Management of hypertension

This guidance is based on NICE CG127

Definitions

• Stage 1 hypertension: Clinic blood pressure greater than or equal to 140/90mmHg; ABPM or HBPM average greater than or equal to 135/85mmHg
• Stage 2 hypertension: Clinic blood pressure greater than or equal to 160/100mmHg; ABPM or HBPM average greater than or equal to 150/95mmHg
• Severe hypertension: Clinic systolic blood pressure greater than or equal to 180mmHg or clinic diastolic blood pressure greater than or equal to 110mmHg
• ABPM: ambulatory blood pressure monitoring
• HBPM: home blood pressure monitoring

Diagnosis

• Measure BP in both arms If difference in readings between arms is greater than 20mmHg, repeat. If difference is greater than 20mmHg on second measurement, measure subsequent BPs using arm with higher reading.
• If BP 140/90mmHg or higher take second measurement. If this is substantially different from the first, take a third. Record the lower of the last two measurements as the clinic BP.

Ensure that devices are properly validated, maintained and regularly recalibrated. A list of validated devices is available on the British Hypertension Society website.

Patients found to have clinic blood pressure between 140/90mmHg and 180/110mmHg should have their blood pressure confirmed using 24 hour ABPM or HBPM.

If the person has severe hypertension, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

While waiting for confirmation of a diagnosis of hypertension, carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy) and a formal assessment of cardiovascular risk using a cardiovascular risk assessment tool.

If hypertension is not diagnosed, measure the person's clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person's clinic blood pressure is close to 140/90 mmHg.

Specialist referral

Refer the person to specialist care the same day if they have:

• accelerated hypertension, that is, 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 diaphoresis).

Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension.

Cardiovascular risk

NICE CG181 recommends the use of the QRISK2 CVD assessment tool.

Note: Clinic blood pressure must be used to calculate CV risk.

Use non-pharmacological measures to reduce cardiovascular risk in all patients with hypertension.

Other drugs that reduce cardiovascular risk must also be considered; this includes aspirin:

• Aspirin 75mg should be considered for those needing secondary prevention of cardiovascular disease. Routine use for primary prevention is not recommended locally.

NICE define a range of targets depending on pathology (all targets refer to clinic BP monitoring)

Primary hypertension (hypertension in the absence of other pathology)

Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following:

• target organ damage
• established cardiovascular disease
• renal disease
• diabetes
• a 10-year cardiovascular risk equivalent equal to or greater than 20%

Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.

For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage.

Offer people with isolated systolic hypertension (systolic blood pressure 160mmHg or higher) the same treatment as people with both raised systolic and diastolic blood pressure.

Patients with primary hypertension, aim for a target blood pressure:

• Less than 140/90mmHg in people aged under 80 years
• Less than 150/90mmHg in people aged 80 years and over

For people identified as having a 'white-coat effect', consider ABPM or HBPM as an adjunct to clinic blood pressure measurements. In this group of patients, aim for a target average blood pressure of:

• Less than 135/85mmHg for people aged under 80 years
• Less than 145/85mmHg for people aged 80 years and over

Type 1 Diabetes Mellitus

Intervention levels for recommending blood pressure management should be 135/85 mmHg unless the adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case it should be 130/80 mmHg.

See CKD section below for targets in kidney disease.

Type 2 Diabetes Mellitus

Aim for target blood pressure of less than 140/80mmHg in all ages.

If the patient has eye or cerebrovascular damage, aim for a target of less than 130/80mmHg.

See CKD section below for targets in kidney disease.

Chronic Kidney Disease (CKD)

In people with CKD aim to keep the systolic blood pressure less than 140 mmHg (target range 120–139mmHg) and the diastolic blood pressure less than 90mmHg (target range 61- 89mmHg).

In people with CKD and diabetes, and also in people with an ACR (albumin: creatinine ratio) of greater than or equal to 70 mg/mmol, aim to keep the systolic blood pressure less than 130mmHg (target range 120–129mmHg) and the diastolic blood pressure less than 80mmHg (target range 61-79mmHg).

Non-pharmacological lifestyle interventions should be offered initially and then periodically to people undergoing assessment or treatment for hypertension.

