Hypertension

Short Text

Clinical management of primary hypertension in adults

Introduction

This pathway covers the clinical management of primary hypertension in adults.
Hypertension is one of the most important preventable causes of premature morbidity and mortality in the UK, and its management is one of the most common interventions in primary care. This guideline contains new and updated recommendations on blood pressure measurement, the use of ambulatory and home blood pressure monitoring, blood pressure targets and antihypertensive drug treatment.
The original guideline on which this pathway is based was developed by the Newcastle Guideline Development and Research Unit and published in 2004. The guideline was updated by the National Clinical Guideline Centre NCGC (formerly the National Collaborating Centre for Chronic Conditions) in collaboration with the British Hypertension Society in 2006 and 2011.

Source guidance

The NICE guidance that was used to create the pathway.
Hypertension. NICE clinical guideline 127 (2011)
Medicines adherence. NICE clinical guideline 76 (2009)

Quality standards

Hypertension quality standard

These quality statements are taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care and should be read in full.

Quality statements

Diagnosis – ambulatory blood pressure monitoring

This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.

Quality statement

People with suspected hypertension are offered ambulatory blood pressure monitoring (ABPM) to confirm a diagnosis of hypertension.

Rationale

ABPM is the most accurate method for confirming a diagnosis of hypertension, and its use should reduce unnecessary treatment in people who do not have true hypertension. ABPM has also been shown to be superior to other methods of multiple blood pressure measurement for predicting blood pressure-related clinical events.

Quality measure

Structure
Evidence of local arrangements to ensure people with suspected hypertension are offered ABPM to confirm a diagnosis of hypertension.
Process
Proportion of people with suspected hypertension who receive ABPM to confirm a diagnosis of hypertension.
Numerator – the number of people in the denominator who receive ABPM to confirm a diagnosis of hypertension.
Denominator – the number of people with suspected hypertension.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to offer ABPM to confirm a diagnosis of hypertension.
Healthcare professionals offer ABPM to confirm a diagnosis of hypertension.
Commissioners ensure they commission services that offer ABPM to confirm a diagnosis of hypertension.
People with suspected hypertension (high blood pressure) are offered ambulatory blood pressure monitoring (which involves wearing a blood pressure monitor during their normal waking hours) to confirm whether or not they have hypertension.

Source clinical guideline references

NICE clinical guideline 127 recommendation 1.2.3 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 127 clinical audit tool: diagnosing hypertension, criterion 1.

Definitions

Ambulatory blood pressure monitoring (ABPM)
Clinical guideline 127 Hypertension: full guideline: Ambulatory blood pressure monitoring (ABPM) involves a cuff and bladder connected to electronic sensors which detect changes in cuff pressure and allow blood pressure to be measured oscillometrically. Systolic and diastolic pressure readings are deduced from the shape of oscillometric pressure changes using an algorithm built into the measuring device. A patient's blood pressure can be automatically measured at repeated intervals throughout the day and night, while they continue routine activities. Systolic and diastolic pressure can be plotted over time, with most devices providing average day, night and 24-hour pressures. NICE recommends recording a daytime average to confirm diagnosis.
Suspected hypertension
NICE clinical guideline 127 recommendation 1.2.3 describes suspected hypertension as clinic blood pressure of 140/90 mmHg or higher without a confirmed diagnosis of hypertension.

Equality and diversity considerations

ABPM may not be suitable for everyone, for example people with particular learning or physical disabilities. Some people may be unable to tolerate ABPM and some people may decline it.
Home blood pressure monitoring should be offered as an alternative to ABPM in such cases, in line with NICE clinical guideline 127 recommendation 1.2.4. If a person is unable to tolerate ABPM, home blood pressure monitoring (HBPM) is a suitable alternative to confirm the diagnosis of hypertension.

Investigations for target organ damage

This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.

Quality statement

People with newly diagnosed hypertension receive investigations for target organ damage within 1 month of diagnosis.

