2022 Hypertension NICE Guidance: diagnosis and management

My name is Fernando Florido and I am a GP in the United Kingdom. In this podcast I go through the NICE Guideline: Hypertension in adults: diagnosis and management (NG136 guideline), updated on 18th March 2022.

This podcast will be saved on a website. 

There is also a YouTube video on this subject and other NICE guidance. You can access the channel here:

https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw

NICE Guideline NG136 can be found here:

https://www.nice.org.uk/guidance/NG136 

Other links referred to in this episode:

·     guideline on hypertension in pregnancy

·     NICE's guideline on cardiovascular disease

·     patient decision aid on treatment options for hypertension

·     NICE's guideline on multimorbidity

·     NICE guidelines on chronic kidney disease

·     type 1 diabetes 

·     MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, recommendations on how to use for breastfeeding and the related clarification on breastfeeding

·      drug therapy for secondary prevention in the NICE guideline on acute coronary syndromes

·      treatment after stabilisation in the NICE guideline on acute heart failure

·      treating heart failure with reduced ejection fraction in the NICE guideline on chronic heart failure

·      drugs for secondary prevention of cardiovascular disease in the NICE guideline on stable angina

·      blood pressure management in the NICE guideline on type 1 diabetes in adults.

·     NICE's guideline on chronic heart failure 

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Transcript

Thank you for downloading and welcome. This podcast is intended for healthcare professionals and it brings you medical information about clinical guidelines by the National Institute for Clinical Excellence or NICE from a Primary Care perspective. My name is Fernando Florido and I am a GP in the United Kingdom.

 

In this episode I am going to tell you about the NICE guidelines on Hypertension in adults: diagnosis and management (NG136 guideline), updated on 18th March 2022.

In this episode I am going to summarise the main body of the guideline and I will provide links in the episode description to other guidance where indicated.

I have also uploaded YouTube videos on this subject and other NICE guidance. A link to access the YouTube channel can be found in the episode description.

 

As ever, all information is correct at the time of recording and all views and opinions are my own. I hope that you enjoy this episode.

This guideline covers identifying and treating primary hypertension (high blood pressure) in people aged 18 and over, including people with type 2 diabetes. It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively.

In March 2022, the updated guideline:

• reviewed the evidence and made a new recommendation on blood pressure targets for people who have both hypertension and cardiovascular disease.
• reassessed evidence on antihypertensive drug treatment and made a new recommendation to cover people who have both hypertension and cardiovascular disease.

NICE has also produced a guideline on hypertension in pregnancy and I will put the link to this in the podcast description.

Recommendations

This guideline includes a variety of recommendations including diagnosis, treatment and monitoring.

The recommendations on measuring blood pressure and diagnosing hypertension in this guideline apply to all adults, including those with type 2 diabetes. The recommendations on treatment and monitoring also apply to adults with type 2 diabetes.

In terms of Measuring blood pressure,

Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), we need to palpate the radial or brachial pulse before measuring the blood pressure. If pulse irregularity is present, we will need to measure blood pressure manually using direct auscultation over the brachial artery. 

When measuring blood pressure in the clinic or in the home, we need to standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. We will also need to use an appropriate cuff size for the person's arm. 

In people with symptoms of postural hypotension (falls or postural dizziness):

·      first we will measure the blood pressure with the person either supine or seated

·      and then measure the blood pressure again with the person standing for at least 1 minute before measurement. 

Then, If the systolic blood pressure falls by 20 mmHg or more when the person is standing:

·      we will need to review the medication

·      we will measure subsequent blood pressure readings with the person standing

·      and we will consider referral to specialist care if symptoms of postural hypotension persist. 

Diagnosing hypertension

When considering a diagnosis of hypertension, we will need to measure the blood pressure in both arms and:

·      If the difference in readings between arms is more than 15 mmHg, we will repeat the measurements and

·      If the difference in readings between arms remains more than 15 mmHg on the second measurement, we will measure subsequent blood pressures in the arm with the higher reading. 

If blood pressure measured in the clinic is 180/120 mmHg or higher, we will identify who and how to refer for further investigation and management and a section about this will be addressed later on in this guideline.

If blood pressure measured in the clinic is 140/90 mmHg or higher:

·      We will Take a second measurement during the consultation and.

