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

NICE Guidelines on Hypertension Management

Diagnosis and Blood Pressure Measurement

NICE uniquely recommends using office blood pressure for initial screening, followed by ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. 1

• Office BP measurements should be used as the initial screening tool 1
• ABPM is the preferred method for confirming hypertension diagnosis (or HBPM if patients are unable or unwilling to use ABPM) 1
• This two-step diagnostic approach distinguishes NICE from other international guidelines that rely primarily on office measurements 1

Blood Pressure Targets

The general target blood pressure is <140/90 mmHg for most adults. 1

• For patients aged ≥80 years, treatment should only be initiated if they have stage 2 hypertension (≥160/100 mmHg), with a target of <150/90 mmHg 1
• Treatment decisions in elderly patients should be based on standing blood pressure and consider co-morbidities such as dementia 1
• Patients already on treatment when they turn 80 should continue their well-tolerated therapy without back-titration 1

When to Initiate Treatment

For stage 1 hypertension (140-159/90-99 mmHg), NICE recommends a trial period of lifestyle modifications before starting pharmacological treatment, except in high-risk patients. 1

• Very low-risk patients (e.g., pre-menopausal women with no other risk factors) with SBP <160 mmHg and DBP <100 mmHg can defer antihypertensive therapy 1
• Stage 2 hypertension (≥160/100 mmHg) warrants immediate pharmacological treatment 1
• High-risk stage 1 patients should receive both lifestyle modifications and pharmacological treatment 1

Lifestyle Modifications

NICE recommends comprehensive lifestyle changes as part of hypertension management, though these should complement rather than replace drug therapy. 1

• Diet: Emphasize fruits, vegetables, low-fat dairy products, dietary fiber, whole grains, and plant-based proteins while reducing saturated fat and cholesterol 1
• Salt reduction: Reduce intake toward 5g of salt daily 1
• Alcohol: Reduce excessive consumption 1
• Physical activity: Provide specific exercise advice 1
• Weight management: Encourage weight reduction if overweight 1
• Smoking cessation: Strongly recommend stopping 1
• Coffee/caffeine: Reduce consumption of caffeine-rich products 1
• Supplements: Calcium, magnesium, and potassium supplements are NOT recommended 1
• Relaxation therapies: May be considered 1

Pharmacological Treatment Algorithm

Step 1 Treatment

For patients under 55 years and non-Black patients, start with an ACE inhibitor or ARB. 1

• For patients aged ≥55 years or Black patients of African/Caribbean origin, start with a calcium channel blocker (CCB) 1
• If bendroflumethiazide or hydrochlorothiazide was previously prescribed and BP is well-controlled, continue these agents 1
• Beta-blockers are NOT preferred as initial therapy but may be considered in younger patients with intolerance/contraindication to ACE inhibitors/ARBs, women of childbearing potential, or those with increased sympathetic drive 1
• If a beta-blocker is started and a second drug is needed, add a CCB rather than a thiazide-like diuretic to reduce diabetes risk 1

Step 2 Treatment

Combine a CCB with either an ACE inhibitor or ARB. 1

• If CCB is unsuitable (due to edema, intolerance, heart failure, or high heart failure risk), offer a thiazide-like diuretic instead 1
• For Black patients of African/Caribbean origin, prefer an ARB over an ACE inhibitor when combining with a CCB 1
• NICE specifically recommends indapamide and chlorthalidone over conventional thiazide diuretics 1

Step 3 Treatment

Use triple therapy with ACE inhibitor or ARB + CCB + thiazide-like diuretic. 1

• Before escalating to Step 3, verify that Step 2 drugs are at optimal or maximum tolerated doses 1

Step 4 Treatment (Resistant Hypertension)

If BP remains >140/90 mmHg despite optimal triple therapy, add low-dose spironolactone (25mg once daily) if serum potassium <4.6 mmol/L. 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 changes 1
• Exercise caution in patients with reduced estimated glomerular filtration rate due to hyperkalaemia risk 1
• If further diuretic therapy is not tolerated, contraindicated, or ineffective, consider an alpha-blocker or beta-blocker 1
• Seek expert advice if BP remains uncontrolled on four drugs at optimal doses 1

Key Implementation Points

Longer-acting drugs requiring once-daily dosing are preferred to improve adherence. 1

• Patient education is critical for achieving BP control 1
• Treatment should be simplified to the fewest number of medications possible 1

Important Caveats

NICE's approach to diagnosis differs significantly from other guidelines by requiring ABPM/HBPM confirmation, which may delay treatment initiation but reduces overdiagnosis of white-coat hypertension. 1

• The focus is shifting toward treating overall cardiovascular risk rather than blood pressure numbers alone 1
• This mirrors the approach used for hypercholesterolemia, where treatment decisions are based on composite cardiovascular risk 1
• The absolute benefit of treatment for individual patients, particularly those at low risk, may be smaller than commonly perceived 1