This is an updated guideline from NICE on managing hypertension in adults. It was published in Aug 2019.
So what is new?
The meat and bones of management is the same. There are a few small differences, which I'll list below.
The biggest difference is that they encourage us to have much more of a discussion with patients about whether to start medication and what to start. Helpfully, they have provided some patient decision aids, which are really good.
We are also being encouraged to consider frailty and multimorbidity when deciding what level of hypertension to treat and what targets to aim for.
Consider treatment at a CV-risk cut-off of 10% rather than 20% now.
The new details are as follows:
- Investigations to allow risk scoring.
- Instead of doing fasting glucose, do HbA1c.
- Instead of a full cholesterol screen, do total and HDL cholesterol.
- Differential BP between each arm.
- If there is more than a 15 mmHg difference between each arm, use the higher reading arm in future. It used to be 20 mmHg.
- Stage 1 - when to start treatment.
- Consider treatment if there is a 10 yr CV risk of 10% or more (this used to be 20%).
- Stage 1 - in the under 60s
- Consider treatment if there is a 10 yr CV risk of less than 10%, as the 10 yr risk may underestimate their lifetime chance of getting CV complications.
- When considering the 'D' option, they mean a thiazide-like diuretic, such as indapamide. They are not now recommending chlortalidone as in the previous guideline (it seems that this is because it is just not being widely used, rather than due to any lack of evidence on its efficacy).
What patient resources are there?
There is an excellent patient decision aid. It goes through:
- what hypertension is.
- what the complications can be.
- pros and cons of using medication.
- pros and cons of all the different medications.
This would be very useful to hand out to patients at diagnosis.
There is also a very good second leaflet, which is billed as a 'patient decision aid user guide'. This explains that we can't advise patients on what absolute risk reduction they'll get from different medications and different lifestyle interventions. Interestingly, there doesn't seem to be a constant relative risk reduction for different drops in blood pressure. This seems to be because the interplay between different risk factors is so complex.
When should we initiate treatment and what should we use?
NICE has provided an excellent visual summary of when to initiate treatment (page 1) and what medications to use. As this is so good, I won't summarise it further. It's probably one for the wall...
So there are a few interesting points in deciding when to initiate treatment in Stage 1 hypertension:
- Discuss with the patient their individual CV risk and their preferences for treatment.
- Use clinical judgement when there is frailty or multi morbidity.
- Patients under 60 with a 10 yr CV risk of < 10% may well actually have a higher lifetime CV risk. You should consider treatment in these patients.
- Patients over 80 with a BP > 150/90 - consider medication.
What medications should we use to treat patients?
As I mentioned above, NICE has done an excellent summary of what medications to use and when and I won't try to summarise it further.
Here are a few useful explanations or added points.
People of Black African or Afro-Caribbean family origin.
In people of Black African or Afro-Caribbean family origin, offer an angiotensin receptor blocker (ARB) in preference to ACEi, if you need to. Remember that ACEi don't work very well in these patients and that there is a higher risk of angioedema. ARBs seem to have a lower risk of angioedema, hence the advice to use those preferentially.
In people of Black African or Afro-Caribbean family origin, who have hypertension and Type 2 Diabetes, the advice used to be to use ACEi + calcium channel blocker, or diuretics. However, there isn't much evidence to support this approach. An ARB should therefore be used as they have been shown to be more cardio-protective in this group of patients than just a calcium channel blocker or diuretic on its own.
ARB or ACEi?
ARB and ACEi are now equal in cost and efficacy, so can be used interchangeably (except in people of Black African or Afro-Caribbean origin as above).
In the previous guideline there were some exceptions where certain groups could be initiated on a beta-blocker. This has been removed from this guideline as it isn't felt to be normal practice, and there isn't much evidence to support their use.
Dual therapy at step 1 treatment
There is some evidence from one study that there may be benefit from starting patients on two therapies at once. However it was felt that the evidence wasn't robust enough to encourage this practice yet.
Is one approach better than another at steps 2 or 3?
No. There isn't much evidence supporting any particular combination of medications at steps 2 or 3. I also couldn't see any advise as to whether we should increase one drug to its maximum dose before adding in another drug or not.