Guidelines for Starting Antihypertensive Medication as per NICE
For most patients with stage 1 hypertension (140-159/90-99 mmHg), a trial period of health behavior modifications should be attempted before initiating pharmacological treatment, while patients with stage 2 hypertension (≥160/100 mmHg) should commence pharmacological treatment immediately following diagnosis. 1
Blood Pressure Thresholds for Initiating Treatment
Stage 1 Hypertension (140-159/90-99 mmHg)
- For patients at low cardiovascular risk, a period of lifestyle modifications is recommended before starting medication 1
- NICE guidelines do not specify an exact time period for this trial of lifestyle changes, unlike other guidelines which recommend 3-6 months 1, 2
- For very low-risk patients (such as pre-menopausal females with no other risk factors or younger people) with SBP <160 mmHg and DBP <100 mmHg, antihypertensive therapy can be deferred 1
- For high-risk patients, drug treatment should be initiated immediately alongside lifestyle modifications 2
Stage 2 Hypertension (≥160/100 mmHg)
- Immediate pharmacological treatment is recommended following diagnosis 1, 3
- No trial period of lifestyle modifications is necessary before starting medication 1
- A two-drug combination is typically recommended for most patients with stage 2 hypertension 1
Special Populations
Elderly Patients
- For patients aged ≥80 years, a higher SBP threshold of ≥160 mmHg is used for initiating pharmacological intervention 1
- A higher target of <150/90 mmHg is appropriate for elderly patients, based largely on data from the HYVET study 1
- If the elderly patient is otherwise considered healthy, a target SBP ≤140 mmHg may still be recommended 1
Initial Drug Therapy Recommendations
First-line Medications
- For most patients, thiazide-type diuretics are recommended as initial therapy 1, 4
- For non-Black patients, starting with low-dose ACEI/ARB is recommended 3, 2
- For Black patients, starting with low-dose ARB plus DHP-CCB (e.g., amlodipine) or DHP-CCB plus thiazide-like diuretic is recommended 3, 2
Combination Therapy
- For stage 2 hypertension, a two-drug combination is usually recommended 1
- Typical combinations include a thiazide-type diuretic with either an ACE inhibitor, ARB, beta-blocker, or calcium channel blocker 1
Monitoring and Follow-up
- Regular BP monitoring is essential to assess response to treatment 3, 2
- Schedule follow-up within 2-4 weeks to assess response to therapy 3
- The goal is to achieve target BP within 3 months of initiating treatment 3, 2
- For those not initially requiring drug therapy, BP should be rechecked every 3-6 months 1
Lifestyle Modifications
- All patients should receive advice on lifestyle modifications regardless of whether medication is initiated 1, 4
- Recommended modifications include:
- Sodium restriction to <1500 mg/d or reduction of at least 1000 mg/d 1
- Increased dietary potassium intake (3500-5000 mg/d) 1
- Weight loss if overweight/obese 1
- Physical activity (90-150 min/week aerobic or dynamic resistance) 1
- Moderation of alcohol intake 1
- DASH-like diet rich in fruits, vegetables, whole grains and low-fat dairy products 1
Blood Pressure Targets
- The general target for most adults is <140/90 mmHg 1, 4
- For elderly patients (≥80 years), a higher target of <150/90 mmHg is appropriate 1
- For patients with diabetes or chronic kidney disease, a lower target of <130/80 mmHg is recommended 1
Common Pitfalls to Avoid
- Failing to confirm elevated readings with multiple measurements using a validated device with appropriate cuff size 3
- Not considering ambulatory or home BP monitoring when clinic BP is ≥140/90 mmHg 5
- Underutilization of thiazide diuretics despite evidence supporting their efficacy and cost-effectiveness 1
- Inadequate follow-up monitoring, particularly in the early phases of treatment 3
The NICE guidelines take a more conservative approach to initiating antihypertensive therapy compared to some other guidelines, emphasizing lifestyle modifications for stage 1 hypertension in low-risk patients while recommending immediate pharmacological intervention for stage 2 hypertension.