What is the next step in managing a patient's hypertension according to NICE CKS (National Institute for Health and Care Excellence Clinical Knowledge Summaries)?

Next Steps in Managing Hypertension According to NICE CKS

The next step in managing hypertension is to follow a stepwise medication approach starting with an ACE inhibitor or ARB (for non-black patients) or calcium channel blocker (for black patients), then adding additional medications if blood pressure targets are not achieved within 3 months. 1

Diagnosis Confirmation

Before proceeding with treatment escalation, ensure hypertension diagnosis is confirmed:

• Verify BP readings ≥140/90 mmHg on multiple office visits
• Consider home BP monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) for confirmation
• Use validated device with appropriate cuff size

Treatment Algorithm

Step 1: Initial Medication Selection

• Non-Black Patients: Start with low-dose ACE inhibitor or ARB
• Black Patients: Start with low-dose ARB + calcium channel blocker (DHP-CCB) or DHP-CCB + thiazide-like diuretic

Step 2: Dose Optimization

• Increase to full dose if BP remains above target after 4 weeks

Step 3: Combination Therapy

• Non-Black Patients: Add thiazide/thiazide-like diuretic
• Black Patients: Add diuretic (if not already prescribed) or ACE inhibitor/ARB

Step 4: Resistant Hypertension

• Add spironolactone if renal function and potassium levels permit
• If spironolactone is contraindicated or not tolerated, consider:
  • Amiloride
  • Doxazosin
  • Eplerenone
  • Clonidine
  • Beta-blocker

Blood Pressure Targets

• General target: <130/80 mmHg
• Minimum goal: Reduce BP by at least 20/10 mmHg
• For elderly patients: Individualize based on frailty assessment

Monitoring

• Assess BP control within 3 months of treatment initiation
• Check medication adherence if targets not achieved
• Monitor for adverse effects, particularly renal function and electrolytes with ACE inhibitors/ARBs

Special Considerations

High-Risk Patients

• Immediate drug treatment is recommended for:
  • Patients with cardiovascular disease
  • Chronic kidney disease
  • Diabetes
  • Evidence of organ damage
  • Patients aged 50-80 years

Low-Risk Patients

• For grade 1 hypertension (140-159/90-99 mmHg) in low-risk patients:
  • Start with lifestyle interventions
  • Add medication if BP remains elevated after 3-6 months

Resistant Hypertension

• If BP remains uncontrolled on ≥3 medications, refer to a specialist with expertise in hypertension management 1

Common Pitfalls to Avoid

1. Failing to confirm diagnosis with out-of-office measurements
2. Not checking adherence before escalating therapy
3. Inadequate dose titration before adding new agents
4. Not considering secondary causes in resistant hypertension
5. Ignoring lifestyle modifications alongside pharmacological treatment

By following this stepwise approach, you can systematically manage hypertension to reduce cardiovascular morbidity and mortality, which should be the primary outcome focus of treatment.