Rationale

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.

Quality measure

Structure
Evidence of local arrangements for people with newly diagnosed hypertension to receive all investigations for target organ damage within 1 month of diagnosis.
Process
Proportion of people with newly diagnosed hypertension who receive all investigations for target organ damage within 1 month of diagnosis.
Numerator – the number of people in the denominator who receive all investigations for target organ damage within 1 month of diagnosis.
Denominator – the number of people with newly diagnosed hypertension.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people with newly diagnosed hypertension to receive all investigations for target organ damage within 1 month of diagnosis.
Healthcare professionals carry out all investigations for target organ damage for people with newly diagnosed hypertension within 1 month of diagnosis.
Commissioners ensure they commission services that carry out all investigations for target organ damage for people with newly diagnosed hypertension within 1 month of diagnosis.
People with newly diagnosed hypertension (high blood pressure) receive tests within 1 month of being diagnosed to check for any damage to organs such as their eyes, heart or kidneys.

Source clinical guideline references

NICE clinical guideline 127 recommendations 1.2.6 and 1.3.3.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE clinical guideline 127 clinical audit tool: diagnosing hypertension, criterion 3.

Definitions

Investigations for target organ damage
NICE clinical guideline 127 recommendation 1.3.3 recommends that for all people with hypertension, healthcare professionals should offer to:
  • test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip
  • take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol
  • examine the fundi for the presence of hypertensive retinopathy
  • arrange for a 12-lead electrocardiograph to be performed.
Target organ damage
NICE clinical guideline 127 recommendation 1.2.6 lists left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy as examples of target organ damage.

Statin therapy

This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.

Quality statement

People with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher are offered statin therapy.

Rationale

Hypertension is associated with a higher risk of cardiovascular events. Primary prevention of cardiovascular disease depends on identification of people who are at risk before disease has become established. Formal cardiovascular risk assessment at the time of diagnosis allows a person’s 10-year risk of cardiovascular events, such as coronary heart disease and stroke, to be estimated. Statin therapy is effective in further reducing acute cardiovascular events in people with hypertension.

Quality measure

Structure
Evidence of local arrangements to ensure people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher are offered statin therapy.
Process
a) Proportion of people with newly diagnosed hypertension who receive a formal assessment of their cardiovascular risk.
Numerator – the number of people in the denominator who receive a formal assessment of their cardiovascular risk.
Denominator – the number of people with newly diagnosed hypertension who do not have established cardiovascular disease.
b) Proportion of people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher who are prescribed statin therapy.
Numerator – the number of people in the denominator who are prescribed statin therapy.
Denominator – the number of people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to offer statin therapy to people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher.
Healthcare professionals offer statin therapy to people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher.
Commissioners ensure they commission services that offer statin therapy to people with newly diagnosed hypertension and a 10-year cardiovascular disease risk of 20% or higher.
People with newly diagnosed hypertension (high blood pressure) and a 20% (1-in-5) or higher chance of developing cardiovascular disease in the next 10 years are offered a type of drug called a statin.

Source clinical guideline references

NICE clinical guideline 127 recommendations 1.3.1 and 1.3.2 and recommendation 1.5.1 (key priority for implementation).
NICE clinical guideline 67 recommendation 1.4.3 (key priority for implementation).

Data source

Structure
Local data collection.
Process
a) and b) Quality and Outcomes Framework (QOF) indicator CVD-PP001: In those patients with a new diagnosis of hypertension aged 30 or over and under the age of 75, recorded between the preceding 1 April to 31 March (excluding those with pre-existing CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk assessment score (using an assessment tool agreed with the NHS CB) of >20% in the preceding 12 months: the percentage who are currently treated with statins.
b) Local data collection. Contained with NICE clinical guideline 127 clinical audit tool: drug treatment, criterion 1.
Local data collection. Contained within NICE clinical guideline 67 audit tool, criterion 3.

