NICE Hypertension Guidelines 2006

Brief summary of NICE recommendations

Lifestyle interventions to reduce blood pressure
•Ask patients about their diet and exercise patterns, and offer guidance and written or audiovisual information.
•Ask about alcohol consumption and encourage patients to cut down if they drink excessively.
•Discourage excessive consumption of coffee and other caffeine-rich products.
•Encourage patients to reduce their salt intake or use a substitute.
•Offer smokers advice and help to stop smoking.
•Tell patients about local initiatives (for example, run by healthcare teams or patient organisations) that provide support and promote lifestyle change.

Assess risk factors
•Urine test for protein (using test strip)
•Plasma glucose, electrolytes, creatinine, serum total cholesterol and HDL cholesterol.
•12-lead electrocardiography.

Treatment
•Offer drug therapy to patients with:
o persistent high blood pressure of 160/100 mmHg or more
o persistent blood pressure above 140/90 mmHg and raised cardiovascular risk (1 0-year risk of cardiovascular disease of at least 20%, existing cardiovascular disease or target organ damage).
•See flow chart below for choice of drugs.
•Aim to reduce blood pressure to 140/90 mmHg or less, adding more drugs as needed, until further treatment is inappropriate or declined.

Abbreviations:
•A = ACE inhibitor
(consider angiotensin-II receptor antagonist if ACE intolerant)
•C = calcium-channel blocker
•D = thiazide-type diuretic





Introduction
This NICE guideline provides recommendations for the primary care management of raised blood pressure (BP).
Hypertension is a major but modifiable contributory factor in cardiovascular diseases (CVD) such as stroke and coronary heart disease (CHD). The objective of this guideline is to decrease cardiovascular morbidity and mortality resulting from these diseases. It is important to assess risk in people before CVD develops and monitoring for persistently raised BP is one aspect of CV risk assessment.
This guideline makes recommendations on primary care management of hypertension. It includes recommendations on approaches to identifying patients with persistently raised BP, and managing hypertension (including lifestyle advice and use of BP-lowering drugs).
This guideline does not address screening for hypertension, management of hypertension in pregnancy or the specialist management of secondary hypertension (where renal or pulmonary disease, endocrine complications or other disease underlie raised blood pressure). Patients with existing coronary heart disease or diabetes should be managed in line with current national guidance for these conditions.
Why a NICE guideline on hypertension?
This NICE guideline on the management of hypertension is based on the best available evidence. A multidisciplinary Guideline Development Group carefully considered evidence of both the clinical effectiveness and cost effectiveness of treatment and care in developing these recommendations. The draft guideline was then modified in the light of two rounds of extensive consultation with the relevant stakeholder groups, including NHS organisations, healthcare professionals, patient/carer groups and manufacturers.
 
Patient-centred care
This guideline offers best practice advice on the care of adults with hypertension.
Treatment and care should take into account patients’ individual needs and preferences. People with hypertension should have the opportunity to make informed decisions about their care and treatment. Where patients do not have the capacity to make decisions, healthcare professionals should follow the Department of Health guidelines – ‘Reference guide to consent for examination or treatment’ (2001) (available from www.dh.gov.uk).
Good communication between healthcare professionals and patients is essential. It should be supported by the provision of evidence-based information offered in a form that is tailored to the needs of the individual patient. The treatment, care and information provided should be culturally appropriate and in a form that is accessible to people who have additional needs, such as people with physical, cognitive or sensory disabilities, and people who do not speak or read English.
Unless specifically excluded by the patient, carers and relatives should have the opportunity to be involved in decisions about the patient’s care and treatment.
Carers and relatives should also be provided with the information and support they need.


Key priorities for implementation
The following recommendations have been identified as priorities for implementation.
Measuring blood pressure
•To identify hypertension (persistent raised blood pressure above 140/90 mmHg), ask the patient to return for at least two subsequent clinics where blood pressure is assessed from two readings under the best conditions available.
•Routine use of automated ambulatory blood pressure monitoring or home monitoring devices in primary care is not currently recommended because their value has not been adequately established; appropriate use in primary care remains an issue for further research.

Lifestyle interventions
•Lifestyle advice should be offered initially and then periodically to patients undergoing assessment or treatment for hypertension.

Cardiovascular risk
•If raised blood pressure persists and the patient does not have established cardiovascular disease, discuss with them the need to formally assess their cardiovascular risk. Tests may help identify diabetes, evidence of hypertensive damage to the heart and kidneys, and secondary causes of hypertension such as kidney disease.
•Consider the need for specialist investigation of patients with signs and symptoms suggesting a secondary cause of hypertension. Accelerated (malignant) hypertension and suspected phaeochromocytoma require immediate referral.

