The National Institute for Health and Clinical Excellence (NICE) has updated its guideline on hypertension, making a number of new recommendations regarding both the diagnosis and treatment of the condition. The new clinical guideline 127 updates and replaces clinical guideline 34, which was published in June 2006.
Key new recommendations include the following:
- Diagnosis of primary hypertension should be confirmed using 24–hour ambulatory blood pressure monitoring, or home blood pressure monitoring, rather than be based solely on measurements of blood pressure taken in the clinic. This is to reduce the occurrence of white coat hypertension, which recent studies have suggested is causing the misdiagnosis of hypertension in up to a quarter of the 12 million patients currently labeled with the condition.
- For the treatment of hypertension, the guideline now recommends that calcium channel blockers (CCBs) should be the first choice of agent used in patients aged over 55 years and to black people of any age. If a CCB is not suitable, for example, because of oedema or intolerance, or if there is evidence or high risk of heart failure, thiazide-like diuretics, such as chlortalidone or indapamide, are recommended in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. For patients aged under 55, angiotensin-coverting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) remain first-line drugs, and CCBs should be added as a second-step drug.
- Patients aged 80 years should be offered the same antihypertensive drug treatment as people aged 55–80 years, taking into account any comorbidities. This is based on the HYVET study of nearly 4,000 hypertensive patients over 80 years, which found standard hypertensive treatment reduced the risk of fatal stroke by almost 40%, heart failure by 64% and all-cause mortality by around 20%.
The updated four-step antihypertensive drug treatment now recommended is shown in figure 1.
The guidance was updated by the National Clinical Guideline Centre in collaboration with the British Hypertension Society. The full guidance can be found on www.nice.org.uk/CG127