Definitions

Clinic blood pressure
Clinic blood pressure refers to blood pressure measured in the clinic.
Formal assessment of cardiovascular risk
NICE does not recommend a particular cardiovascular risk assessment tool. Three commonly used tools validated for use in primary care in England are:
  • Framingham
  • Joint British Societies’ guidelines (JBS2)
  • QRISK(2).
Statin therapy
NICE clinical guideline 67 recommendation 1.4.3 recommends statin therapy as part of the management strategy for the primary prevention of CVD (cardiovascular disease) for adults who have a 20% or greater 10-year risk of developing CVD. This level of risk should be estimated using an appropriate risk calculator, or by clinical assessment for people for whom an appropriate risk calculator is not available or appropriate (for example, older people, people with diabetes and people in high-risk ethnic groups). The timeframe from diagnosis to initiation of treatment is anticipated to be no longer than 3 months.
NICE clinical guideline 67 recommends that before people are offered lipid modification therapy for primary prevention, all other modifiable CVD risk factors should be considered and their management optimised if possible.

Equality and diversity considerations

Clinical assessment should be carried out for people for whom an appropriate risk calculator is not available or appropriate (for example, some groups of older people and some younger people) to determine their level of risk.
Younger people are unlikely to have a 10-year cardiovascular disease risk of 20% or higher because risk assessment is strongly influenced by age. This group would still receive statin therapy if they have a specific indication for statin therapy, that is an unequivocally elevated LDL-cholesterol level, for example because of familial hypercholesterolaemia, or if they have clinical evidence of cardiovascular disease.

Blood pressure targets

This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.

Quality statement

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.

Rationale

Hypertension is associated with a higher risk of cardiovascular events. Setting blood pressure to recommended levels aims to promote primary and secondary prevention of cardiovascular disease, and to lower the risk of cardiovascular events.

Quality measure

Structure
a) Evidence of local arrangements to ensure people aged under 80 years with treated hypertension have a clinic blood pressure target set to below 140/90 mmHg.
b) Evidence of local arrangements to ensure people aged 80 years and over with treated hypertension have a clinic blood pressure target set to below 150/90 mmHg.
Outcome
People with treated hypertension whose target blood pressure is achieved.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for people aged under 80 years with treated hypertension to have a clinic blood pressure target set to below 140/90 mmHg, and for people aged 80 years and over with treated hypertension to have a clinic blood pressure target set to below 150/90 mmHg.
Healthcare professionals ensure that people aged under 80 years with treated hypertension have a clinic blood pressure target set to below 140/90 mmHg, and people aged 80 years and over with treated hypertension have a clinic blood pressure target set to below 150/90 mmHg.
Commissioners ensure they commission services that have arrangements for people aged under 80 years with treated hypertension to have a clinic blood pressure target set to below 140/90 mmHg, and for people aged 80 years and over with treated hypertension to have a clinic blood pressure target set to below 150/90 mmHg.
People who are receiving treatment for hypertension (high blood pressure) have a target clinic blood pressure (blood pressure measured in their GP practice or clinic) below 140/90 mmHg if they are aged under 80 years, or a clinic blood pressure below 150/90 mmHg if they are aged 80 years or over.

Source clinical guideline references

NICE clinical guideline 127 recommendations 1.5.5 and 1.5.6.

Data source

Structure
a) and b) Local data collection.
Outcome
Quality and Outcomes Framework (QOF) indicator HYP002:The percentage of patients with hypertension in whom the last blood pressure reading (measured in the preceding 9 months) is 150/90 mmHg or less.
Quality and Outcomes Framework (QOF) indicator HYP003:The percentage of patients aged 79 and under with hypertension in whom the last blood pressure reading (measured in the preceding 9 months) is 140/90 mmHg or less.