Pharmacological interventions
•Drug therapy reduces the risk of cardiovascular disease and death. Offer drug therapy to:
 patients with persistent high blood pressure of 160/100 mmHg or more
 patients at raised cardiovascular risk (10 year risk of CVD of 20% or more, or existing CVD or target organ damage) with persistent blood pressure of more than 140/90 mmHg.
•In hypertensive patients aged 55 or older or black patients of any age, the first choice for initial therapy should be either a calcium-channel blocker or a thiazide-type diuretic. For this recommendation, black patients are considered to be those of African or Caribbean descent, not mixed-race, Asian or Chinese.
•In hypertensive patients younger than 55, the first choice for initial therapy should be an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated).

Continuing treatment
•Provide an annual review of care to monitor blood pressure, provide patients with support and discuss their lifestyle, symptoms and medication.
•Patients may become motivated to make lifestyle changes and want to stop using antihypertensive drugs. If at low cardiovascular risk and with well controlled blood pressure, these patients should be offered a trial reduction or withdrawal of therapy with appropriate lifestyle guidance and ongoing review.


The following guidance is evidence based. The evidence supporting each recommendation is provided in the full guideline (see Section 5). Recommendations are classified according to the type of evidence they are based on (see appendix A).
1 Guidance
1.1 Measuring blood pressure

1.1.1 Healthcare professionals taking blood pressure measurements need adequate initial training and periodic review of their performance. D

1.1.2 Healthcare providers must ensure that devices for measuring blood pressure are properly validated, maintained and regularly recalibrated according to manufacturers’ instructions. D

1.1.3 Where possible, standardise the environment when measuring blood pressure: provide a relaxed, temperate setting, with the patient quiet and seated and with their arm outstretched and supported*. D
* The principles of good technique for measuring blood pressure are presented in box

1.
1.1.4 If the first measurement exceeds 140/90 mmHg*, if practical, take a second confirmatory reading at the end of the consultation. D
* Blood pressure is recorded as systolic/diastolic blood pressure measured in millimetres of mercury (mmHg). Raised blood pressure is noted when either systolic pressure exceeds 140 mmHg or diastolic blood pressure exceeds 90 mmHg.

1.1.5 Measure blood pressure on both of the patient’s arms with the higher value identifying the reference arm for future measurement. D

1.1.6 In patients with symptoms of postural hypotension (falls or postural dizziness) measure blood pressure while patient is standing. In patients with symptoms or documented postural hypotension (fall in systolic BP when standing of 20 mmHg or more) consider referral to a specialist. D
1.1.7 Refer immediately patients with accelerated (malignant) hypertension (BP more than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage) or suspected phaeochromocytoma (possible signs include labile or postural hypotension, headache, palpitations, pallor and diaphoresis). D
1.1.8 To identify hypertension (persistent raised blood pressure, above 140/90 mmHg), ask the patient to return for at least two subsequent clinics where blood pressure is assessed from two readings under the best conditions available. D
1.1.9 Measurements should normally be made at monthly intervals. However, patients with more severe hypertension should be re evaluated more urgently. D
1.1.10 Routine use of automated ambulatory blood pressure monitoring or home monitoring devices in primary care is not currently recommended because their value has not been adequately established; appropriate use in primary care remains an issue for further research. C
•Readings from clinic and ambulatory blood pressure devices, when used side-by-side, may differ from one another and from true arterial pressure because they use different methods and assumptions.
•Average ambulatory readings from a series of patients, taken over 24 hours, are commonly lower than clinic readings by between 10/5 and 20/10 mmHg. However, an individual patient may have ambulatory readings higher or lower than clinic readings. Studies comparing clinic and ambulatory measurement vary in their design, setting, conduct of measurement and analysis: estimated differences between ambulatory and clinic values vary with these factors.
•Clinic and ambulatory readings may also differ because of a ‘white coat’ effect − that is, a response to the setting or clinician.
•Epidemiological studies are inconsistent in demonstrating the additional prognostic value of ambulatory blood pressure monitoring to predict cardiovascular disease in unselected patients.

1.1.11 Consider the need for specialist investigation of patients with unusual signs and symptoms, or of those whose management depends critically on the accurate estimation of their blood pressure. D
BOX 1 Estimation of blood pressure by auscultation