·      If the second measurement is substantially different from the first, we will take a third measurement.

Then we will Record the lower of the last 2 measurements as the clinic blood pressure. 

Then, If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, we will offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension and

If ABPM is unsuitable or the person is unable to tolerate it, we will offer home blood pressure monitoring (HBPM) to confirm the diagnosis. 

While waiting for confirmation of a diagnosis of hypertension, we will carry out:

·      investigations for target organ damage (there is a section later in this guideline covering this) followed by

·      a formal assessment of cardiovascular risk using a cardiovascular risk assessment tool (there is also a section later in this guideline covering this). 

When using ABPM to confirm a diagnosis of hypertension, we will ensure that at least 2 measurements per hour are taken during the person's usual waking hours (for example, between 08:00 and 22:00) and we will use the average value of at least 14 measurements taken during the person's usual waking hours to confirm a diagnosis of hypertension. 

When using HBPM to confirm a diagnosis of hypertension, we will ensure that:

·      for each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute apart and with the person seated and

·      the blood pressure is recorded twice daily, ideally in the morning and evening and

·      the blood pressure recording continues for at least 4 days, ideally for 7 days.

We will Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. 

We will Confirm diagnosis of hypertension in people with a:

·      clinic blood pressure of 140/90 mmHg or higher and

·      ABPM daytime average or HBPM average of 135/85 mmHg or higher. 

If hypertension is not diagnosed but there is evidence of target organ damage, we will consider carrying out investigations for alternative causes of the target organ damage.

If hypertension is not diagnosed, we will measure the person's clinic blood pressure at least every 5 years subsequently, and we will consider measuring it more frequently if the person’s clinic blood pressure is close to 140/90 mmHg. 

Annual blood pressure measurement for people with type 2 diabetes

We will however Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease.

Specialist investigations for possible secondary causes of hypertension

And we will Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. 

Assessing cardiovascular risk and target organ damage

We will use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options and we will estimate the cardiovascular risk in line with the NICE recommendations on identifying and assessing cardiovascular disease risk (I will put the link to this guideline in the episode description). We will use clinic blood pressure measurements to calculate cardiovascular risk. 

For all people with hypertension we will offer investigations for target organ damage which will include all of the following:

·      We will test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and we will test for haematuria using a reagent strip

·      We will take a blood sample to measure glycated haemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol

·      We will examine the fundi for the presence of hypertensive retinopathy and

·      We will arrange for a 12‑lead ECG

When it comes to Treating and monitoring hypertensionLifestyle interventions

We will offer lifestyle advice

We will encourage a healthy diet and regular exercise because they can reduce blood pressure.

We will encourage a reduced intake of alcohol if they drink excessively, because this can reduce blood pressure and has broader health benefits.

We will discourage excessive consumption of coffee and other caffeine-rich products. 

We will also encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. We need to be aware that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin II receptor blockers. We will just encourage salt reduction in these groups. 

We will not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure.

And we will offer advice and help to smokers to stop smoking.

In respect of Starting antihypertensive drug treatment

NICE has produced a patient decision aid on treatment options for hypertension to help people and their healthcare professionals discuss the different types of treatment and make a decision that is right for each person. A link to this aid is in the episode description.

We will offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension (which is a clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher). We will use our clinical judgement for people of any age with frailty or multimorbidity

We will discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension (which is a clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg) who have 1 or more of the following:

·      target organ damage

·      established cardiovascular disease

·      renal disease

·      diabetes

·      or an estimated 10‑year risk of cardiovascular disease of 10% or more but we will consider the antihypertensive drug treatment if the risk is below 10% bearing in mind that the risk calculation may underestimate the lifetime probability of developing cardiovascular disease.

We will again use clinical judgement for people with frailty or multimorbidity (there is a specific NICE guideline in about this and I will put the link in the episode description) (see also NICE's guideline on multimorbidity). 

We will consider antihypertensive drug treatment for people aged over 80 with stage 1 hypertension if their clinic blood pressure is over 150/90 mmHg and we will use clinical judgement for people with frailty or multimorbidity.

