Professor Mark Caulfield explores how recent recommendations on the assessment, diagnosis, and treatment of hypertension offer improved and targeted care
  • Hypertension is the most common risk factor for cardiovascular disease
  • Treatment of hypertension is more cost effective than taking no action
  • Healthcare professionals should focus on achieving blood-pressure targets for those people whose hypertension is uncontrolled
  • NICE Quality Standard 28 was developed to support the implementation of NICE Clinical Guideline 127 on the clinical management of primary hypertension in adults
  • Ambulatory blood pressure monitoring should be used to confirm a diagnosis of hypertension
  • The recommended treatment targets for blood pressure are:
    • <140/90 mmHg for people aged under 80 years
    • <150/90 mmHg for people aged 80 years and over
  • Following a diagnosis of hypertension, target organ damage should be assessed within 1 month
  • Statin therapy should be offered to people with newly diagnosed hypertension and a 10-year CVD risk of 20% or higher
  • Patients with resistant hypertension who are receiving four antihypertensive drugs and whose blood pressure remains uncontrolled should be referred for specialist assessment and optimisation of
    blood-pressure control.

H ypertension affects at least 25% of the UK adult population and is the most common risk factor for cardiovascular disease (CVD), being implicated in 69% of stroke and 49% of coronary artery disease cases.1 The World Health Report 2002 suggests that 11% of all disease burden in developed countries is caused by raised blood pressure, and over 50% of coronary heart disease and almost 75% of stroke in developed countries is due to systolic blood pressure levels in excess of 115 mmHg.2 This means that even though treating hypertension is now cheaper than doing nothing, it remains a significant contributor to the total cost of CVD, which in the UK in 2009 was £18.9 billion.3

Background

In 2011, NICE and the British Hypertension Society (BHS) collaborated on NICE Clinical Guideline (CG) 127 on Hypertension: clinical management of primary hypertension in adults (see www.nice.org.uk/guidance/cg127), which updated and replaced CG34. This update changed several key recommendations on the clinical management of hypertension. The principal changes were: 1

  • the diagnosis of hypertension should be confirmed by ambulatory blood pressure monitoring (ABPM), which offers superior diagnostic precision compared with clinic and home blood pressure, and is cost effective
  • the blood pressure threshold of >150/90 mmHg for diagnosis of hypertension was recommended for people aged 80 years and over
  • the treatment algorithm was revised to prioritise calcium-channel blockers (CCBs) over diuretics at step 1 of treatment in people aged over 55 years; this is partly because of the slight superiority that CCBs offer in stroke reduction and their efficacy when combined with angiotensin-converting enzyme (ACE) inhibitors at step 2
  • thiazide-type diuretics should be used (indapamide and chlortalidone) in preference to less effective thiazide diuretics (e.g. bendroflumethiazide)
  • spironolactone should be considered as an additional diuretic at step 4
  • resistant hypertension was defined as a blood pressure >140/90 mmHg despite step 3 treatment (with the optimal or best-tolerated doses of an ACE inhibitor or an angiotensin II receptor blocker [ARB] plus a CCB plus a diuretic)
  • treatment targets for blood pressure were confirmed as <140/90 mmHg for people aged under 80 years and <150/90 mmHg for people aged 80 years and over
  • for the first time, cost-effectiveness analysis showed that treating hypertension was more cost effective than taking no action.4

Current management of blood pressure

Results from a study of 470,000 people with hypertension between 2000 and 2007,5 have suggested that the quality and outcomes framework (QOF)6 had little impact upon blood pressure control. This contrasts with data from the Health Survey for England 2011, which surveyed a random sample of the population, and tells a different story. These data show important improvements in people with a diagnosis of hypertension who have received treatment, and a higher percentage of people attaining target blood pressures of <140/90 mmHg between 2003 and 2011.7 The prevalence of untreated hypertension has fallen over this period, from 20% of men and 16% of women in 2003, down to 14% of men and 11% of women in 2011. The prevalence of controlled hypertension has also improved over this period, from 5% of men and 6% of women in 2003, to 11% of men and 10% of women in 2011.7 However, the proportion of people whose blood pressure remains uncontrolled is relatively constant, suggesting that there is a residual and unmet need for hypertensive control and that clinical practice should be focusing on achieving target values for those people whose blood pressure is uncontrolled.