1.2 Lifestyle interventions
1.2.1 Ascertain patients’ diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes. B
•Education about lifestyle on its own is unlikely to be effective.
•Healthy, low-calorie diets had a modest effect on blood pressure in overweight individuals with raised blood pressure, reducing systolic and diastolic blood pressure on average by about 5−6 mmHg in trials. However, there is variation in the reduction in blood pressure achieved in trials and it is unclear why. About 40% of patients were estimated to achieve a reduction in systolic blood pressure of 10 mmHg systolic or more in the short term, up to 1 year.
•Taking aerobic exercise (brisk walking, jogging or cycling) for 30–60 minutes, three to five times each week, had a small effect on blood pressure, reducing systolic and diastolic blood pressure on average by about 2–3 mmHg in trials. However, there is variation in the reduction in blood pressure achieved in trials and it is unclear why. About 30% of patients were estimated to achieve a reduction in systolic blood pressure of 10 mmHg or more in the short term, up to 1 year.
•Interventions actively combining exercise and diet were shown to reduce both systolic and diastolic blood pressure by about 4–5 mmHg in trials. About one-quarter of patients receiving multiple lifestyle interventions were estimated to achieve a reduction in systolic blood pressure of 10 mmHg systolic or more in the short term, up to 1 year.
•A healthier lifestyle, by lowering blood pressure and cardiovascular risk, may reduce, delay or remove the need for long-term drug therapy in some patients.

1.2.2 Relaxation therapies* can reduce blood pressure and individual patients may wish to pursue these as part of their treatment. However, routine provision by primary care teams is not currently recommended. B
* Examples include: stress management, meditation, cognitive therapies, muscle relaxation and biofeedback.
•Overall, structured interventions to reduce stress and promote relaxation had a modest effect on blood pressure, reducing systolic and diastolic blood pressure on average by about 3–4 mmHg in trials. There is variation in the reduction in blood pressure achieved in trials and it is unclear why. About one-third of patients receiving relaxation therapies were estimated to achieve a reduction in systolic blood pressure of 10 mmHg systolic or more in the short term, up to 1 year.
•The current cost and feasibility of providing these interventions in primary care has not been assessed and they are unlikely to be routinely provided.

1.2.3 Ascertain patients’ alcohol consumption and encourage a reduced intake if patients drink excessively, because this can reduce blood pressure and has broader health benefits. B
•Excessive alcohol consumption (men: more than 21 units/week; women: more than 14 units/week) is associated with raised blood pressure and poorer cardiovascular and hepatic health.
•Structured interventions to reduce alcohol consumption, or substitute low alcohol alternatives, had a modest effect on blood pressure, reducing systolic and diastolic blood pressure on average by about 3–4 mmHg in trials. Thirty percent of patients were estimated to achieve a reduction in systolic blood pressure of 10 mmHg systolic or more in the short term, up to 1 year.
•Brief interventions by clinicians of 10–15 minutes, assessing intake and providing information and advice as appropriate, have been reported to reduce alcohol consumption by one-quarter in excessive drinkers with or without raised blood pressure, and to be as effective as more specialist interventions.
•Brief interventions have been estimated to cost between £40 and £60 per patient receiving intervention. The structured interventions used in trials of patients with hypertension have not been costed.

1.2.4 Discourage excessive consumption of coffee and other caffeine-rich products. C
•Excessive consumption of coffee (five or more cups per day) is associated with a small increase in blood pressure (2/1 mmHg) in participants with or without raised blood pressure in studies of several months duration.

1.2.5 Encourage patients to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. B
•Advice to reduce dietary salt intake to less than 6.0 g/day (equivalent to 2.4 g/day dietary sodium) was shown to achieve a modest reduction in systolic and diastolic blood pressure of 2–3 mmHg in patients with hypertension, at up to 1 year in trials. About one-quarter of patients were estimated to achieve a reduction in systolic blood pressure of 10 mmHg systolic or more in the short term, up to 1 year.
•Long-term evidence over 2–3 years from studies of normotensive patients shows that reductions in blood pressure tend to diminish over time.
•One trial suggests that reduced sodium salt, when used as a replacement in both cooking and seasoning, is as effective in reducing blood pressure as restricting the use of table salt.

1.2.6 Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. B
•The best current evidence does not show that calcium, magnesium or potassium supplements produce sustained reductions in blood pressure.
•The best current evidence does not show that combinations of potassium, magnesium and calcium supplements reduce blood pressure.

1.2.7 Offer advice and help to smokers to stop smoking. A
•There is no strong direct link between smoking and blood pressure. However, there is overwhelming evidence of the relationship between smoking and cardiovascular and pulmonary diseases, and evidence that smoking cessation strategies are cost effective.
•See: Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation, NICE technology appraisal no. 39, March 2002. www.nice.org.uk/TA039

1.2.8 A common aspect of studies for motivating lifestyle change is the use of group working. Inform patients about local initiatives by, for example, healthcare teams or patient organisations that provide support and promote healthy lifestyle change. D

1.3 Estimating cardiovascular risk
1.3.1 If raised blood pressure persists and the patient does not have established cardiovascular disease, discuss with them the need to formally assess their cardiovascular risk. Tests may help identify diabetes, evidence of hypertensive damage to the heart and kidneys, and secondary causes of hypertension such as kidney disease. D