For adults aged under 40 with hypertension, we will consider seeking specialist evaluation of secondary causes of hypertension

When it comes to Monitoring treatment and blood pressure targets,

For specific recommendations on blood pressure control in people with other conditions or who are pregnant, there is specific guidance for people with CKD, type 1 diabetes and who are pregnant> There is separate guidance for these and I will put links in the episode description. see also the NICE guidelines on chronic kidney disease, type 1 diabetes and hypertension in pregnancy.

We will use clinic blood pressure measurements to monitor the response to treatment and

We will measure standing as well as seated blood pressure in people with hypertension and:

·      with type 2 diabetes or

·      with symptoms of postural hypotension or

·      aged 80 and over.

In people with a significant postural drop or symptoms of postural hypotension, we will treat to a blood pressure target based on standing blood pressure. 

We will consider ABPM or HBPM, in addition to clinic blood pressure measurements, for people with a white-coat effect or masked hypertension (in which clinic and non-clinic blood pressure results are conflicting), being aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurements

When setting Blood pressure targets,

For adults aged under 80, we will reduce the clinic blood pressure to below 140/90 mmHg and

For adults aged 80 and over, we will reduce clinic blood pressure to below 150/90 mmHg, using our clinical judgement for people with frailty or multimorbidity

When using ABPM or HBPM, we will use the average blood pressure level taken during the person's usual waking hours, aiming to reduce it to:

·      below 135/85 mmHg for adults aged under 80

·      below 145/85 mmHg for adults aged 80 and over.

We will use the same blood pressure targets for people with and without cardiovascular disease. 

And we will provide an annual review of care for adults with hypertension.

Treatment review when type 2 diabetes is diagnosed

Finally, when diabetes is diagnosed, we will review the antihypertnsive medication making changes if drug treatment is not appropriate because of microvascular complications or metabolic problems. 

When it comes to choosing antihypertensive drug treatment (for people with or without type 2 diabetes)

 

We need to be aware that ACE inhibitors and angiotensin II receptor antagonists should not be used in pregnant or breastfeeding women or women planning pregnancy unless absolutely necessary, in which case the potential risks and benefits should be discussed. There is MHRA guidance in tis respect and I will put the links to this in the episode description. Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, recommendations on how to use for breastfeeding and the related clarification on breastfeeding.

For guidance on choice of hypertensive agent in people with chronic kidney disease or women considering pregnancy or who are pregnant or breastfeeding, we will follow separate guidance specific to this area and links to this guidance will also appear in the episode description. see NICE's guideline on chronic kidney disease.

Whenever possible, we will offer treatment with drugs taken only once a day and we will prescribe generic drugs to minimise the cost. 

We will offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure. 

When choosing antihypertensive drug treatment for adults of Black African or African–Caribbean family origin, we will consider an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor. 

For people with cardiovascular disease:

·      we will follow the recommendations for disease-specific indications in the NICE guideline on their condition. Relevant recommendations include acute coronary syndromes, acute and chronic heart failure, stable angina and type 1 diabetes and links to these guidelines will be available in the episode description.

o  drug therapy for secondary prevention in the NICE guideline on acute coronary syndromes

o  treatment after stabilisation in the NICE guideline on acute heart failure

o  treating heart failure with reduced ejection fraction in the NICE guideline on chronic heart failure

o  drugs for secondary prevention of cardiovascular disease in the NICE guideline on stable angina

o  blood pressure management in the NICE guideline on type 1 diabetes in adults.

Now, for Step 1 treatment

We will offer an ACE inhibitor or an ARB to adults who:

·      have type 2 diabetes and are of any age or family origin or

·      are aged under 55 but not of Black African or African–Caribbean family origin. 

If an ACE inhibitor is not tolerated, for example because of cough, we will offer an ARB to treat hypertension. 

We will not combine an ACE inhibitor with an ARB to treat hypertension. 

We will offer a calcium-channel blocker (CCB) to adults who:

·      are aged 55 or over and do not have type 2 diabetes or

·      are of Black African or African–Caribbean family origin and do not have type 2 diabetes (of any age). 

If a CCB is not tolerated, for example because of oedema, we will offer a thiazide-like diuretic to treat hypertension. 

If there is evidence of heart failure, we will offer a thiazide-like diuretic and follow the NICE's guideline on chronic heart failure. 

If starting or changing diuretic treatment for hypertension, we will offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. 

However, for adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, we will continue with their current treatment. 

