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					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 Changes
 Ambulatory 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 readings
 Use 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.
CBPM ≥140/90 mmHg          CBPM ≥160/100 mmHg
  & ABPM/HBPM                 & ABPM/HBPM
  ≥ 135/85 mmHg               ≥ 150/95 mmHg
Stage 1 hypertension        Stage 2 hypertension
             Care pathway
     If target organ damage present or                      Offer antihypertensive
     10-year cardiovascular risk > 20%                          drug treatment

                                         Consider specialist
        If younger than 40 years              referral


                            Offer lifestyle interventions


    Offer patient education and interventions to support adherence to treatment


    Offer annual review of care to monitor blood pressure, provide support and
                    discuss lifestyle, symptoms and medication
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.
                 Aged over 55 years
                 or black person of
                 African or Caribbean
Aged under
 55 years
                 family origin of any            Summary of
                 age                             antihypertensive
                                                 drug treatment
    A                     C2            Step 1


                                                    Key
              A+   C2                   Step 2      A – ACE inhibitor or low-cost
                                                    angiotensin II receptor
                                                    blocker (ARB)1
             A+C+D                      Step 3      C – Calcium-channel
                                                    blocker (CCB)
                                                    D – Thiazide-like diuretic
     Resistant hypertension             Step 4
   A + C + D + consider further
      diuretic3, 4 or alpha- or
          beta-blocker5
                                                           See slide notes for details of
 Consider seeking expert advice                            footnotes 1-5
Drug therapy
 Aim for drugs to be taken once a day
 Do 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 28
   Indapamide 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 80
  150/90 mmHg in people aged 80 and over
    For people identified as having treatment (2)
   Monitoring drug 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 80
       below 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 recommendations
 Lifestyle interventions
 Offer guidance and advice about:
 – diet (including sodium and caffeine intake) and exercise

 – alcohol consumption

 – smoking.


 Patient education and adherence
 Provide:
 – information about benefits of drugs and side effects

 – details of patient organisations

 – an annual review of care.
Summary
 Ambulatory blood pressure investigation of choice
 Clinic BP readings no longer recommended for
  diagnosis of hypertension
 Can be used to monitor treatment
 Hypertension defined as stage 1 and 2
 Thresholds 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)

				
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