Professor Terry McCormack highlights key learning points from NICE’s 2019 update on diagnosing and managing hypertension
Read this article to learn more about:
- changes to the cardiovascular disease (CVD) risk level at which treatment for high blood pressure can be started in people aged under 80 years
- assessing and managing people with severe hypertension
- treatment criteria and targets.
High blood pressure affects around one-quarter of the adult population, making it one of the most common conditions requiring diagnosis and management in primary care. A report published in 2014 suggested that a 5 mmHg reduction in the average population systolic blood pressure in England would save around 45,000 years of life and reduce health and social care costs by £850 million over 10 years.1
The recent NICE Guideline (NG) 136 on Hypertension in adults: diagnosis and management replaces the 2011 NICE Clinical Guideline (CG) 127; it also includes updates on the management of blood pressure in people with type 2 diabetes, replacing recommendations on blood pressure management in NG28 on Type 2 diabetes in adults: management.2,3,4
NG136 is similar to CG127, but has been criticised both for ‘concerns about overdiagnosis’ and for being ‘surprisingly conservative’.5 This article will focus on the changes from the previous guidance in five key areas. NG136 includes a useful ‘visual summary’ on updated recommendations on the diagnosis, monitoring, and treatment of hypertension (see Figures 1 and 2).
1. Offer medication to people with stage 1 hypertension and specific circumstances
As in CG127, NG136 recommends that ambulatory or home blood pressure measurement (ABPM/HBPM) is used to confirm a diagnosis of hypertension, except in people with severe hypertension. People in the range 140/90 to 159/99 mmHg in clinic, or 135/85 to 149/94 mmHg using ABPM/HBPM, are termed as having stage 1 hypertension.
While all people with stage 1 hypertension require lifestyle advice, only those with specific circumstances, such as established cardiovascular disease (CVD) or target organ damage (TOD), require drugs to control their blood pressure.2
The major change in this new guideline is that it includes people with a moderate risk of developing CVD, rather than just those at high risk of CVD, to the list of circumstances in which drug treatment can be offered. These are people with a QRISK of between 10% and 19% of developing CVD in the next 10 years. It also goes further to make a ‘consider’ recommendation regarding younger patients (under 60 years) with less than 10% risk where there might be concerns about their ‘lifetime risk’. The British Medical Association and the Royal College of General Practitioners voiced concerns about the increased workload that these changes might create during consultation,6 but evidence suggests that about one-half of these people are already being treated.7
2. People with severe hypertension need rapid confirmation and treatment
If the clinic blood pressure measurement (CBPM) is 180/120 mmHg or greater after repeated measurements, the person has severe hypertension.2 Note that the diastolic cut-off for severe hypertension has risen from 110 mmHg to 120 mmHg.2
If the person also has any signs of TOD, you should initiate antihypertensive drug treatment straight away. If there are no signs of TOD, you should arrange a further CBPM within 7 days and initiate treatment if that confirms severe hypertension.2 The person should be referred for a ‘same-day’ assessment by a specialist if you suspect a phaeochromocytoma or if they have any red flag symptoms or signs such as:2
- chest pain
- new-onset confusion
- signs of heart failure or acute kidney injury
- retinal haemorrhage or papilloedema.
3. Measure blood pressure while standing or in a specific arm, in some circumstances
NG136 recommends using standing, as well as sitting, blood pressure measurements in people:2
- with type 2 diabetes or
- with symptoms of postural hypotension or
- who are aged 80 years or more.
If the standing blood pressure is significantly lower, then use that measurement as your treatment target.2 In people with frailty or multimorbidity, you should adapt treatment using your clinical judgment.2
The other change in the diagnostic criteria in NG136 was the reduction of significant inter-arm blood pressure from 20 mmHg to 15 mmHg.2 People with this difference should always have their blood-pressure taken in the arm with the higher pressure.2,8
4. Ensure that everyone achieves and maintains the <140/90 mmHg target
The European Society of Cardiology and European Society of Hypertension (ESC/ESH) 2018 guidelines suggest,9 for those aged under 65 years, a systolic blood pressure target between 120 and 129 mmHg, and for those aged 65 years or over, a systolic blood pressure target of 130–139 mmHg, providing that treatment is well tolerated. The diastolic target, for most people, is <80 mmHg.9 The American College of Cardiology/American Heart Association 2017 guideline went even further and recommended that hypertension is diagnosed in anyone with a blood pressure greater than 130/80 mmHg; they also recommended a target blood pressure of <130/80 mmHg for everyone.10
Both guidelines9,10 based this advice on the American SPRINT study, which found that using a systolic blood pressure target of <120 mmHg reduced cardiovascular events and death.11 NICE NG136 did not follow this trend and recommends that the CBPM target should be <140/90 mmHg for everyone aged under 80 years, including people with type 2 diabetes. The ABPM/HBPM target is <135/85 mmHg. The targets for those aged 80 years or more are CBPM <150/90 mmHg and ABPM/HBPM <145/85 mmHg.
The NG136 guideline committee took into account the greater harm that occurred in the SPRINT intensive-care arm11 and expressed concern that we do not know the long-term effects of that harm.2 The committee also had concerns about the method of blood pressure measurement used in SPRINT and the fact that medications were stopped in the control arm. They also emphasised the importance of ‘achieving and maintaining’ the blood pressure below 140/90 mmHg.2 The decision to treat people with type 2 diabetes to the same target was based on the ACCORD study, which was similar to SPRINT but conducted in a diabetic population.12
The new treatment recommendations in NG136 are, on the whole, minor alterations. They can be found in the second page of the visual summary (see Figure 2).
