Hypertension in adults: diagnosis and management - NICE guideline

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The Hypertension in adults: diagnosis and management offers evidence-based advice on the care and treatment of adults with primary hypertension.

Key recommendations

Out-of-office monitoring

In adults with primary hypertension, does the use of out-of-office monitoring (HBPM or ABPM) improve response to treatment?

Why this is important

There is likely to be increasing use of HBPM and for the diagnosis of hypertension as a consequence of this guideline update. There are, however, very few data regarding the utility of HBPM or ABPM as means of monitoring blood pressure control or as indicators of clinical outcome in treated hypertension, compared with clinic blood pressure monitoring. Studies should incorporate HBPM and/or ABPM to monitor blood pressure responses to treatment and their usefulness as indicators of clinical outcomes.

Intervention thresholds for people aged under 40 with hypertension

In people aged under 40 years with hypertension, what are the appropriate thresholds for intervention?

Why this is important

There is uncertainty about how to assess the impact of blood pressure treatment in people aged under 40 years with stage 1 hypertension and no overt target organ damage or cardiovascular disease (CVD). In particular, it is not known whether those with untreated hypertension are more likely to develop target organ damage and, if so, whether such damage is reversible. Target organ damage and CVD as surrogate or intermediate disease markers are the only indicators that are likely to be feasible in younger people because traditional clinical outcomes are unlikely to occur in sufficient numbers over the timescale of a typical clinical trial. The data will be important to inform treatment decisions for younger people with stage 1 hypertension who do not have overt target organ damage.

Methods of assessing lifetime cardiovascular risk in people aged under 40 years with hypertension

In people aged under 40 years with hypertension, what is the most accurate method of assessing the lifetime risk of cardiovascular events and the impact of therapeutic intervention on this risk?

Why this is important

Current short-term (10-year) risk estimates are likely to substantially underestimate the lifetime cardiovascular risk of younger people (aged under 40 years) with hypertension, because short-term risk assessment is powerfully influenced by age. Nevertheless, the lifetime risk associated with untreated stage 1 hypertension in this age group could be substantial. Lifetime risk assessments may be a better way to inform treatment decisions and evaluate the cost effectiveness of earlier intervention with pharmacological therapy.

Optimal systolic blood pressure

In people with treated hypertension, what is the optimal systolic blood pressure?

Why this is important

Data on optimal blood pressure treatment targets, particularly for systolic blood pressure, are inadequate. Current guidance is largely based on the blood pressure targets adopted in clinical trials but there have been no large trials that have randomised people with hypertension to different systolic blood pressure targets and that have had sufficient power to examine clinical outcomes.

Antihypertensive treatment

In adults with hypertension, which drug treatment (diuretic therapy versus other step 4 treatments) is the most clinically and cost effective for step 4 antihypertensive treatment?

Why this is important

Although this guideline provides recommendations on the use of further diuretic therapy for treatment at step 4 (resistant hypertension), they are largely based on post-hoc observational data from clinical trials. More data are needed to compare further diuretic therapies, for example a potassium-sparing diuretic with a higher-dose thiazide-like diuretic, and to compare diuretic therapy with alternative treatment options at step 4 to define whether further diuretic therapy is the best option.

Automated blood pressure monitoring in people with atrial fibrillation

Which automated blood pressure monitors are suitable for people with hypertension and atrial fibrillation?

Why this is important

Atrial fibrillation may prevent accurate blood pressure measurement with automated devices. It would be valuable to know if this can be overcome.

What is hypertension?

High blood pressure (hypertension) is one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension is usually associated with a progressive rise in blood pressure. The vascular and renal damage that this may cause can culminate in a treatment-resistant state.

Blood pressure is normally distributed in the population and there is no natural cut-off point above which 'hypertension' definitively exists and below which it does not. The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke. Hypertension is remarkably common in the UK and the prevalence is strongly influenced by age. In any individual person, systolic and/or diastolic blood pressures may be elevated. Diastolic pressure is more commonly elevated in people younger than 50. With ageing, systolic hypertension becomes a more significant problem, as a result of progressive stiffening and loss of compliance of larger arteries. At least one quarter of adults (and more than half of those older than 60) have high blood pressure.

You can read the guideline on NICE's website.