1.3.2 Test for the presence of protein in the patient’s urine. Take a blood sample to assess plasma glucose, electrolytes, creatinine, serum total cholesterol and HDL cholesterol. Arrange for a 12-lead electrocardiograph to be performed. D

1.3.3 Consider the need for specialist investigation of patients with signs and symptoms suggesting a secondary cause of hypertension. Accelerated (malignant) hypertension and suspected phaeochromocytoma require immediate referral. D
•An identifiable cause of hypertension is more likely when hypertension occurs in younger patients (less than 30 years of age), worsens suddenly, presents as accelerated (malignant) hypertension (BP more than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage) or responds poorly to treatment.
•An elevated creatinine level may indicate renal disease. Labile or postural hypotension, headache, palpitations, pallor and diaphoresis are potential signs of phaeochromocytoma. Hypokalaemia, abdominal or flank bruits, or a significant rise in serum creatinine when starting an ACE-inhibitor may indicate renovascular hypertension. Isolated hypokalaemia may be due to hyperaldosteronism. Potential signs of Cushing syndrome include osteoporosis, truncal obesity, moon face, purple striae, muscle weakness, easy bruising, hirsutism, hyperglycaemia, hypokalaemia and hyperlipidaemia.

1.3.4 Use the cardiovascular risk assessment to discuss prognosis and healthcare options with patients, both for raised blood pressure and other modifiable risk factors. D
•Risk models provide a useful prognostic tool for clinicians and patients in primary care. They reinforce the need to offer treatment to patients based on their profile of cardiovascular risk rather than focusing on blood pressure in isolation.
•Most risk models derive from the Framingham Heart Study: a cohort of over 5000 men and women aged 30–62 years from Framingham, Massachusetts followed up from 1971 to assess the determinants of cardiovascular disease.
•Limitations of commonly used risk models include poor validation in UK ethnic minorities and younger populations.
•Framingham risk calculator computer programmes currently provide the best assessment of risk of coronary heart disease and stroke over 10 years. The latest version developed by the Joint British Societies* gives the risk of a cardiovascular event over 10 years (a combined score including the risk of coronary heart disease and stroke).
•Risk charts may be relatively imprecise, placing patients in bands of risks, although the visual presentation may be helpful to some patients. Evidence suggests the Joint British Societies chart adheres most closely to Framingham risk calculators.
•When only the CHD risk score is known, CVD risk score can be approximated by multiplying by 4/3. When CHD and stroke risk are reported, the CVD risk can be approximated by adding these two scores together.
* Joint British Societies Cardiovascular Risk Charts are available from the British National Formulary.

1.4 Pharmacological interventions
For this updated guideline issued by NICE and the British Hypertension Society (www.bhsoc.org), new studies published since July 2004 were appraised and the data considered together with those from the earlier studies, using meta-analysis where appropriate. The Guideline Development Group (GDG) considered this evidence in the context of other available evidence. Adverse events data and issues of patient concordance were particularly noted, and the GDG also had access to a detailed health economic analysis comparing the cost-effectiveness of the main drug classes. Consideration was also given to the pathogenesis of hypertension and the mechanism of action of the different classes of drugs used to lower blood pressure, taking age and ethnicity into account. Finally, where the evidence did not prove definitive, the GDG took into account existing guidelines and constructed recommendations most compatible with current good practice.
In formulating its recommendations, the GDG has assumed a ’drug class effect’ unless there was clear evidence to the contrary. However, clinical-outcome trials involving thiazide-type diuretics have used a variety of different drugs at different doses. Moreover, the GDG felt that the benefits from ACE inhibitors and angiotensin-II receptor antagonists were closely correlated and that they should be treated as equal in terms of efficacy (although, because of cost differences, ACE inhibitors should be initiated first).
One class of drugs that caused particular debate was the beta-blockers. In head-to-head trials, beta-blockers were usually less effective than a comparator drug at reducing major cardiovascular events, in particular stroke. Atenolol was the beta-blocker used in most of these studies and, in the absence of substantial data on other agents, it is unclear whether this conclusion applies to all beta-blockers.
The evidence showed calcium-channel blockers or thiazide-type diuretics to be the drugs most likely to confer benefit as first-line treatment for most patients. The health economic model slightly favoured calcium-channel blockers, with thiazide-type diuretics as the next most cost-effective option. On balance, the GDG decided that calcium-channel blockers and thiazide-type diuretics should be offered as equal alternatives for clinicians and patients to consider as initial treatment. Consideration should be given to the patient’s risk of adverse effects and preferences.
This conclusion is less certain for younger patients (defined pragmatically as those younger than 55, who were often not included in the clinical trials reviewed). In the absence of clinical outcomes data in younger patients, the GDG considered that for pragmatic reasons it was essential to make a recommendation, and considered blood pressure lowering as the most suitable surrogate for clinical outcomes. What data there are suggest that initial therapy with a beta-blocker or an ACE inhibitor may provide superior initial blood pressure lowering compared with a calcium-channel blocker or a thiazide-type diuretic. The studies suggesting beta-blockers are generally an inferior choice have already been covered. Consequently, for patients younger than 55, an ACE inhibitor (or an angiotensin-II receptor antagonist if an ACE-inhibitor is not tolerated) is a better choice as initial therapy.
Many patients will require more than one drug to achieve adequate blood pressure control. An algorithm is provided on page 45. Pathophysiological reasoning suggests that adding an ACE inhibitor to a calcium-channel blocker or a diuretic (or vice versa in the younger group – that is, adding either a calcium-channel blocker or a diuretic to an ACE inhibitor) are logical combinations. In addition, these combinations have been commonly used at step 2 in clinical trials. Beyond this point there is even less evidence to guide practice, but the GDG concluded that the most straightforward choice is to recommend combining the three drug classes that have been used at steps 1 and 2 in treatment – that is, offering a three-drug combination of an ACE inhibitor (or angiotensin-II receptor antagonist) plus a calcium-channel blocker plus a thiazide-type diuretic.
The GDG was also concerned by the higher risk of patients developing diabetes, particularly when treated with the combination of a beta-blocker and a thiazide-type diuretic. Omitting beta-blockers from the routine treatment algorithm was therefore justified. Nevertheless, the GDG noted that there are certain compelling indications for beta-blockers and these have been specified.
Recommendations beyond a three-drug combination are based on consensus rather than hard evidence, but it was felt that practitioners would appreciate some guidance. The GDG also felt that if three drugs in combination were failing to provide adequate blood pressure control, a practitioner might consider seeking expert advice.
The recommendations below should be read in conjunction with the algorithms on pages 44 and 45.

