts 581

Hypertension Nurse Specialist, Addenbrooke’s Hospital, Cambridge 582

Naomi Stetson 583

Primary Care Nurse, Watling Medical Centre, London 584

Richard McManus 585

Professor of Primary Care Cardiovascular Research, University of 586

Birmingham 587

Shelley Mason 588

Patient and carer member 589

Terry McCormack 590

General Practitioner, Spring Vale Medical Centre, North Yorkshire 591



National Clinical Guideline Centre (2011 update) 592

Bernard Higgins 593

Clinical Director 594

Kate Lovibond 595

Senior Health Economist 596

Paul Miller 597

Senior Information Scientist 598

Rachel O’Mahony 599

Senior Research Fellow 600

Taryn Krause 601

Senior Project Manager/Research Fellow 602

NICE project team (2011 update) 603

Phil Alderson 604

Associate Director 605

Sarah Dunsdon 606

Guideline Commissioning Manager 607

Andrew Gyton 608

Guideline Coordinator 609

Ruaraidh Hill 610

Technical Lead 611

Prashanth Kandaswamy 612

Health Economist 613

Judy McBride 614

Editor 615



Guideline Development Group (2006 update) 616

Dr Bernard Higgins (Chair) 617

Consultant Respiratory Physician, Freeman Hospital; Director, National 618

Collaborating Centre for Chronic Conditions 619

Professor Morris Brown 620

Professor of Medicine, Cambridge University and Addenbrooke’s Hospital; 621

President, British Hypertension Society 622

Dr Mark Davis 623

General Practitioner, West Yorkshire; Primary Care Cardiovascular Society 624

Professor Gary Ford 625

Consultant Stroke Physician, University of Newcastle and Freeman Hospital; 626

Royal College of Physicians 627

Mr Colin Penney 628

Patient and carer representative 629

Ms Jan Procter-King 630

Nurse Practitioner, West Yorkshire; Primary Care Cardiovascular Society 631

Mrs Jean Thurston 632

Patient and carer representative 633

Professor Bryan Williams 634

Clinical Adviser; Professor of Medicine, University of Leicester School of 635

Medicine and University Hospitals Leicester NHS Trust 636

National Collaborating Centre for Chronic Conditions 637

(2006 update) 638

Ms Lina Bakhshi 639

Information Scientist 640

Mr Rob Grant 641

Senior Project Manager; Medical Statistician, Royal College of Physicians 642



Mr Mike Hughes 643

Health Services Research Fellow in Guideline Development 644

Dr Ian Lockhart 645

Health Services Research Fellow in Guideline Development 646

Mr Leo Nherera 647

Health Economist; Health Economics Fellow, Queen Mary, University of 648

London 649

Guideline Development Group (2004 guideline) 650

Ms Susan L Brent 651

Acting Head of Prescribing Support, Northern and Yorkshire Regional Drug 652

and Therapeutics Centre, Newcastle upon Tyne 653

Dr Paul Creighton 654

General Practitioner, Northumberland 655

Dr William Cunningham 656

General Practitioner, Northumberland 657

Dr Heather Dickinson 658

Technical Support, Newcastle upon Tyne 659

Dr Julie Eccles (Group Leader) 660

General Practitioner, Tyne and Wear 661

Professor Gary Ford 662

Professor of Pharmacology of Old Age and Consultant Physician, Newcastle 663

upon Tyne 664

Dr John Harley 665

General Practitioner, Stockton on Tees 666

Ms Suzanne Laing 667

Nurse Practitioner, Tyne and Wear 668



Professor James Mason 669

Methodologist and Technical Support, Newcastle upon Tyne 670

Mr Colin Penney 671

Patient Representative 672

Dr Wendy Ross 673

General Practitioner, Newcastle upon Tyne 674

Mrs Jean Thurston 675

Patient Representative 676

Professor Bryan Williams 677

Professor of Medicine and Director, Cardiovascular Research Unit, Leicester 678

679



Appendix B: The Guideline Review Panels 680

The Guideline Review Panel is an independent panel that oversees the 681

development of the guideline and takes responsibility for monitoring 682

adherence to NICE guideline development processes. In particular, the panel 683

ensures that stakeholder comments have been adequately considered and 684

responded to. The panel includes members from the following perspectives: 685

primary care, secondary care, lay, public health and industry. 686

Guideline Review Panel (2011 update) 687

NICE to add 688

Guideline Review Panel (2006 update) 689

Dr Peter Rutherford (Chair) 690

Senior Lecturer in Nephrology, University of Wales College of Medicine 691

Dr John Harley 692

General Practitioner, North Tees PCT 693

Dr Rob Higgins 694

Consultant in Renal and General Medicine, University Hospitals Coventry and 695

Warwickshire NHS Trust, Coventry 696

Dr Kevork Hopayian 697

General Practitioner, Suffolk 698

Dr Robert Walker 699

Clinical Director, West Cumbria Primary Care Trust 700

Guideline Review Panel (2004 guideline) 701

Professor Mike Drummond (Chair) 702

Director, Centre for Health Economics (CHE), University of York 703

Dr Kevork Hopayian 704

General Practitioner, Suffolk 705



Mr Barry Stables 706

Patient/Lay representative 707

Dr Imogen Stephens 708

Joint Director of Public Health, Western Sussex Primary Care Trust 709

Dr Robert Walker 710

