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This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
NICE stands for "National Institute for Health and Care Excellence" and is an independent organization within the UK healthcare system that produces evidence-based guidelines and recommendations to help healthcare professionals deliver the best possible care to patients, particularly within the NHS (National Health Service) by assessing new health technologies and treatments and determining their cost-effectiveness; essentially guiding best practices for patient care across the country.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I review a section of the NICE guideline on Hypertension in adults, always focusing on what is relevant in Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
Disclaimer:
The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.
In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
There is a podcast version of this and other videos that you can access here:
Primary Care guidelines podcast:
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There is a YouTube version of this and other videos that you can access here:
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https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The NICE clinical guideline on Hypertension in adults: diagnosis and management [NG136] can be found here:
· https://www.nice.org.uk/guidance/NG136
Transcript
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Hello and welcome, I’m Fernando, a GP in the UK. Today we are reviewing the NICE guideline on hypertension in adults, always focusing on what is relevant in Primary Care only.
In previous episodes we covered the diagnosis, criteria for urgent referral, when to start drug treatment and blood pressure targets.
Today we will focus on antihypertensive drug treatment.
Right, let’s jump into it.
Let’s start with what antihypertensive treatment to choose.
The recommendations in this guideline apply to people with hypertension, with or without type 2 diabetes, but for people with type 1 diabetes or CKD, we should refer to the relevant NICE guideline.
We should also remember that ACE inhibitors and angiotensin receptor blockers should not be used in pregnancy, breastfeeding, or when planning pregnancy, unless absolutely necessary. If used, we must discuss risks and benefits and follow safety guidance.
In general, and if possible, we should choose once daily treatments.
For isolated systolic hypertension, defined as a systolic blood pressure of 160 or higher, we should treat in the same way as people with both raised systolic and diastolic blood pressure.
We should offer antihypertensive drug treatment to women of childbearing potential with diagnosed hypertension, in line with the general guideline on hypertension.
For women planning pregnancy, who are pregnant, or breastfeeding, we should manage hypertension in line with the specific NICE guideline on hypertension in pregnancy, including guidance during breastfeeding.
When choosing antihypertensive treatment for adults of Black African or African Caribbean family origin, we should consider an angiotensin receptor blocker in preference to an ACE inhibitor. This is because ACE inhibitors may be less effective in this group, partly because low renin hypertension is more common, and they also carry a higher risk of angioedema.
For people with cardiovascular disease, we should first follow the disease specific recommendations in the relevant NICE guideline for their condition. These include:
· acute coronary syndromes,
· acute and chronic heart failure,
· stable angina, and
· type 1 diabetes.
If blood pressure remains uncontrolled despite following these disease specific recommendations, we should then offer the general stepwise approach outlined in the hypertension guideline. Let’s have a look at it.
As step 1 treatment, we should offer an ACE inhibitor or an ARB as step 1 treatment if they have type 2 diabetes, regardless of age or family origin.
We should also offer an ACE inhibitor or an ARB to adults under the age of 55, provided they are not of Black African or African Caribbean family origin.
If an ACE inhibitor is not tolerated, for example because of cough, we should offer an ARB instead. We should not combine an ACE inhibitor with an ARB.
We should offer a calcium channel blocker as step 1 treatment if they are aged 55 or over and do not have type 2 diabetes.
We should also offer a calcium channel blocker to adults of Black African or African Caribbean family origin who do not have type 2 diabetes, regardless of age.
If a calcium channel blocker is not tolerated, for example because of oedema, we should offer a thiazide like diuretic.
Equally, if there is evidence of heart failure, we should offer a thiazide like diuretic and follow the NICE guideline on chronic heart failure.
If starting or changing diuretic treatment, we should prefer a thiazide like diuretic, such as indapamide, over conventional thiazides such as bendroflumethiazide or hydrochlorothiazide.
If blood pressure is stable and well controlled on bendroflumethiazide or hydrochlorothiazide, we should continue the current treatment.
Now let’s move on to step 2 treatment.
Before considering the next step, we should discuss with the person whether they are taking their medication as prescribed.
If blood pressure is not controlled on step 1 treatment with an ACE inhibitor or an ARB, we should offer one of the following in addition:
a calcium channel blocker, or
a thiazide like diuretic.
If blood pressure is not controlled in adults taking step 1 treatment with a calcium channel blocker, we should offer one of the following in addition:
an ACE inhibitor,
an ARB, or
a thiazide like diuretic.
For adults of Black African or African Caribbean family origin without type 2 diabetes, not controlled on step 1 treatment, we should consider an ARB in preference to an ACE inhibitor as the add on treatment.
Now let’s move on to step 3 treatment.
Before considering the next step, we should make sure that optimal tolerated doses are being taken, and we should discuss adherence.
If blood pressure is not controlled on step 2 treatment, we should offer a combination of three drugs, that is:
an ACE inhibitor or an ARB,
plus a calcium channel blocker,
plus a thiazide like diuretic.
And finally, let’s now move on to step 4 treatment.
If blood pressure is not controlled despite optimal tolerated doses of an ACE inhibitor or an angiotensin receptor blocker, plus a calcium channel blocker, plus a thiazide like diuretic, we should regard this as resistant hypertension.
Before considering further treatment, we should confirm the elevated clinic readings using ambulatory or home blood pressure monitoring.
We should assess for postural hypotension.
And we should discuss adherence.
If resistant hypertension is confirmed, we should consider a fourth antihypertensive drug or seek specialist advice.
If considering a fourth drug. we should consider adding low dose spironolactone if the blood potassium is 4.5 millimoles per litre or less, using caution if kidney function is reduced, because of hyperkalaemia.
When starting further diuretic therapy, we should monitor sodium, potassium, and renal function within one month, and repeat as needed.
If potassium is above 4.5, we should consider an alpha blocker or a beta blocker instead.
If blood pressure remains uncontrolled despite four drugs at optimal tolerated doses, we should seek specialist advice.
So that is it, a review of a section of the NICE guideline on hypertension.
We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