1.4.1 Drug therapy reduces the risk of cardiovascular disease and death. Offer drug therapy to: A
•patients with persistent high blood pressure of 160/100 mmHg or more
•patients at raised cardiovascular risk (10 year risk of CVD of 20% or more, or existing cardiovascular disease or target organ damage) with persistent blood pressure of more than 140/90 mmHg.
•In placebo-controlled trials, blood pressure management beginning with a low-dose thiazide-type diuretic or beta-blocker has been shown to reduce mortality, myocardial infarction and stroke (relative risk reductions of 8%, 15% and 25%, respectively).

1.4.2 Provide appropriate guidance and materials about the benefits of drugs and the unwanted side effects sometimes experienced in order to help patients make informed choices. D

1.4.3 Offer drug therapy, adding different drugs if necessary, to achieve a target of 140/90 mmHg, or until further treatment is inappropriate or declined. Titrate drug doses as described in the ‘British national formulary’ noting any cautions and contraindications. A
•In trials aiming to reduce blood pressure to below 140/90 mmHg using stepped medication regimens, between one-half and three-quarters of patients achieved target blood pressure.
•In these trials about one-half of patients needed treatment with more than one drug.

1.4.4 New In hypertensive patients aged 55 or older or black patients of any age, the first choice for initial therapy should either be a calcium-channel blocker or a thiazide-type diuretic. For this recommendation, black patients are considered to be those of African or Caribbean descent, not mixed-race, Asian or Chinese. A*

1.4.5 New In hypertensive patients younger than 55, the first choice for initial therapy should be an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated). C*

1.4.6 New If initial therapy was with a calcium-channel blocker or a thiazide-type diuretic and a second drug is required, add an ACE inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated). If therapy was initiated with an ACE inhibitor (or angiotensin-II receptor antagonist), add a calcium-channel blocker or a thiazide-type diuretic. B*

1.4.7 New If treatment with three drugs is required, the combination of ACE inhibitor (or angiotensin-II receptor antagonist), calcium-channel blocker and thiazide-type diuretic should be used. B*

1.4.8 New If blood pressure remains uncontrolled on adequate doses
of three drugs, consider adding a fourth and/or seeking expert advice. C*

1.4.9 New If a fourth drug is required, one of the following should be considered: C*
•a higher dose of a thiazide-type diuretic or the addition of another diuretic (careful monitoring is recommended) or
•beta-blockers or
•selective alpha-blockers.

1.4.10 New If blood pressure remains uncontrolled on adequate doses of four drugs, and expert advice has not yet been obtained, this should now be sought. C*

1.4.11 New Beta-blockers are not a preferred initial therapy for hypertension. However, beta-blockers may be considered in younger people, particularly: B*
•those with an intolerance or contraindication to ACE inhibitors and angiotensin-II receptor antagonists or
•women of child-bearing potential or
•people with evidence of increased sympathetic drive.