Hypertension targets in QOF 2013/14

Alongside this, recent changes have been made to the hypertension indicators in the QOF 2013/14,6 based on evidence relating to blood pressure levels achieved in multiple clinical trials, as reviewed in NICE CG127.1 The data showed that people aged under 80 years receiving treatment for hypertension should be given a blood pressure target of <140/90 mmHg, and that, importantly, this figure is attainable for the majority of patients (50%–60% of people with hypertension in trials). This shifts the emphasis from achieving the less optimal blood pressure of <150/90 mmHg to <140/90 mmHg, which should lead to achievement of blood pressure levels between the optimal and the audit standard.8 A successful pilot undertaken for the NICE QOF programme in primary care during 2011–2012 is summarised in Table 1 (below).8 The pilot showed that control of blood pressure was achievable in the majority of practices, by implementing the lower <140/90 mmHg target.8

Table 1: Impact of implementing a blood pressure target of <140/90 mmHg in a QOF pilot8
Characteristic Baseline After 6 months
Practice population from 16 practices included in pilot 100,897 101,271
Total number of patients on hypertension register 14,049 14,105
People over 80 years of age 3305 3322
Total excluded patients including those over 80 years of age 3709 3788
Total number of people with hypertension under the age of 80 years 10,340 10,317
Number of people with hypertension under 80 years who attain a blood pressure <140/90 mmHg at baseline and after 6 months 5417 6283
Percentage at target 52.4% 60.9%
The pilot was run across 16 practices over 6 months.

The results show that a higher number of people achieved their target blood pressure of <140/90 mmHg after 6 months and without a dramatic increase in exclusions.

QOF=quality and outcomes framework

Quality standard for hypertension

NICE quality standard (QS) for hypertension (QS28)9 contains six key statements for service providers, healthcare professionals, and commissioners to ensure systems are in place. The quality standard was the next step for the NICE/BHS partnership in implementing NICE CG127. For each statement, the proportion of people in whom the quality measure has been successfully implemented can be judged as the number of people with hypertension who met or attained the quality standard (the numerator), compared with the total number of eligible patients with hypertension (the denominator). (See also Audit points box.) Frequently-asked questions about CG127 and QS28 are listed in Table 3.

Table 2: Quality standard for hypertension (QS28)9
No. Quality statement
1 People with suspected hypertension are offered ABPM to confirm a diagnosis of hypertension.
2 People with newly diagnosed hypertension receive investigations for target organ damage within 1 month of diagnosis.
3 People with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher are offered statin therapy.
4 People with treated hypertension have a clinic blood pressure target set to below 140/90 mmHg if aged under 80 years, or below 150/90 mmHg if aged 80 years and over.
5 People with hypertension are offered a review of risk factors for cardiovascular disease annually.
6 People with resistant hypertension who are receiving four antihypertensive drugs and whose blood pressure remains uncontrolled are referred for specialist assessment.
ABPM=ambulatory blood pressure monitoring NICE (2013) QS28. Quality standard for hypertension. Available at: publications.nice.org.uk/quality-standard-for-hypertension-qs28

Diagnosis and investigations—statements 1–2

Confirm diagnosis of hypertension with ABPM—statement 1

From the evaluation in NICE CG127, ABPM is the most accurate method for confirming a diagnosis of hypertension. Its use should reduce unnecessary treatment in people who do not have true hypertension by as much as 25%.10 Ambulatory blood pressure monitoring has also been shown to be currently superior and cost effective when compared with other methods of taking multiple measurements for blood pressure to predict related clinical outcomes.10 The most reliable prognostic indicator of outcomes is the daytime average blood pressure with >135/85 mmHg being equivalent to >140/90 mmHg in the clinic.10 This statement requires evidence of local arrangements to ensure people with suspected hypertension are offered ABPM to confirm the diagnosis. It indicates that successful implementation can be assessed by measuring the number of people with suspected hypertension who receive ABPM to confirm diagnosis (the numerator), compared with the total population of people with suspected hypertension (the denominator). The quality statement acknowledges that ABPM may not be acceptable or tolerated by all.9 In this setting, home blood pressure monitoring with a series of readings taken seated over 4–7 days using a validated monitor is the next best alternative.10

 

Investigations for target organ damage—statement 2

Assessment of target organ damage can alert the clinician to possible secondary causes of hypertension, some of which are potentially life threatening, and some that may be amenable to potentially curative interventions. It can also support the clinician to decide the appropriate blood-pressure threshold at which to consider drug therapy for the treatment of hypertension. Healthcare providers will need to provide evidence of local arrangements for people with newly diagnosed hypertension to receive all investigations for target organ damage within 1 month of diagnosis. This will be assessed by comparing the number of people with newly diagnosed hypertension who receive all investigations for target organ damage within 1 month of diagnosis, with the total number of people with newly diagnosed hypertension.9


