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**** Under review: NICE has issued updated guidance ****
NICE NG136: Hypertension in adults: diagnosis and management (August 2019)
NICE NG203: Chronic kidney disease: assessment and management (August 2021, updated November 2021)
The information below is based on the following NICE guidelines:
This guidance is based on NICE CG127
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.
Refer the person to specialist care the same day if they have:
Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension.
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:
NICE define a range of targets depending on pathology (all targets refer to clinic BP monitoring)
Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following:
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:
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:
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.
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.
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).
DASH eating plan (link)
Dietary sodium restriction
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.
See 2.5 Hypertension and heart failure
See 2.5 Hypertension and heart failure
Review medication to ensure step 2 treatment is at optimal or best tolerated doses. See 2.5 Hypertension and heart failure
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.
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:
If there is kidney damage (including microalbuminuria), follow the guidance for CKD.
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:
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.
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.
Add CCB or diuretic
Add the other drug if target not reached at step two (diuretic or CCB)
Add alpha-blocker, beta-blocker or potassium-sparing diuretic.
Offer a low-cost ACE inhibitor or ARB (as recommended by NICE CG182) to people with CKD
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.
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