Definitions

Clinic blood pressure
Clinic blood pressure refers to blood pressure measured in the clinic.
For a clinic blood pressure of 140/90 mmHg, the corresponding ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg.
For a clinic blood pressure of 160/100 mmHg or higher, the corresponding ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
Treated hypertension
Treated hypertension includes treatment with antihypertensive drugs.

Equality and diversity considerations

Targets are based on evidence of safe practice. A person aged 80 years or over with treated hypertension would not have a target clinic blood pressure of 150/90 mmHg if their blood pressure was already treated to below this threshold.

Review of cardiovascular disease risk factors

This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.

Quality statement

People with hypertension are offered a review of risk factors for cardiovascular disease annually.

Rationale

People’s blood pressure and cardiovascular disease risk will increase over time. A review of risk factors for cardiovascular disease delivered as part of an annual review of care should support identification of increased risk and provide an opportunity to address modifiable risk factors.

Quality measure

Structure
Evidence of local arrangements to ensure people with hypertension are offered a review of risk factors for cardiovascular disease annually.
Process
Proportion of people who have had hypertension for 12 months or longer who have had a review of risk factors for cardiovascular disease within the past 12 months.
Numerator – the number of people in the denominator who have had a review of risk factors for cardiovascular disease within the past 12 months.
Denominator – the number of people who have had hypertension for 12 months or longer who do not have established cardiovascular disease.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to offer people with hypertension a review of risk factors for cardiovascular disease annually.
Healthcare professionals offer people with hypertension a review of risk factors for cardiovascular disease annually.
Commissioners ensure they commission services that offer people with hypertension a review of risk factors for cardiovascular disease annually.
People with hypertension (high blood pressure) are offered a review of risk factors for cardiovascular disease annually.

Source clinical guideline references

NICE clinical guideline 127 recommendation 1.7.3.

Data source

Structure
Local data collection.
Process
Quality and Outcomes Framework (QOF) indicator CVD-PP02: The percentage of patients diagnosed with hypertension (diagnosed on or after 1 April 2009) who are given lifestyle advice in the preceding 12 months for: smoking cessation, safe alcohol consumption and healthy diet.
Quality and Outcomes Framework (QOF) indicator SMOK005: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 12 months?

Definitions

Annual review of care
NICE clinical guideline 127 recommendation 1.7.3 recommends that an annual review of care should be provided to monitor blood pressure, provide people with support and discuss their lifestyle, symptoms and medication.
Review of risk factors for cardiovascular disease
Review of risk factors for cardiovascular disease could include:
  • smoking status
  • alcohol consumption
  • blood pressure
  • body mass index or other measure of obesity
  • total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides
  • blood glucose
  • renal function
  • liver function (transaminases) if receiving statins
  • heart rate and rhythm (pulse measurement).
(adapted from NICE clinical guideline 67 recommendation 1.4.2).
Blood pressure should be measured more frequently than annually for patients who need more frequent monitoring.

Referral to a specialist for people with resistant hypertension

This quality statement is taken from the hypertension quality standard. The quality standard defines clinical best practice in hypertension care for children and young people and should be read in full.

Quality statement

People with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled are referred for specialist assessment.

Rationale

People with resistant hypertension will usually be at high risk of cardiovascular disease. Specialist assessment and evaluation supports management of their condition.

Quality measure

Structure
Evidence of local arrangements for people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled to be referred for specialist assessment.
Process
Proportion of people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled who are referred for specialist assessment.
Numerator – the number of people in the denominator who are referred for specialist assessment.
Denominator – the number of people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled.

Description of what the quality statement means for each audience

Service providers ensure local arrangements are in place for people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled to be referred for specialist assessment.
Healthcare professionals refer people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled for specialist assessment.
Commissioners ensure they commission services that refer people with resistant hypertension who are receiving 4 antihypertensive drugs and whose blood pressure remains uncontrolled for specialist assessment.
People with resistant hypertension (high blood pressure that is difficult to control) who are receiving 4 antihypertensive drugs (drugs to treat high blood pressure) and whose blood pressure is still high are referred for a specialist assessment.

