What are the NICE (National Institute for Health and Care Excellence) guidelines for managing hypertension?

NICE Guidelines for Managing Hypertension

NICE recommends a stepwise treatment algorithm starting with calcium channel blockers (CCB) for patients ≥55 years or of Black African/Caribbean origin, and ACE inhibitors (ACEI) or angiotensin receptor blockers (ARB) for patients <55 years, with ambulatory blood pressure monitoring (ABPM) as the gold standard for diagnosis before initiating therapy. 1

Diagnosis and Blood Pressure Measurement

• NICE uniquely recommends ABPM (or home blood pressure monitoring if ABPM is unavailable) to confirm diagnosis after initial office screening, with daytime average BP ≥135/85 mmHg defining hypertension. 1
• Office BP measurements serve as the initial screening tool, but ABPM confirmation is required before starting treatment to avoid overdiagnosis of white-coat hypertension. 1
• This approach differs from most international guidelines that rely primarily on office BP measurements. 1

Treatment Thresholds by Age

• For patients ≥80 years, offer treatment only if they have stage 2 hypertension (clinic BP ≥160/100 mmHg or ABPM/HBPM ≥150/95 mmHg). 1
• Base treatment decisions on standing blood pressure and consider comorbidities such as dementia. 1
• Patients already on treatment when they turn 80 should continue their current therapy—do not back-titrate medications based on age alone. 1

Stepwise Pharmacological Treatment Algorithm

Step 1: Initial Monotherapy

• For patients <55 years: Start with ACEI (or ARB if ACEI not tolerated). 1
• For patients ≥55 years OR Black African/Caribbean patients of any age: Start with CCB. 1
• Beta-blockers are NOT preferred initial therapy. However, consider them in younger patients with contraindications to ACEI/ARB, women of childbearing potential, or those with evidence of increased sympathetic drive. 1

Step 2: Dual Therapy

• Combine CCB with either ACEI or ARB. 1
• If CCB is unsuitable (due to edema, intolerance, heart failure, or high heart failure risk), substitute with a thiazide-like diuretic. 1
• For Black patients of African/Caribbean origin, prefer ARB over ACEI when combining with CCB. 1
• If beta-blocker was started at Step 1 and a second drug is needed, add CCB rather than thiazide-like diuretic to reduce diabetes risk. 1

Step 3: Triple Therapy

• Before escalating to Step 3, verify that Step 2 drugs are at optimal or maximum tolerated doses. 1
• Use the combination: ACEI or ARB + CCB + thiazide-like diuretic. 1

Step 4: Resistant Hypertension

• If BP remains ≥140/90 mmHg despite optimal doses of three drugs, add a fourth agent and seek expert advice. 1
• First choice: Add low-dose spironolactone 25 mg once daily if serum potassium <4.6 mmol/L. 1
• Exercise caution with spironolactone in patients with reduced estimated glomerular filtration rate due to hyperkalemia risk. 1
• If serum potassium >4.5 mmol/L, increase the thiazide-like diuretic dose instead. 1
• Monitor serum sodium, potassium, and renal function within 1 month of dose adjustment and repeat as needed. 1
• If further diuretic therapy is not tolerated, contraindicated, or ineffective, consider alpha-blocker or beta-blocker. 1
• Seek expert advice if BP remains uncontrolled on four drugs at optimal doses. 1

Target Blood Pressure Goals

• General population target: <140/90 mmHg in clinic. 1
• ABPM/HBPM target: <135/85 mmHg (daytime average). 1
• For patients ≥80 years, individualize targets based on standing BP and comorbidities. 1

Important Caveats and Pitfalls

• Never combine ACEI and ARB—this increases risk of hyperkalemia and acute kidney injury without additional benefit. 2
• Use thiazide-like diuretics (indapamide, chlorthalidone) rather than bendroflumethiazide or hydrochlorothiazide for better cardiovascular outcomes. 1
• NICE emphasizes treating cardiovascular risk, not just blood pressure numbers—consider overall 5-10 year cardiovascular risk when making treatment decisions. 1
• Regular monitoring every 2-4 weeks is required when adjusting treatment until BP is controlled. 1

Lifestyle Modifications

• Recommend lifestyle changes for all patients with BP >120/80 mmHg, including dietary sodium reduction, increased physical activity, weight loss, and alcohol moderation. 2, 3
• Lifestyle modifications enhance the efficacy of pharmacological therapy and should be initiated before or alongside drug treatment. 1, 3