Treatment, review, and referral—statements 3–6

Statin therapy—statement 3

Hypertension is associated with a higher risk of cardiovascular events. A formal cardiovascular risk assessment at diagnosis enables a person’s 10-year risk of cardiovascular events (such as coronary heart disease and stroke) to be estimated.9 There is evidence that statin therapy reduces cardiovascular events in people with hypertension.11 This statement is aimed at ensuring that people with newly diagnosed hypertension and a 10-year CVD risk of 20% or higher are offered statin therapy. The effectiveness will be judged by the proportion of people with a new diagnosis of hypertension who receive formal risk assessment by the available tools, and the proportion of eligible patients with a 10-year CVD risk of 20% or higher who are prescribed statin therapy.9

Targets for blood pressure—statement 4

Hypertension is associated with a higher risk of cardiovascular events. The aims of setting evidence-based targets for blood pressure are to prevent and reduce the risk of CVD. This parallels the changes in the QOF, which will additionally now measure the proportion of people aged:6

  • 79 years or under with hypertension attaining a target <140/90 mmHg (clinical indicator no. HYP003)
  • 80 years and over achieving <150/90 mmHg.

Annual review of risk factors for CVD—statement 5

As people age, their risk of high blood pressure and CVD increases. This risk can be assessed by an annual review of risk factors for CVD, which would identify any increased risk, and offers an opportunity to address modifiable factors. Quality statement 5 will be evaluated by the proportion of eligible patients who receive an annual review of blood pressure and CVD risk.9

Specialist referral of people with resistant hypertension—statement 6

In NICE CG127, we defined people with resistant hypertension as having a clinic blood pressure that remains higher than 140/90 mmHg in spite of them taking optimal or best tolerated doses of three agents from step 3 treatment, which will usually be an ACE inhibitor (or an ARB), plus a CCB, plus a diuretic. These people will usually be treated with an ACE inhibitor (or ARB), a CCB, a thiazide-type diuretic, and a fourth medication.1 If the patient remains above the target, specialist assessment for secondary causes of hypertension and optimisation of blood-pressure control is recommended.1 This statement will be evaluated as the proportion of those people with uncontrolled hypertension at step 4 of NICE CG127 taking four or more antihypertensive agents who are referred for specialist assessment.

Table 3: Frequently asked questions about the NICE hypertension guideline (CG127) and the quality standard for hypertension (QS28)
ABPM monitors are expensive—how can this be cost effective?
  • ABPM improves precision over clinic diagnosis, reducing treatment by 25%
  • A list of 10,000 patients would have 80–100 new patients with hypertension per year and could manage with three machines
  • The cost-effectiveness analysis on NICE CG127 suggested that by using ABPM, there would be savings from fewer clinic appointments (more rapid diagnosis) and less drug use.
ABPM records output a lot of data—how can I use this quickly in the real world?
  • Ensure there is a minimum of 14 daytime recordings to pass quality control
  • Focus on the daytime average—if it is below 135/85 mmHg, then the diagnosis is not confirmed.
Why is ABPM so good in diagnosis but we revert to clinic blood pressure to monitor control?
  • The evidence for diagnostic precision and relationships to prognosis is of high quality
  • There are almost no outcome trials that have used ABPM as the method for assessing target attainment. Almost all are based on clinic blood pressure.
Can I use home recordings that patients bring me as well?
  • Yes—in CG127, the analysis suggested home blood-pressure measurement was still better than clinic, but not as good as ABPM
  • In CG127, NICE recommends that a series of readings over 4 or up to 7 concurrent days can be used in diagnosis if ABPM could not be performed.
Isn’t changing the QOF target to 140/90 mmHg a marginal gain for a significant consumption of resources?
  • Epidemiological data suggests that, for each 20 mmHg rise above 115 mmHg systolic blood pressure, there is a doubling of mortality
  • There are clear benefits of blood pressure lowering down to 140/90 mmHg and though it is challenging, the QOF showed that such a goal led to improved blood-pressure control over as little as 6 months.
CG=clinical guideline; QS=quality standard; ABPM=ambulatory blood pressure monitoring; QOF=quality and outcomes framework

Conclusion

The pharmacological control of hypertension is more cost effective than doing nothing, and NICE QS28 sets out six key auditable quality statements that sit alongside the QOF to enhance blood-pressure control and reduce cardiovascular events. NICE has produced a support document for commissioners and others on the commissioning implications and potential resource impact of this quality standard.4 A multidisciplinary team was convened by the Department of Health to support development of a Patient Decision Aid on the management of hypertension, based on NICE CG127, which may be helpful in advising patients on where to get more information.12 If we can implement the NICE quality standard and deliver the QOF indicators for 2013/14, we will make giant strides towards delivery of the new Department of Health strategy for cardiovascular disease.13 Most importantly for our patients, we will have made even greater progress toward control of blood pressure and reduction of CVD.

