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Management of hypertension: following NICE guidelines

February 13th, 2012

An Incidental blood pressure of 148/94 in a fit and well 50 year old man. What next?

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Photo by jasleen_kaurManagement of hypertension is becoming increasingly complex.

Here our contributors summarise the complex use of BP to measure cardiovascular risk.

“Its always a case of measuring multiple things. We know we should be aggressively treating BP with patients with chronic renal disease and diabetes, but what about those without? Follow the NICE guidelines with our quick digest.”

 

We recommend management in accordance with the recently released NICE 2011 Hypertension guidelines.

Our step-by-step guide is below:

Action Discussion Comments
Concerned about high blood pressure? If your first reading is >140/90, take two further readings, then take the lower reading of the second two to record as ‘clinic blood pressure’. If blood pressure is close to 140/90, repeat after an interval e.g. 3-6 months.
If the blood pressure is elevated (>140/90) by this method, perform ambulatory blood pressure monitoring Ambulatory blood pressure recording is the preferred choice for measuring is someone has hypertension. This averages waking BP measurements, to give a more accurate reflection of cardiovascular risk. Regimes for home BP measurement are also available from NICE
Classify according to Stage

 Stage 1 HypertensionAmbulatory BP >135/85 and <150/95

‘Clinic’ >140/90 – <160/100
Stage II HypertensionAmbulatory BP >150/95

Clinic >160/100
Stages III and IV:Clinic BP >180/110
Treat everyone with hypertension and ANY of the following.
  • A CVS Risk of >20% over 10 years.
  • Target organ damage
  • Established cardiovascular disease
  • Renal disease
  • Diabetes
Consider immediate treatment +/- other investigations for stage III /IV hypertension BP of >180 /110 should be considered for immediate treatment, +/- specialist advice and referral.
Treatments:Use the ACD combination Step 1 (A or C)Start with either an A or a C. Use an ‘A’ in <55y.o. patient.

Use a C in >55 or all black patients (more likely to have ‘low renin’ hypertension, and are therefore less likely to benefit from an ACE inhibitor).

Step 2 (A&C)

Then add in the other

Step 3 (A&C&D)

Add in a thiazide e.g. bendroflumethiazide

Step 4 Others

Consider spironolactone or beta blocker

 A=Ace inhibitor or ARIIRBC=Calcium channel blocker

D=thiazide like diuretic

 
Key points
  • Beta-blockers have no role in the first line management of hypertension.
  • Cardiovascular risk assessment using the Joint British Societies charts (back of the BNF) requires age, smoking status, blood pressure and lipid profile.

 

So the answer is?

In the case above, with a BP of 148/94,  we need to do two further blood pressure measurements in the clinic. If the lower of these is >140/90, then offer home ambulatory blood pressure measurement.

You can read a quick reference version of the 2011 NICE guidelines here.

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