NICE has recently updated and replaced its guideline on the management of hypertension. The new clinical guideline (CG127) includes recommendations on how to confirm diagnosis and when to initiate treatment, and updates the treatment options.
There is an online MIMS Summary of this new guideline at Hypertension - management of hypertension in adults in primary care (NICE Clinical Guideline 127).
Following clinic BP measurements of 140/90mmHg or higher, the patient should be offered ambulatory BP monitoring (ABPM) to confirm the diagnosis of hypertension. Measurements should be taken during the patient’s normal waking hours and the average value of at least 14 measurements should be used. If the patient is unable to tolerate ABPM, home BP monitoring (HBPM) is a suitable alternative.
The specified values for diagnosis of hypertension now include the ABPM (or average HBPM) in addition to the values taken in the clinic, for example, stage 1 hypertension is defined as clinic BP of 140/90mmHg or higher plus ABPM (or HBPM) average of 135/85mmHg or higher.
Treatment should be initiated in patients aged under 80 years with stage 1 hypertension who also have target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk of 20% or greater.
Patients under 40 years diagnosed with stage 1 hypertension but without target organ damage, established cardiovascular disease, renal disease, or diabetes should be referred to a specialist for further investigation to rule out secondary causes of hypertension and for a more detailed assessment of potential organ damage.
The initial pharmacological treatment options have been changed, with NICE recommending that patients aged 80 years and over should be treated with the same antihypertensive drugs as patients aged 55–80 years, although consideration must be given to the possible presence of comorbidities in older patients.
For patients over 55 years and patients of black African or Caribbean origin, treatment should be initiated with a calcium-channel blocker. If calcium-channel blockers are unsuitable, for example in oedema or intolerance, or if there is evidence of, or high risk of, heart failure, the patient should be offered a thiazide-like diuretic, such as chlortalidone or indapamide.
If diuretic treatment is indicated or requires changing, a thiazide-like diuretic, such as chlortalidone or indapamide, is preferred to a conventional thiazide, such as bendroflumethiazide or hydrochlorothiazide. However, if a patient is already receiving a conventional thiazide and their hypertension is adequately controlled, treatment should be continued.