For Step 2 treatment

If hypertension is not controlled in adults taking an ACE inhibitor or ARB, we will add 1 of the following drugs:

·      a CCB or

·      a thiazide-like diuretic. 

If hypertension is not controlled in adults taking a CCB, we will add 1 of the following drugs:

·      an ACE inhibitor or

·      an ARB (and this is in preference to ACE inhibitor in adults of Black African or African–Caribbean family origin) or

·      a thiazide-like diuretic. 

For step 3 treatment

If hypertension is not controlled in adults taking step 2 treatment, offer triple therapy as a combination of:

·      an ACE inhibitor or ARB (again, the latter in preference for people of Black African or African–Caribbean family origin) and

·      a CCB and

·      a thiazide-like diuretic. 

And finally, for Step 4 treatment

If hypertension is not controlled in adults taking triple therapy, we will regard them as having resistant hypertension and

Before considering further treatment:

·      we will confirm the elevated clinic blood pressure measurements using ambulatory or home blood pressure recordings.

·      We will assess for postural hypotension.

·      And we will discuss adherence.

For people with confirmed resistant hypertension, we will consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice. 

When adding a fourth drug, we will consider further diuretic therapy with low-dose spironolactone when the blood potassium level is 4.5 mmol/l or less and we will be particularly cautious in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia. 

When doing this, we will monitor blood sodium and potassium and renal function within 1 month of starting treatment and repeat as needed thereafter. 

We will consider an alpha-blocker or beta-blocker as a fourth drug for those who have a blood potassium level of more than 4.5 mmol/l. 

If blood pressure remains uncontrolled taking 4 drugs, we will seek specialist advice. 

Identifying who to refer for same-day specialist review

We will refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:

·      signs of retinal haemorrhage or papilloedema (which is what we will call accelerated hypertension) or

·      life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. 

We will also refer people for specialist assessment, carried out on the same day, if they have suspected phaeochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis). 

If a person has a clinic blood pressure of 180/120 mmHg or higher, but no symptoms or signs, we will carry out investigations for target organ damage as soon as possible, including all of the following:

·      testing for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and testing for haematuria using a reagent strip

·      taking a blood sample to measure glycated haemoglobin (HbA1C), electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol

·      examining the fundi for the presence of hypertensive retinopathy

·      and arranging for a 12‑lead ECG

And then:

·      If target organ damage is identified, we will consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.

·      However, if no target organ damage is identified, we will confirm the diagnosis by:

o  repeating clinic blood pressure measurement within 7 days, or

o  considering ABPM (or HBPM if ABPM is not suitable or not tolerated) and we will review within 7 days.

We have come to the end of the actual guideline but it is worth going through the definition of the Terms used by NICE in this guideline, and these are:

 Accelerated hypertension

Which is defined as a severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (or swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension.

The term Established cardiovascular disease

Refers to a Medical history of ischaemic heart disease, cerebrovascular disease, peripheral vascular disease, aortic aneurysm or heart failure. Cardiovascular disease is usually associated with a build-up of fatty deposits inside the arteries (or atherosclerosis) and an increased risk of blood clots.

The concept of Masked hypertension

Refers to when Clinic blood pressure measurements are normal (that is, less than 140/90 mmHg), but blood pressure measurements are higher when taken outside the clinic using an ABPM or a HBPM.

Stage 1 hypertension

Is when the clinic blood pressure ranges from 140/90 mmHg to 159/99 mmHg and subsequent ABPM or HBPM average blood pressure ranges from 135/85 mmHg to 149/94 mmHg.

Stage 2 hypertension

Is when the clinic blood pressure is 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM or HBPM average blood pressure is 150/95 mmHg or higher.

And Stage 3 or severe hypertension

Is when the clinic systolic blood pressure is 180 mmHg or higher or the clinic diastolic blood pressure of 120 mmHg or higher.

Target organ damage

Is defined as damage to organs such as the heart, brain, kidneys and eyes. Examples are left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy or increased urine albumin:creatinine ratio.

And finally, a White-coat effect

Is defined as a discrepancy of more than 20/10 mmHg between clinic and ABPM or HBPM blood pressure measurements at the time of diagnosis.

We have come to the end of this episode. I hope that you have enjoyed it and found it useful and I hope that you will join me in the next one. Thank you for listening and goodbye.