Non-pharmacological measures; weight reduction, reduced salt intake, reduced fat intake, limited alcohol consumption, aerobic exercise and increased fruit and vegetable consumption are effective in lowering blood pressure (level 1 evidence).

Weight reduction

• Recommendation: Maintain BMI 20-25
• Expected SBP reduction: 5-10mmHg per 10kg weight loss

DASH eating plan (link)

• Recommendation: Diet rich in fruit, vegetables, low-fat dairy produce
• Expected SBP reduction: 8-14mmHg

Dietary sodium restriction

• Recommendation: <6g salt per day (= 2.4g sodium or 100mmol)
• Expected SBP reduction: 2-8mmHg

Physical activity

• Recommendation: At least 30 minutes most days
• Expected SBP reduction: 4-9mmHg

Alcohol moderation

• Expected SBP reduction: Men 21 units or under per week, Women 14 units or under per week
• Recommendation: 2-4mmHg

Alone or in combination these interventions can reduce the need for drug therapy and enhance the effect of antihypertensive agents. A favourable effect on cardiovascular outcome is assumed, but not proven.

To reduce overall cardiovascular risk, patients should stop smoking, reduce total fat and saturated fat intake and increase consumption of monounsaturated fats and oily fish.

Device-guided breathing (Resperate®)

Results from randomised trials involving Resperate® are contradictory, although it would appear the device may reduce blood pressure by approximately 3.5/2.5mmHg when used over an 8 week period. The long-term effectiveness of Resperate is not known.

The British Hypertension Society (BHS) advises that there is currently insufficient evidence to recommend the use of Resperate devices.

In the absence of long-term efficacy data involving patient-centred outcomes Resperate® devices should not be prescribed on NHS prescriptions. Patients wishing to use Resperate® may purchase the device privately.

Where possible, recommend medication taken only once daily and prescribe non-proprietary drugs.

Patients should be offered an annual review of care to monitor their BP, provide them with support and discuss lifestyle, symptoms and medication.

Step 1

See 2.5 Hypertension and heart failure

Patient aged less than 55 years:

ACE inhibitor

or

Low cost ARB

Patient aged over 55 years and black people of African / Caribbean descent of any age:

Calcium channel blocker

Notes

1. Beta-blockers are not a preferred initial therapy for hypertension. However, beta-blockers may be considered in younger people, particularly:
   1. those with an intolerance or contraindication to ACE inhibitors and ARB or
   2. women of child-bearing potential or
   3. people with evidence of increased sympathetic drive
2. 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.
3. Ace inhibitors and angiotensin II receptor antagonists should be avoided in pregnancy, and should be avoided in women who are planning pregnancy unless absolutely necessary (Management of hypertension in pregnancy)
4. Do not combine an ACE inhibitor with an ARB to treat hypertension.

Step 2

See 2.5 Hypertension and heart failure

If blood pressure is not controlled on Step 1 treatment:

ACEi / low cost ARB

plus

Calcium channel blocker

Notes

1. If a CCB is not suitable for step 2 treatment, 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.
2. If therapy is initiated with a beta-blocker and a second drug is required, add a CCB rather than a thiazide-like diuretic to reduce the person's risk of developing diabetes.
3. For black people of African or Caribbean family origin, ACE inhibitors are associated with an increased risk of developing angioedema which can be life threatening. Although the incidence of this adverse effect is low, consider an ARB in preference to an ACE inhibitor, in combination with a CCB.

Step 3

Review medication to ensure step 2 treatment is at optimal or best tolerated doses. See 2.5 Hypertension and heart failure

If treatment with 3 drugs is required give:

ACEi / low cost ARB

plus

Calcium channel blocker

plus

Thiazide-like diuretic

Step 4 (Resistant hypertension)

Clinic BP greater than 140/90mmHg despite treatment described in Step 3 is classified as resistant hypertension. Consider adding 4th agent and / or seeking specialist advice. See 2.5 Hypertension and heart failure.

If blood potassium less than or equal to 4.5mmol/L:

Spironolactone 25mg daily

plus

ACEi / low cost ARB

plus

Calcium channel blocker

plus

Thiazide-like diuretic

Notes

1. If blood potassium greater than 4.5mmol/L consider higher dose thiazide-like diuretic.
2. Monitor blood sodium and potassium, and renal function within 1 month and repeat required thereafter when using further diuretic therapy.
3. If further diuretic therapy not tolerated, contraindicated or ineffective: consider an alpha-blocker or beta-blocker.
4. If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained.