In these circumstances, if therapy is initiated with a beta-blocker and a second drug is required, add a calcium-channel blocker rather than a thiazide-type diuretic to reduce the patient’s risk of developing diabetes. C*

1.4.12 New In patients whose blood pressure is not controlled (that is, above 140/90 mmHg) despite a treatment regimen that includes a beta-blocker, treatment should be revised according to the treatment algorithm on page 45 (see also 1.4.14). C*

1.4.13 New In patients whose blood pressure is well controlled (that is, 140/90 mmHg or below) with a regimen that includes a beta-blocker, long-term management should be considered as part of their routine review. In these patients there is no absolute need to replace the beta-blocker with an alternative agent. C*

1.4.14 New When a beta-blocker is withdrawn, the dose should be stepped down gradually. Beta-blockers should not be withdrawn in patients who have compelling indications for beta-blockade, for example those who have symptomatic angina or who have had a myocardial infarction. C*

1.4.15 Offer patients with isolated systolic hypertension (systolic BP 160 mmHg or more) the same treatment as patients with both raised systolic and diastolic blood pressure. A
•Patients with isolated systolic hypertension received similar benefits from treatment to other patients with raised blood pressure.

1.4.16 Offer patients over 80 years of age the same treatment as other patients over 55, taking account of any comorbidity and their existing burden of drug use. A
•Patients over 80 years of age are poorly represented in clinical trials and the effectiveness of treatment in this group is less certain. However, it is reasonable to assume that older patients will receive worthwhile benefits from drug treatment, particularly in terms of reduced risk of stroke.

1.4.17 Where possible, recommend treatment with drugs taken only once a day. A
•A meta-analysis found that patients adhered to once-daily blood pressure lowering regimens better than to regimens requiring two or more doses a day (91% versus 83%). Similarly, once-daily regimens were better adhered to than twice-daily regimens (93% versus 87%).

1.4.18 Prescribe non-proprietary drugs where these are appropriate and minimise cost. D
•Drug treatment beginning with either a non-proprietary thiazide-type diuretic or beta-blocker minimises cost.
•From a model of lifetime costs and effects, based on the findings of trials, treatment using stepped care including thiazide-type diuretics, beta-blockers, ACE-inhibitors/angiotensin receptor blockers and calcium-channel blockers is estimated to be cost effective.

1.5 Continuing treatment
1.5.1 The aim of medication is to reduce blood pressure to 140/90 mmHg or below. However, patients not achieving this target, or for whom further treatment is inappropriate or declined, will still receive worthwhile benefit from the drug(s) if these lower blood pressure. C
•In trials aiming to reduce blood pressure to below 140/90 mmHg using stepped medication regimens, between one-half and three-quarters of patients achieve target blood pressure.
•In these trials about one-half of patients needed treatment with more than one drug.

1.5.2 Patients may become motivated to make lifestyle changes and want to reduce or stop using antihypertensive drugs. If at low cardiovascular risk and with well controlled blood pressure, these patients should be offered a trial reduction or withdrawal of therapy with appropriate lifestyle guidance and ongoing review. B
•When normal blood pressure has been established through drug therapy, the patients most likely to remain normotensive if they stop taking drugs are those who are relatively young, with lower on-treatment blood pressure, taking only one drug and who adopt lifestyle changes.
•Withdrawal of antihypertensive drugs has a much better chance of being successful when supported by structured interventions to encourage patients to restrict their salt intake and to lose weight if they are overweight.

1.5.3 Patients vary in their attitudes to their hypertension and their experience of treatment. It may be helpful to provide details of patient organisations that provide useful forums to share views and information. D

1.5.4 Provide an annual review of care to monitor blood pressure, provide patients with support and discuss their lifestyle, symptoms and medication. D
•Listening to patients’ views about the pros and cons of treatment for hypertension, involving patients in each stage of the management of their condition and providing clearly written supportive information is good clinical practice.

2 Notes on the scope of the guidance
All NICE guidelines are developed in accordance with a scope document that defines what the guideline will and will not cover. The scope of this guideline was established, after a period of consultation, at the start of the guideline development process; it is available from www.nice.org.uk/CG034
This guideline provides recommendations for the care of patients with raised blood pressure. It does not address screening for hypertension, management of hypertension in pregnancy or the specialist management of secondary hypertension (where renal or pulmonary disease, endocrine complications or other disease underlie raised blood pressure). The updated recommendations exclude people with significant comorbidities, people who are unconscious and older people in long-term care facilities.