Source clinical guideline references

NICE clinical guideline 127 recommendations 1.6.18 and 1.6.22.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Referral for specialist assessment
Referral should be to a healthcare professional, usually in secondary care, with specialist expertise in high blood pressure.
Resistant hypertension
NICE clinical guideline 127 recommendation 1.6.18 recommends that clinic blood pressure that remains higher than 140/90 mmHg despite step 3 treatment with the optimal or best tolerated doses of an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) plus a calcium-channel blocker (CCB) plus a diuretic should be regarded as resistant hypertension. People aged 80 years and over are considered to have resistant hypertension if their clinic blood pressure remains higher than 150/90 mmHg despite optimal or best tolerated doses of step 3 treatment.
Recommendation 1.6.22 recommends that expert advice should be sought if blood pressure remains uncontrolled with step 4 treatment of optimal or maximum tolerated doses of 4 drugs if expert advice has not yet been obtained.

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

6 February 2014 Minor maintenance updates
20 January 2014 Minor maintenance updates
17 January 2014 Minor maintenance updates
23 October 2013 Link to NICE pathway on obesity added to this pathway.
10 September 2013 Minor maintenance updates
9 August 2013 Quality and Outcomes Framework indicators updated in hypertension quality standard (QS28).
5 June 2013 Minor maintenance update.
20 March 2013 Hypertension quality standard (QS28) added to pathway.
22 January 2013 Shared learning example added to supporting products.
15 January 2013 Medical technology guidance 13 on WatchBP Home A added to measuring blood pressure.

Supporting information

Glossary

Angiotensin-converting enzyme inhibitor
Angiotensin II receptor blocker
Calcium-channel blocker
Ambulatory blood pressure monitoring
Estimated glomerular filtration rate
Home blood pressure monitoring
Clinic systolic blood pressure 180 mmHg or higher or clinic diastolic blood pressure 110 mmHg or higher
Clinic blood pressure 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring daytime average or home blood pressure monitoring average blood pressure 135/85 mmHg or higher
Clinic blood pressure 160/100 mmHg or higher and subsequent ambulatory blood pressure monitoring daytime average or home blood pressure monitoring average blood pressure 150/95 mmHg or higher
A discrepancy of more than 20/10 mmHg between clinic and average daytime ambulatory blood pressure monitoring or average home blood pressure monitoring measurements at the time of diagnosis

People starting antihypertensive drug treatment

People starting antihypertensive drug treatment

General principles

General principles

General principles

If possible, offer drugs taken only once a day.
Prescribe non-proprietary drugs if these are appropriate and minimise cost.
Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or higher) the same treatment as people with both raised systolic and diastolic blood pressure.
Do not combine an ACE inhibitor with an ARB.

People aged over 80 years

Offer people aged over 80 years the same antihypertensive drug treatment as people aged 55–80 years, taking into account any comorbidities.

Women of child-bearing potential

Offer antihypertensive drug treatment to women of child-bearing potential in line with the recommendations on management of pregnancy with chronic hypertension and breastfeeding in the NICE clinical guideline on Hypertension in pregnancy.

Implementation tools

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Source guidance

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Blood pressure targets

Blood pressure targets

Blood pressure targets

Clinic blood pressure

People aged under 80 years: lower than 140/90 mmHg
People aged over 80 years: lower than 150/90 mmHg

Daytime average ABPM or HBPM blood pressure during the person's usual waking hours

People aged under 80 years: lower than 135/85 mmHg
People aged over 80 years: lower than 145/85 mmHg

Quality standards

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Source guidance

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Patient education and adherence to treatment

Patient education and adherence to drug treatment

Patient education and adherence to treatment

Help people to make informed choices by providing guidance and materials about the benefits of drugs and the unwanted side effects sometimes experienced.
Tell people about patient organisations that have forums for sharing views and information.

