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

NICE Guidelines for Managing Hypertension

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 before initiating treatment. 1, 2

Diagnostic Approach

Blood Pressure Measurement

• Office BP serves as the screening tool, but diagnosis should not be made on a single visit 1, 2
• ABPM is the preferred confirmatory method (or HBPM if patients are unable or unwilling to use ABPM) 1
• This distinguishes NICE from most other international guidelines that rely primarily on office measurements 1
• For office BP 140-160/90-100 mmHg, measurements should be taken on 4-5 separate occasions, or self-monitoring/ABPM should be used before confirming diagnosis 1

Diagnostic Thresholds

• Stage 1 hypertension: Office BP 140-159/90-99 mmHg 1
• Stage 2 hypertension: Office BP ≥160/100 mmHg 1
• Confirm all new diagnoses with out-of-office monitoring to detect white coat hypertension 2

Treatment Initiation

When to Start Pharmacological Treatment

Stage 1 Hypertension (140-159/90-99 mmHg):

• Initiate health behavior modifications first 1
• For very low-risk patients (e.g., pre-menopausal females with no other risk factors, younger people with SBP <160 mmHg and DBP <100 mmHg), defer antihypertensive therapy due to low cardiovascular risk and lack of evidence for benefit 1
• For higher-risk patients, proceed with pharmacological treatment after lifestyle intervention period 1

Stage 2 Hypertension (≥160/100 mmHg):

• Commence pharmacological treatment immediately following diagnosis, combined with lifestyle modifications 1

Elderly Patients (≥80 years):

• Initiate treatment only if SBP ≥160 mmHg 1
• This higher threshold reflects evidence from the HYVET study 1

Blood Pressure Targets

General Population

• Target office BP <140/90 mmHg for most adults 1
• Both systolic and diastolic values must be achieved 1

Elderly Patients (≥80 years)

• Target BP <150/90 mmHg based on HYVET study data 1
• This is a more conservative target recognizing the unique physiology of this age group 1

Patients with Diabetes or Chronic Kidney Disease

• Target <140/90 mmHg - NICE does not recommend lower targets 1
• This differs from older guidelines that recommended <130/80 mmHg, as recent evidence (including the ACCORD trial) showed no additional benefit of more intensive lowering 1
• However, some guidelines suggest targeting DBP <85 mmHg in diabetes based on HOT and UKPDS trials 1

Audit Standards

• Minimum acceptable control: <150/90 mmHg for general population 1
• For diabetes: <140/85 mmHg 1
• These represent minimum standards; optimal targets remain <140/90 mmHg 1

Pharmacological Treatment

First-Line Drug Classes

Four major classes are recommended as first-line therapy:

• Thiazide or thiazide-like diuretics (e.g., indapamide, chlorthalidone) 1
• ACE inhibitors 1
• Angiotensin receptor blockers (ARBs) 1
• Calcium channel blockers (dihydropyridine) 1

Beta-Blockers

• Not advised for general population treatment 1, 2
• Reserve for compelling indications: post-myocardial infarction, heart failure, angina, or heart rate control 1

Drug Selection Based on Patient Characteristics

Compelling Indications:

• Heart failure/LV dysfunction: ACE inhibitors or ARBs 1
• Post-MI or angina: Beta-blockers 1
• Type 1 diabetic nephropathy: ACE inhibitors 1
• Type 2 diabetic nephropathy: ACE inhibitors or ARBs 1
• Chronic kidney disease: ACE inhibitors or ARBs (with caution and close monitoring) 1

Compelling Contraindications:

• Pregnancy: ACE inhibitors and ARBs absolutely contraindicated 1
• Asthma/COPD: Beta-blockers contraindicated 1
• Gout: Thiazides contraindicated 1

Combination Therapy

Initial Combination Treatment

• Most patients require multiple drugs to achieve BP control 1, 2
• Preferred two-drug combinations: RAS blocker (ACE inhibitor or ARB) + calcium channel blocker OR RAS blocker + thiazide diuretic 1, 2
• Single-pill combinations are recommended to improve adherence 1

Three-Drug Combination

• If BP not controlled on two drugs, escalate to three-drug combination: RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic 1, 2
• Preferably use single-pill combination 1

Prohibited Combinations

• Never combine ACE inhibitor with ARB - no benefit and increased adverse effects 1, 2

Resistant Hypertension

• If BP remains ≥160/100 mmHg on ≥3 drugs or multiple drug intolerances, refer to specialist with expertise in hypertension 1

Lifestyle Modifications

All patients should receive lifestyle intervention advice:

• Diet: Mediterranean or DASH diet, rich in fruits and vegetables, low in saturated fat 1
• Sodium restriction: Aim for <5g salt (<2000mg sodium) per day 1
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Physical activity: Regular moderate-intensity aerobic exercise, complemented with resistance training 2-3 times/week 1
• Alcohol: Limit to <100g/week of pure alcohol, or preferably avoid entirely 1
• Smoking cessation: Mandatory recommendation with referral to cessation programs 1
• Sugar restriction: Limit free sugars to <10% of energy intake, avoid sugar-sweetened beverages 1

Timing of Lifestyle Intervention

• NICE recommends a period of lifestyle modifications before initiating pharmacological treatment in Stage 1 hypertension (though duration not specified) 1
• Lifestyle measures are complementary to drug therapy, not an alternative 1

Monitoring and Follow-Up

During Treatment

• Regular monitoring is required to assess BP control and medication adherence 1
• HBPM is more suitable than ABPM for ongoing monitoring after diagnosis 1
• If marked difference between clinic BP and ABPM/HBPM (>20/10 mmHg), repeat out-of-office measurement with treatment target <150/95 mmHg 1

Long-Term Management

• Maintain BP-lowering treatment lifelong, even beyond age 85 years if well tolerated 1
• Medication timing: Take at most convenient time to establish habitual pattern and improve adherence 1

Key Pitfalls to Avoid

• Do not diagnose hypertension on single office visit - always confirm with ABPM/HBPM 1, 2
• Do not use beta-blockers as first-line unless compelling indication exists 1, 2
• Do not target excessively low BP in elderly - use <150/90 mmHg for those ≥80 years 1
• Do not combine ACE inhibitor with ARB 1
• Do not defer treatment in Stage 2 hypertension - initiate immediately 1
• Do not use potassium supplementation routinely - insufficient evidence per NICE 1