Type 1 Diabetes Mellitus

Start a trial of a renin–angiotensin system blocking drug as first-line therapy for hypertension in adults with type 1 diabetes.

Provide information to adults with type 1 diabetes on the potential for lifestyle changes to improve blood pressure control and associated outcomes, and offer assistance in achieving their aims in this area.

Do not allow concerns over potential side effects to inhibit advising and offering the necessary use of any class of drugs, unless the side effects become symptomatic or otherwise clinically significant. In particular:

• do not avoid selective beta-adrenergic blockers where indicated in adults on insulin
• low-dose thiazides may be combined with beta-blockers
• when calcium-channel blockers (CCBs) are prescribed, use only long-acting preparations
• use direct questioning to detect the potential side effects of erectile dysfunction, lethargy and orthostatic hypotension with different drug classes.

If there is kidney damage (including microalbuminuria), follow the guidance for CKD.

Type 2 Diabetes Mellitus

NICE NG28 - Type 2 diabetes in adults (2015) provides guidance on blood pressure therapy for patients with type 2 diabetes.

Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice.

For an adult with type 2 diabetes on antihypertensive drug treatment when diabetes is diagnosed, review blood pressure control and medications used. Make changes only if there is poor control or if current drug treatment is not appropriate because of microvascular complications or metabolic problems.

Repeat blood pressure measurements within:

• 1 month if blood pressure is higher than 150/90 mmHg
• 2 months if blood pressure is higher than 140/80 mmHg
• 2 months if blood pressure is higher than 130/80 mmHg and there is kidney, eye or cerebrovascular damage.

Provide lifestyle advice (diet and exercise) at the same time.

Add medications if lifestyle advice does not reduce blood pressure to below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye or cerebrovascular damage).

Monitor blood pressure 1–2-monthly, and intensify therapy below until blood pressure is consistently less than 140/80mmHg (less than 130/80 mmHg if there is eye or cerebrovascular disease).

Monitor the blood pressure of a person who has attained and consistently remained at his or her blood pressure target every 4–6 months, and check for possible adverse effects of antihypertensive therapy – including the risks from unnecessarily low blood pressure.

Step 1

Start a once daily ACE inhibitor and titrate dose.

If African-Caribbean descent, first line treatment should be an ACE inhibitor plus either a diuretic or a CCB.

A CCB should be first line for a woman for whom there is a possibility of becoming pregnant.

Notes

1. Patients of African-Caribbean descent are noted to respond less well to renin-angiotensin-system-blockers and hence dual therapy is advised.
2. For a person with continuing intolerance to an ACE inhibitor (other than renal deterioration or hyperkalaemia), substitute an ARB for the ACE inhibitor.
3. Do not combine an ACE inhibitor with an angiotensin II-receptor antagonist to treat hypertension.

Step 2

Add CCB or diuretic

Notes

1. Usually a thiazide or thiazide-related diuretic

Step 3

Add the other drug if target not reached at step two (diuretic or CCB)

Notes

1. Usually a thiazide or thiazide-related diuretic

Step 4

Add alpha-blocker, beta-blocker or potassium-sparing diuretic.

Notes

1. Add a potassium sparing diuretic with caution if the individual is already taking an ACE inhibitor or an ARB

Offer a low-cost ACE inhibitor or ARB (as recommended by NICE CG182) to people with CKD

and:

• diabetes and an ACR of 3mg/mmol or more (ACR category A2 or A3)
• hypertension and an ACR of 30mg/mmol or more (ACR category A3)
• an ACR of 70mg/mmol or more (irrespective of hypertension or cardiovascular disease)

Second line treatment (or first line in those who cannot tolerate ACEi or ARB) is a CCB. Specialist advice should be sought for further treatment if necessary.

Do not offer a combination of renin–angiotensin system antagonists to people with CKD.

Follow the treatment recommendations in the essential hypertension section for people with CKD, hypertension and an ACR of less than 30mg/mmol (ACR categories A1 and A2), if they do not have diabetes; take into account the need to prevent or ameliorate progression of CKD.