Interventions to support adherence to treatment

Only use interventions to overcome practical problems associated with non-adherence if a specific need is identified.
Target the intervention to the need. Interventions might include:
  • suggesting that people record their medicine-taking
  • encouraging people to monitor their condition
  • simplifying the dosing regimen
  • using alternative packaging for the medicine
  • using a multi-compartment medicines systemThis recommendation is taken from the NICE clinical guideline on medicines adherence..

Source guidance

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Step 1 ACE inhibitor or low-cost angiotensin II receptor blocker

Step 1
ACE inhibitor or low-cost angiotensin II receptor blocker

Step 1 ACE inhibitor or ARB

Offer people aged under 55 years an ACE inhibitor or a low-cost ARB. If an ACE inhibitor is prescribed and is not tolerated (for example, because of cough), offer a low-cost ARB.
Beta-blockers are not preferred in step 1. However, they may be considered for younger people if ACE inhibitors and ARBs are contraindicated or not tolerated or there is evidence of increased sympathetic drive, and for women of child-bearing potential.

Implementation tools

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Source guidance

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Person aged over 55 or black person of African or Caribbean family origin of any age

Person aged over 55 or black person of African or Caribbean family origin of any age

Step 1 Calcium-channel blocker

Step 1
Calcium-channel blocker

Step 1 CCB

Offer people aged over 55 years and black people of African or Caribbean family origin of any age a CCB. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic.
If treatment with a diuretic is being started, or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.
For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide.

Implementation tools

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Source guidance

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Step 2

Step 2
ACE inhibitor or angiotensin II receptor blocker + calcium-channel blocker

Step 2

Offer a CCB in combination with either an ACE inhibitor or an ARB Choose a low-cost ARB..
If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic.
For black people of African or Caribbean family origin, consider an ARB in preference to an ACE inhibitor, in combination with a CCB.
If a beta-blocker was used in step 1, add a CCB rather than a thiazide-like diuretic, to reduce the person's risk of developing diabetes.
Before considering step 3 treatment, review medication to ensure step 2 treatment is at optimal or best tolerated doses.

Implementation tools

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Source guidance

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Step 3 ACE inhibitor or angiotensin II receptor blocker + calcium-channel blocker + thiazide-like diuretic

Step 3
ACE inhibitor or angiotensin II receptor blocker + calcium-channel blocker + thiazide-like diuretic

Step 3

Offer an ACE inhibitor or an ARBChoose a low-cost ARB. in combination with a CCB and a thiazide-like diuretic.
Regard clinic blood pressure that remains 140/90 mmHg or higher after step 3 treatment with optimal or best tolerated doses as resistant hypertension. Consider step 4 treatment or seeking expert advice.

Quality standards

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Implementation tools

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Source guidance

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[[CG127]

Step 4 Resistant hypertension

Step 4 Resistant hypertension
ACE inhibitor or angiotensin II receptor blocker + calcium-channel blocker + thiazide-like diuretic + consider further diuretic or alpha-blocker or beta-blocker
Consider seeking expert advice

Step 4 Resistant hypertension

Consider further diuretic therapy with low-dose (25 mg once daily) spironolactoneAt the time this pathway was published (August 2011), spironolactone did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. if blood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a reduced eGFR, because they have an increased risk of hyperkalaemia.
Consider further diuretic therapy with a higher-dose thiazide-like diuretic if blood potassium level is higher than 4.5 mmol/l.
When using further diuretic therapy, monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter.
If further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker.
If blood pressure remains uncontrolled with optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained.

Quality standards

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Implementation tools

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Source guidance

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Monitoring drug treatment

Monitoring drug treatment

Monitoring drug treatment

Use clinic blood pressure measurement to monitor the response to treatment.
For people identified as having a white-coat effect, consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor the response to treatment.

Implementation tools

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Source guidance

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Paths in this pathway

Pathway created: August 2011 Last updated: February 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.



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