  • Proportion of eligible people:
    • with a new diagnosis of hypertension who receive ABPM
    • with a new diagnosis of hypertension who are investigated for target organ damage within 1 month of diagnosis
    • with hypertension who are prescribed statin therapy
  • Proportion of people:
    • under 80 years of age with hypertension who attain blood pressure targets <140/90 mmHg
    • over 80 years of age with hypertension who attain blood pressure
      targets <150/90 mmHg
    • with hypertension who have an annual review of risk factors for cardiovascular disease
    • with uncontrolled resistant hypertension who are referred for specialist assessment.

ABPM=ambulatory blood pressure monitoring

  • CCGs should review current commissioned services for the diagnosis and management of hypertension against NICE Quality Standard 28 and NICE Clinical Guideline 127
  • Most hypertension care is provided by general practice, which is commissioned by NHS England, but CCGs have a legal duty to help improve the quality of primary care
  • One major issue is the cost of ABPM monitors:
    • this cost currently falls to the provider (GPs), yet cost savings from decreased diagnosis of hypertension fall mainly to CCGs (through prescribing budgets) and NHSE (through reduced dispensing payments)
    • CCGs should consider funding ABPM monitors for GPs to:
      • help improve care
      • implement this guidance
      • reduce unnecessary prescribing costs (drugs and pharmacy payments)
  • CCGs and NHS England could look at QOF achievement data (alongside cardiovascular disease incidence and outcome data) to target any support to, or intervention with, GP practices.

CCG=clinical commissioning group; ABPM=ambulatory blood pressure monitoring; NHSE=National Health Service Employers; QOF=quality and outcomes framework

  1. NICE. Hypertension: clinical management of primary hypertension in adults. Clinical Guideline 127. NICE, 2011. Available at: www.nice.org.uk/cg127 nhs_accreditation
  2. World Health Organisation. The World Health Report 2002. Reducing risks, promoting healthy life. Geneva: WHO, 2002. Available at: www.who.int/whr/2002/en/whr02_en.pdf
  3. British Heart Foundation website. Economic costs. www.bhf.org.uk/research/heart-statistics/economic-costs.aspx (accessed 6 November 2013).
  4. NICE. NICE support for commissioners using the quality standard for hypertension. www.nice.org.uk/nicemedia/live/14102/63150/63150.pdf
  5. Serumaga B, Ross-Degnan D, Avery A et al. Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study. BMJ 2011; 342 (1): d108.
  6. British Medical Association. NHS Employers. Quality and outcomes framework guidance for GMS contract 2013/14. London: BMA, NHS Employers, 2013. Available at: www.nhsemployers.org/Aboutus/Publications/Documents/qof-2013-14.pdf
  7. Knott C, Mindell J (eds). Health survey for England 2011: volume 1, chapter 3: health, social care and lifestyles: hypertension. Leeds: The Health and Social Care Information Centre, 2012. Available at: catalogue.ic.nhs.uk/publications/public-health/surveys/heal-surv-eng-2011/HSE2011-Ch3-Hypertension.pdf
  8. University of Birmingham and University of York Health Economics Consortium. Development feedback report on piloted indicator(s): hypertension. 1 October 2011 to 30 April 2012. Available at: www.nice.org.uk/nicemedia/live/13812/60092/60092.pdf
  9. NICE website. Hypertension quality standard. Quality Standard 28. www.nice.org.uk/qs28
  10. National Clinical Guideline Centre. Hypertension: the clinical management of primary hypertension in adults. Methods, evidence, and recommendations. Clinical Guideline 127. NCGC, 2011. Available at: www.nice.org.uk/nicemedia/live/13561/56007/56007.pdf
  11. NICE. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Clinical Guideline 67. NICE, 2010. Available at: www.nice.org.uk/cg67 nhs_accreditation
  12. NHS shared decision making website. High blood pressure. Available at: sdm.rightcare.nhs.uk/pda/high-blood-pressure/ (accessed 21 October 2013).
  13. Department of Health. Cardiovascular disease outcomes strategy: improving outcomes for people with or at risk of cardiovascular disease. London: DH, 2013. Available at: www.gov.uk/government/publications/improving-cardiovascular-disease-outcomes-strategy (accessed 30 October 2013). G