NICE feels that patients should be empowered to choose their own antihypertensive treatment, where appropriate. To that end, a patient decision aid was developed to support healthcare professionals and people with hypertension to discuss their treatment options and make informed decisions.2
The updated recommendations in NG136 will mean that more people with mild hypertension will receive drug treatment; however, unlike with other major hypertension guidelines,9,10 the blood pressure target remains the same as before. Blood pressure targets for people with type 2 diabetes are now the same as for people without diabetes. There is clear advice on who needs urgent treatment or referral.
Professor Terry McCormack
GP and Honorary Professor in Primary Care, Hull York Medical School
Member of the NG136 guideline development group
The author is Vice-President of the British and Irish Hypertension Society and a member of the NICE NG136 Guideline Committee. Because he received a fee from AstraZeneca for giving a lecture on the management of hyperkalaemia, he was excluded from contributing to the guideline section on fourth-line treatment.
Implementation actions for STPs and ICSs
written by Dr David Jenner, GP, Cullompton, Devon
The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.
- Review andupdate local formularies for clinicians, especially in primary care, in line with the updated advice from NICE
- Ensure appropriate funding is available to manage the impact of a potential increase in demand on prescribing budgets
- Assess local implementation of the NICE recommendations by reviewing QOF performance data for local practices and PCNs, and offer additional support where necessary
- Consider supporting practices with the cost of purchasing ABPM monitoring devices as these are likely to provide savings for the CCG prescribing budget, but the purchasing cost falls to practices themselves.
STP=sustainability and transformation partnership; ICS=integrated care system; QOF=quality and outcomes framework; PCN=primary care network; ABPM=ambulatory blood pressure monitoring
Implementation actions for clinical pharmacists in general practice
written by Gupinder Syan, Training and Clinical Outcomes Manager, Soar Beyond Ltd
The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level.
- Agree scope:
- adopt a systematic and stratified approach (e.g. by using the i2i Network Soar Beyond ABCDE change management methodology) in line with the NICE guidance and to meet QOF requirements
- create searches to identify the hypertension population and stratify and prioritise patients according to CVD risk and/or those targeted by QOF. For example, search for patients at different stages (stages 1–3) of hypertension and tackle those with the more severe stages of hypertension first. Further stratification can be done e.g. by looking at the number of medications the patient is taking, those with a QRISK >10%, or those with/without CVD or TOD
- Buy-in: ask the practice to review existing resources to ensure that BP readings can be taken by other healthcare staff when needed
- Prepare adequately to ensure that you have the competencies to carry out reviews, including knowledge of:
- the updated national guidelines and any investigations required
- how to calculate QRISK and counsel patients on risks and treatments
- the new BP targets and differences between ABPM/HBPM readings and CBPM readings
- Demonstrate good BP technique for both standing and sitting readings using manual and electronic devices
- Know when to treat and when to refer; use NICE NG136 patient decision aid to help ensure that the consultation individualises treatment and lifestyle advice, so that the patient feels empowered to take ownership to manage their condition
- Deliver reviews and evaluate outcomes to demonstrate added value and clinical outcomes, e.g. the number of patients who achieved target BP and maintenance at <140/90 mmHg.
QOF=quality and outcomes framework; CVD=cardiovascular disease; TOD=target organ damage; BP=blood pressure; ABPM=ambulatory blood pressure monitoring; HBPM=home blood pressure monitoring; CBPM=clinic blood pressure monitoring; NG=NICE guideline
- Public Health England. Tackling high blood pressure: from evidence into action. London: Public Health England, 2014. assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/375985/20141018_Tackling_high_blood_pressure_-_FINAL_INCL_LINK_CHANGES.pdf
- NICE. Hypertension in adults: diagnosis and management. NICE Guideline 136. NICE, 2019. Available at: www.nice.org.uk/ng136
- Krause T, Lovibond K, Caulfield M et al on behalf of the Guideline Development Group. Management of hypertension: summary of NICE guidance. BMJ 2011; 343: d4891. Correction at BMJ 2011; 343: d6255.
- NICE. Type 2 diabetes in adults: management. NICE Guideline 28. NICE, 2015 (last updated August 2019). Available at: www.nice.org.uk/ng28
- Pike H. NICE proposes lower threshold for treating high blood pressure. BMJ 2019; 364: l1105.
- NICE. Hypertension in adults: diagnosis and management. Consultation comments and responses. NICE, 2019. Available at: www.nice.org.uk/guidance/ng136/documents/consultation-comments-and-responses-3
- Sheppard J, Stevens S, Stevens R et al. Association of guideline and policy changes with incidence of lifestyle advice and treatment for uncomplicated mild hypertension in primary care: a longitudinal cohort study in the Clinical Practice Research Datalink. BMJ Open 2018; 8: e021827.
- Clark C, Taylor R, Shore A, Campbell J. The difference in blood pressure readings between arms and survival: primary care cohort study BMJ 2012; 344: e1327. Correction at BMJ 2012; 344: e2714
- Williams B, Mancia G, Spiering W et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J 2018; 39 (33): 3021–3104.
- Whelton P, Carey R, Aronow W et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol 2018; 71 (19): e127–e248. Correction at J Am Coll Cardiol 2018; 71 (19): 2275–2279.
- Wright J, Williamson J, Whelton P et al; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015; 373 (22): 2103–2016.
- Cushman W, Evans G, Byington R et al; ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010; 362 (17): 1575–1585.