Clinical Director, West Cumbria Primary Care Trust 711



Appendix C: The algorithms

Diagnosis of hypertension

Initial clinic blood pressure ≥140/90 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‡.

Initial clinic blood pressure ≥180/110 mmHg

No target organ damage

No established CVD

10-year CV risk <20%

Initial clinic blood pressure <140/90 mmHg

Blood pressure usually >180/110mmHg

Signs or symptoms of papilloedema and/or retinal haemorrhage or suspected phaeochromotcytoma

Refer for specialist

care immediately

Evidence of target organ damage**

ABPM/HBPM <135/85 mmHg

ABPM/HBPM ≥135/85 mmHg

ABPM/HBPM ≥ 150/90 mmHg

Target organ damage present

10-year CV risk >20%

Person younger than 40

Consider treatment/specialist

referral

Offer antihypertensive drug treatment

Review blood pressure at least every 12 months

*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 guideline 67)

Person 40 or older

Normotensive Stage 2+

hypertension

Stage 1

hypertension

Higher risk

Lower risk

Severe hypertension

Accelerated hypertension

Start antihypertensive drug

treatment immediately




Antihypertensive drug treatment

Step 1

Step 2

Step 3

Step 4 (resistant

hypertension)

People aged

< 55 years

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

A C*

A + C + D

A + C*

A + C + D + further diuretic** or alpha-blocker or beta-blocker

Consider seeking specialist advice.

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



Appendix D: Recommendations to be deleted

Recommendation Comment

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)

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.

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)

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.

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

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.

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)

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.

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 person’s arm.



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)

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).

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)

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

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)

We are now recommending ABPM routinely for diagnosis.

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)

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

Test for the presence of protein in the patient’s 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)

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.

Drug therapy reduced the risk of cardiovascular disease and death. Offer

Replaced by:

Offer antihypertensive drug treatment



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.

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 thiazide-type 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)

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.

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)

Replaced by:

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

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)

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.

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

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



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.

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)

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.

If initial therapy was with a calcium-channel 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 calcium-channel blocker or a thiazide-type diuretic. (Recommendation 1.4.6 in 2006 guideline)

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

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)

This algorithm has been superseded in the 2011 guidance.

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 beta-blocker with an alternative agent. (Recommendation 1.4.13 in 2006 guideline)

This recommendation was relevant in 2006, as many people were taking beta-blockers 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.



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)

As above – the 2006 guideline recommended that beta-blockers should not be used as a first line treatment for hypertension.

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)

Replaced by:

Offer people older than 80 years the same antihypertensive treatment as people aged 55-80 years, taking into account any comorbidities.

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)

This recommendation doesn’t add any value – it is a redundant recommendation so therefore has been removed.

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)

This has been superseded by NICE guidance on lifestyle.

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nice guideline of hypertension

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