3 Implementation in the NHS
The Healthcare Commission assesses the performance of NHS organisations in meeting core and developmental standards set by the Department of Health in ‘Standards for better health’ issued in July 2004. Implementation of clinical guidelines forms part of the developmental standard D2. Core standard C5 says that national agreed guidance should be taken into account when NHS organisations are planning and delivering care.
NICE has developed costing tools to help organisations implement this guidance (listed below). These tools include:
•a costing report to estimate the national savings and costs associated with implementation
•a costing template to estimate the local costs and savings involved.
These are available on our website (www.nice.org.uk/CG034).
Suggested audit criteria based on the key priorities for implementation are listed in appendix D of this document (see page 38), and can be used to audit practice locally.
4Research recommendations

The Guideline Development Groups have made the following recommendations for research, on the basis of their reviews of the evidence. The Groups regard these recommendations as the most important research areas to improve NICE guidance and patient care in the future. The Guideline Development Groups’ full sets of research recommendations are detailed in the full guideline (see section 4).
•The role of ambulatory and home blood pressure monitoring devices in improving patient care and health outcomes. The consequences for resource use (reflecting equipment purchase, maintenance, recalibration, staff, training and medication costs), patient participation in treatment and quality of life. The appropriate use of these devices either as a routine strategy or in self-selecting patients.
•The long-term value of table salt substitutes in lowering blood pressure.
•The long-term value of pragmatic multifaceted lifestyle interventions, including diet, exercise and relaxation, that could be supported by the NHS and other government agencies.
•The validity of cardiovascular risk prediction models in British patient populations, particularly in young people and in ethnic minority groups.
•The presentation of individual benefits and risks of treatment to patients.
•The influence of class of drug on morbidity and mortality in different age and ethnic groups.
•The relationship between thiazide diuretic/beta-blocker co-treatment and new-onset diabetes. Whether all patients are at increased risk or there are specific high-risk groups.
•Determinants of current patterns of care and use of antihypertensive drugs. Methods to improve uptake where it is shown to be sub-optimal.
•The clinical and cost effectiveness of antihypertensive therapies in people younger than 55.
•The clinical effectiveness of antihypertensive therapies in people from minority ethnic groups, particularly black and Asian people.
•The adoption of quality of life measures within future clinical trial protocols of antihypertensive therapy to allow measures of drug class utility.
•The most effective treatment of hypertension resistant to therapy with three blood pressure lowering drugs.

5 Other versions of this guideline
The previous NICE guidance on hypertension (NICE clinical guideline 18) was developed by the Newcastle Guideline Development and Research Unit. The National Institute for Health and Clinical Excellence commissioned the update of this guidance from the National Collaborating Centre for Chronic Conditions. The Centre established a Guideline Development Group, which reviewed the evidence and developed the recommendations. The members of the Guideline Development Group are listed in appendix B. Information about the independent Guideline Review Panel is given in appendix C.

The booklet ‘The guideline development process – an overview for stakeholders, the public and the NHS’ has more information about the Institute’s guideline development process. It is available from www.nice.org.uk/guidelinesprocess

5.1 Full guideline
The full guideline, ‘Management of hypertension in adults in primary care: partial update’, describes the methods and evidence used for updating section 1.4. For details of the evidence for the other recommendations, see the full version of NICE clinical guideline 18 (www.nice.org.uk/CG018). It is published by the National Collaborating Centre for Chronic Conditions; it is available from www.rcplondon.ac.uk/pubs/books, the NICE website (www.nice.org.uk/CG034fullguideline) and the website of the National Library for Health (www.nlh.nhs.uk).

5.2 Quick reference guide
A quick reference guide for healthcare professionals is also available from the NICE website (www.nice.org.uk/CG034quickrefguide) or from the NHS Response Line (telephone 0870 1555 455; quote reference number N1050).

5.3 Understanding NICE guidance: information for patients and carers
A version of this guideline for people with hypertension and their carers is available from our website (www.nice.org.uk/CG034publicinfo) and the NHS Response Line (telephone 0870 1555 455; quote reference number N1051).

6 Related NICE guidance
Prophylaxis for patients who have experienced a myocardial infarction: drug treatment, cardiac rehabilitation and dietary manipulation. NICE inherited guideline A (2001). Available from www.nice.org.uk/guidelineA
Management of type 2 diabetes – management of blood pressure and blood lipids. NICE inherited guideline H (2002). Available from www.nice.org.uk/guidelineH
Statins for the prevention of cardiovascular events in patients at increased risk of developing cardiovascular disease or those with established cardiovascular disease. NICE technology appraisal no. 94 (2006). Available from www.nice.org.uk/TA094
Cardiovascular risk assessment: the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. NICE clinical guideline. Publication expected December 2007. See www.nice.org.uk/guidelines.inprogress.hyperlipidaemiacardiovascular

7 Review date
The process of reviewing the evidence is expected to begin 4 years after the date of issue of this guideline. Reviewing may begin before this if significant evidence that affects the guideline recommendations is identified sooner. The updated guideline will be available within 2 years of the start of the review process.

