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New NICE guidelines for diagnosing and treating high BP

Posted on 13/03/2012


In new guidelines on the diagnosis and treatment of high blood pressure (hypertension), NICE has made a number of new recommendations that are set to significantly change the way high blood pressure is diagnosed and subsequently treated.

In one of the biggest changes to NICE's original guidance, published in 2004, the draft guideline recommends that a diagnosis of primary hypertension should be confirmed using 24-hour ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), rather than be based solely on measurements of blood pressure taken in the clinic. Allied to this, the draft guideline also proposes new thresholds for diagnosis and grades of hypertension which better reflect the values obtained using ABPM.

High blood pressure is one of the most important preventable causes of premature ill health and death in the UK. It is a major risk factor for stroke, heart attack, heart failure, chronic kidney disease and cognitive decline. Primary hypertension is diagnosed when there is no simple identifiable cause of the raised blood pressure: the hypertension may be related, in part, to obesity, poor diet, physical inactivity or genetic inheritance.

Secondary hypertension, the treatment of which is not covered in this guideline, means there is an identifiable cause such as kidney disease. About 9 out of every 10 people with hypertension have primary hypertension.

Other recommendations that have been reviewed in this partial update of the guideline for the clinical management of primary hypertension in adults, include; blood pressure targets for treatment; the pharmacological treatment of hypertension; the treatment of hypertension in the very elderly (people aged over 80); treatment of hypertension in younger adults (younger than 40); and the treatment of drug resistant hypertension.

Draft new recommendations include:

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.

Offer antihypertensive treatment to people with stage 2 hypertension, (that is, initial clinic systolic blood pressure exceeds ≥160 mmHg and/or diastolic blood pressure ≥100 mmHg and subsequent ABPM daytime average or HBPM average of 150/95 mmHg or higher.

Offer antihypertensive drug treatment to people with stage 1 hypertension (that is, initial clinic systolic blood pressure of 140/90 mmHg or higher and subsequent ABPM daytime average or HBPM average of 135/85 mmHg or higher) 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.

Professor Bryan Williams, Professor of Medicine, University of Leicester and University Hospitals NHS Trust, Leicester, and Chair of the Guideline Development Group said: “The wealth of new evidence generated since the original guideline was published in 2004, and the subsequent partial update in 2006, has largely served to further validate the recommendations already made. The areas where we have been able to recommend significant changes based on this new evidence will, nonetheless, have a major impact on how hypertension is diagnosed and subsequent treatment monitored. Of perhaps greatest significance are the findings which suggest that the current practice of using a series of blood pressure readings taken in the clinic alone for the diagnosis of hypertension can lead to inaccurate diagnosis. The resulting draft recommendation to use ambulatory blood pressure monitoring to confirm a diagnosis of hypertension recognises that the measurement of blood pressure, away from the clinic, in a more usual setting canreduce the over-diagnosis of high blood pressure and unnecessary treatment – for example, because of white-coat hypertension. In addition this new approach would not only improve diagnosis but would ultimately be cost-saving for the NHS.

“One of the other areas this update considers is how to manage people aged 40 years and under who are diagnosed as being hypertensive but who have no evidence of target organ damage, such as chronic kidney disease, and who do not have diabetes or renal disease. In these people short-term cardiovascular risk assessments can underestimate their lifetime risk of cardiovascular events because they are powerfully influenced by age. The draft guideline therefore recommends that consideration be given in such cases to seeking a specialist assessment for evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage, as well as a review of their blood pressure at least every 12 months.”


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