Clinical Management of Primary Hypertension in Adults (NICE Guideline)

Summary of NICE guidance on high blood pressure.

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Measurement

  • If BP ≥140/90mmHg, take a second reading; if considerably different, take a third. Record the lower of the last two measurements as clinic BP.
  • Take a supine or seated reading in patients with symptoms of postural hypotension, followed by a reading after ≥1 min standing.
  • If clinic BP is ≥140/90mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm diagnosis.
  • If patient is unable to tolerate ABPM, offer home blood pressure monitoring (HBPM).
  • If severe hypertension, consider starting treatment immediately without waiting for results of ABPM or HBPM.
  • Measure BP on both of patient’s arms, if difference is >20mmHg repeat the measurement and if it remains >20mmHg use the arm with the higher reading for future measurements.
  • While waiting for ABPM or HBPM results, test for proteinuria. Measure plasma glucose, electrolytes, creatinine, eGFR, serum total cholesterol and HDL-cholesterol. Arrange a 12-lead ECG. Assess for hypertensive retinopathy.
  • Estimate 10-year cardiovascular disease (CVD) risk in accordance with the NICE guideline on lipid modification.
  • If hypertension is not diagnosed, assess in 5 years or consider more frequently if clinic BP is close to 140/90mmHg.

ABPM

  • Take ≥2 measurements per hour during patient’s usual waking hours.
  • Use average value of ≥14 measurements to confirm diagnosis.

HBPM

  • For each BP recording, take two measurements ≥1 min apart whilst patient is seated.
  • Record BP twice daily, ideally in the morning and evening.
  • Record BP for ≥4 days, ideally 7 days.
  • Discard measurements on day 1 and use the average value of remaining measurements to confirm diagnosis.

Aims

  • To reduce clinic BP to < 140/90mmHg or average ABPM/HBPM to < 135/85mmHg in patients < 80 years
  • To reduce clinic BP to < 150/90mmHg or average ABPM/HBPM to < 145/85mmHg in patients ≥80 years.

Note: See Hypertension in Pregnancy () for advice on the management of hypertension in women of childbearing potential.

Clinic BP (mmHg)Average ABPM or HBPM (mmHg)Recommended Action
Stage 1 hypertension ≥140/90 and ≥135/85 Offer treatment to patients < 80 years with ≥1 of the following: target organ damage, established CVD, renal disease, diabetes or a 10 year CVD risk 20% 
Stage 2 hypertension ≥160/100 and ≥150/95 Offer treatment to patients of any age.
Severe hypertension systolic ≥180 or diastolic ≥110 Consider immediate treatment.

Lifestyle measures

  • Offer lifestyle advice to all patients undergoing assessment or treatment for hypertension.
  • Assess patients' diet and exercise patterns and encourage appropriate lifestyle changes.
  • Advise patients to:
    – Limit weekly alcohol intake.
    – Avoid excessive consumption of coffee and other caffeine-rich products.
    – Limit dietary sodium intake by reducing intake or substituting sodium salt.
  • Offer smoking cessation help and advice.
  • Encourage stress reduction.

Note: Calcium, magnesium or potassium supplements should not be offered as a method for reducing BP.

Treatment

  • Offer patients ≥80 years the same treatment as younger patients taking account of any co-morbidity and patient’s existing burden of drug use.
  • Offer patients with isolated systolic hypertension (systolic BP ≥160mmHg) the same treatment as patients with both raised systolic and diastolic BP.
  • Provide patients with appropriate guidance and material about the benefits of drugs and the unwanted side effects that may occur in order to help patients make informed choices.
  • Where possible, recommend treatment with drugs that can be taken once daily.
  • Prescribe generic preparations where these are appropriate and minimise cost.
  • Use clinic BP measurements to monitor response to treatment. Consider ABPM or HBPM as an adjunct in patients identified as having ‘white-coat effect’.

Refer to Treatment Algorithm at top of article

Note

  • β-blockers are not a preferred initial therapy but are an alternative in patients < 55 years with an intolerance or contraindication to ACE inhibitors (or angiotensin II receptor antagonists), women of childbearing potential, or if evidence of increased sympathetic drive.
  • If therapy initiated with a β-blocker, add a calcium-channel blocker rather than a thiazide-like diuretic to reduce risk of diabetes.
  • In patients well controlled with a regimen that includes a conventional thiazide diuretic, there is no absolute need to replace the conventional thiazide diuretic with an alternative agent.
  • If calcium–channel blocker not suitable or not tolerated, offer thiazide-like diuretic.
  • Angiotensin II receptor antagonist preferred to ACE inhibitor in black patients of African/Caribbean descent.

Follow-up

  • Annual review – monitor BP, provide patients with support and discuss lifestyle, symptoms and medication.

Specialist referral

  • Consider in patients with signs and symptoms suggesting secondary cause of hypertension. Accelerated (malignant) hypertension or suspected phaeochromocytoma require immediate referral.
  • Consider in patients with symptoms of, or documented, postural hypotension (fall in systolic BP when standing of 20mmHg or more).
  • Consider in patients with unusual signs or symptoms or in those whose management depends critically on the accurate measurement of their BP.
  • Consider if < 40 years and no evidence of target organ damage, CVD, renal disease or diabetes.

Adapted from:


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