Appendix A: Grading scheme
Clinical guideline 18
The grading scheme and hierarchy of evidence used to develop the original NICE clinical guideline (that is, all the recommendations except those in section 1.4) are shown in the table below. Please note the full guideline used a different system for grading of the evidence that was being piloted by the Newcastle Guideline Development and Research Unit.
Hierarchy of evidence
Grade Type of evidence
Ia Evidence from a meta-analysis of randomised controlled trials
Ib Evidence from at least one randomised controlled trial
IIa Evidence from at least one controlled study without randomisation
IIb Evidence from at least one other type of quasi-experimental study
III Evidence from observational studies
IV Evidence from expert committee reports or experts
Grading of recommendation
Grade Evidence
A Directly based on category I evidence
B Directly based on category II evidence or extrapolated from category I evidence
C Directly based on category III evidence or extrapolated from category I or II evidence
D Directly based on category IV evidence or extrapolated from category I, II or III evidence
Adapted from the Agency for Healthcare Policy and Research (AHCPR) system. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research (1992) Acute pain management: operative or medical procedures and trauma. Rockville MD: Agency for Health Care Policy and Research Publications.
 
Update
The grading scheme and hierarchy of evidence used in updating section 1.4 are shown in the tables on pages 31 and 32 (the GREG scheme). This system grades evidence from ‘I’ (high) to ’III’ (low) for each type of study (evaluation of treatment, diagnosis or prognosis) according to a series of quality criteria. It also provides a flexible framework for assessing studies that address the process of care (such as patient surveys) and economic analyses. Research provides robust evidence when it has been conducted to exclude bias, to include suitable populations in adequate numbers, and to measure suitable outcomes. Recommendations reflect the evidence, importance and feasibility of defined steps in the provision of healthcare. Grade A* recommendations indicate a clear basis and conditions for providing (or not providing) a pattern of care. Grade B* means there are important uncertainties that need more careful consideration. Grade C* means that key information is unavailable but that the Guideline Development Group has reached a consensus recommendation based on its shared understanding of the issue.
Guideline recommendation and evidence grading (GREG) scheme for assessing evidence and writing recommendations
EVIDENCE
Evidence statements provide information about disease, diagnosis and treatment, and are used to support recommendations. Each evidence statement is graded by scoring the study design and applying quality corrections.
Design Design scores
Treatment
Randomised controlled trial 1
Non-randomised controlled study 2
Uncontrolled study 3
Diagnosis
Blinded cohort study a 1
Unblinded cohort study 2
Other design 3
Prognosis
Incident cohort study b 1
Other cohort study 2
Descriptive data
Population data 1
Representative sample 2
Convenience sample 3
Quality corrections
Flawed design, conduct or analysis c +1
Imprecise findings d +1
Lack of consistency or independence e +1
Inadequate relevance f +1
Very strong association g -1
Evidence grade Score
I: High ≤ 1
II: Intermediate 2
III: Low ≥ 3
a Blinding refers to independent interpretation of a test and reference standard.
b An incident cohort is identified and followed in time from a defined point in the progress of disease or care.
c Important flaws may be judged to occur when adequate standards of research are not followed or are unreported in published findings. Potential examples include failure to analyse by intention-to-treat, over-interpretation of secondary analyses, failure to adjust for potential confounding in non-randomised designs. For diagnostic studies this includes the need for an adequate reference standard and to apply different tests in an adequately short timescale.
d Sparse data (too few events or patients) are the most common reason for imprecision. A confidence interval including both no effect and a clinically important effect is an example of an imprecise finding.
e Consistency in design: involves methods, patients, outcome measures; and findings: involves homogeneity of summary estimates. Independence refers to the availability of research from at least two independent sources. Evidence of publication bias also denotes lack of consistency.
f Adequate relevance requires use in studies of a relevant patient-oriented health outcome or a strongly linked surrogate endpoint; and a sufficiently representative and relevant patient group or mix.
g In comparative designs a very strong association can raise the quality score.

Recommendations
Recommendations provide guidance about appropriate care. Ideally, these should be based on clear evidence: a robust understanding of the benefits, tolerability, harms and costs of alternative patterns of care. They also need to be feasible in the healthcare setting addressed. There are three categories, and each recommendation may be positive or negative, conditional or unconditional reflecting current evidence and the understanding of the Guideline Development Group.
A* Recommendation There is robust evidence to recommend a pattern of care.
B* Provisional recommendation On balance of evidence, a pattern of care is recommended with caution.
C* Consensus opinion Evidence being inadequate, a pattern of care is recommended by consensus.