Download NICE Guidelines for Hypertension

NICE Guidelines for Hypertension
Ben Selph
Mercer COPHS, Class of 2012
SEGA Geriatrics
Importance of lowering blood pressure
 Lowering blood pressure can significantly decrease risk of CV
disease.
 61 prospective observational trials, nearly 1 million people, age
bands from 40 to 89
 Examined relationship between blood pressure level and 12,000
strokes, 34,000 heart disease events over an average of 13.2
years follow-up
 Reductions in systolic of 20mmHg and diastolic 10mmHg was
associated with reductions in death from stroke and ischemic
heart disease of about one half (~50%)
Importance of lowering blood pressure
 A similar analysis of 9 observational studies looking at
relationship between BP level and strokes/coronary events
found:
 Reductions in diastolic BP of 5, 7.5, and 10 was associated with
reductions in stroke of 34%, 46%, and 56%, and coronary heart
disease of 21%, 29%, and 37%, respectively
Cardiovascular risk assessment
 Important to determine presence of CV disease or high CV
risk states (diabetes or CKD).
 Risk models have been developed for doctors to assess
likelihood of patients developing cardiovascular disease. (10
year risk).
 Factors involved in risk assessment include:
 Gender, age, diabetic status, smoking status, total cholesterol,
HDL cholesterol, and blood pressure.
 Allows for identification of patients under greatest overall
risk and treatment of modifiable risk factors.
Target Organ Damage
Medscape Cardiology. 2008 Medscape. http://www.medscape.org/viewarticle/577753
Target Organ Damage
 Another important objective in assessing people with
suspected hypertension is:
 To document presence of absence of target organ damage.
 Examples include:
 Left ventricular hypertrophy, hypertensive retinopathy, and increased
albumin:creatinine ratio (kidney damage)
Clinical Tests
 Important to perform full CV assessment in patients with
persistently high BP that do not have established CV disease.
 May detect diabetes and signs of developing target organ
damage (damage to heart and kidneys)
 These include: urine strip test for blood and protein, blood
electrolytes and creatinine, blood glucose, serum total and
HDL cholesterol, and 12 lead electrocardiogram
Diagnosis of Hypertension
 If clinic blood pressure is >140/90, offer AMBULATORY
BLOOD PRESSURE MONITORING to confirm
diagnosis.
 When ABPM is used, at least two measurements per hour
should be taken during person’s waking hours.
 Use the average value of at least 14 measurements taken during
person’s waking hours to confirm diagnosis of hypertension.
The Oscar 2 monitor.
The ambulatory blood pressure
monitor. 2007. gizmag.com
Diagnosis
 Another option is Home Blood
Pressure Monitoring (HBPM).
When this is used:
 For each blood pressure




recording, two consecutive
measurements are taken, at least 1
minute apart and with person
seated,
Blood pressure is recorded twice
daily, in morning and evening,
Blood pressure recording
continues for at least 4 days,
ideally for 7 days.
Measurements on first day are
discarded
Average of remaining
measurements are used to confirm
diagnosis
Omron blood pressure monitor.
BP monitor ratings. 2011.
effectsofhighbloodpressure.com
Diagnosis
 ABPM/HBPM
 <135/85 mmHg = Normal
 >135/85 mmHg = Stage 1 Hypertension
 >150/95 mmHg = Stage 2 Hypertension
Treatment algorithm
Lifestyle Modifications
 Dietary modifications and exercise
 Low calorie diets have modest effect on BP in overweight
individuals (avg. 5-6 mm Hg).
 Aerobic exercise (brisk walking, jogging, or cycling) for 30-60
min., 3-5 times/week, had small effect on BP (2-3 mm Hg).
 Relaxation therapies
 These activities (stress management, meditation, cognitive
therapy, muscle relaxation) reduce by average of 3-4 mm Hg.
Lifestyle Modifications
 Limit alcohol consumption
 Excessive alcohol consumption is associated with raised blood
pressure, poorer CV and hepatic health.
 Reducing alcohol can lower BP 3-4 mm Hg.
 Limiting excessive consumption of coffee/caffeine (small
benefit).
 Limit dietary sodium intake
 < 6 g/day, modest reduction of 2-3 mm Hg.
 Encourage smoking cessation (reduce risk of CV/pulmonary
disease).
Initiating Treatment
 Offer antihypertensive drug treatment to people aged under
80 years with Stage 1 hypertension who have one or more of
the following:
 Target organ damage, established cardiovascular disease, renal
disease, diabetes, and 10-year CV risk equivalent to 20% or
greater.
 Offer antihypertensive drug treatment to people of any age
with stage 2 hypertension.
Initiating Treatment
 For people aged under 40 years with stage 1 hypertension
and no evidence of target organ damage, CV disease, renal
disease or diabetes, consider specialist evaluation of
secondary causes of hypertension and more detailed
assessment of potential target organ damage.
Step 1 Treatment
 > 55 yearsCALCIUM CHANNEL BLOCKER
 Offer to people aged over 55 years and to black people of
African or Caribbean family origin of any age.
 If CCB is not suitable (i.e. edema, intolerance, evidence of heart
failure or risk of heart failure), offer a thiazide-like diuretic over
conventional thiazide diuretics
 Chlorthalidone 12.5-25 mg daily; indapamide 1.5-2.5 mg once daily
 Calcium Channel Blockers examples—amlodipine, nifedipine,
felodipine, verapamil, diltiazem.
Step 1 Treatment
 < 55 yearsACE INHIBITOR or ARB
 Offer people aged under 55 years an ACE inhibitor or a low-
cost ARB.
 If ACE inhibitor is prescribed and is not tolerated (i.e. because
of cough), offer a low-cost ARB.
 ACE inhibitor examples—benazepril (Lotensin), captopril
(Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril
(Zestril), quinapril (Accupril), ramipril (Altace)
 ARB examples—candesartan (Atacand), irbesartan (Avapro),
losartan (Cozaar), olmesartan (Benicar), telmisartan (Micardis),
valsartan (Diovan)
Step 2 Treatment
 ACE inhibitor/ARB + Calcium Channel Blocker
 For those intolerant to CCBs or at high risk of heart failure:
ACE inhibitor/ARB + Thiazide-like diuretic.
 ACCOMPLISH trial and updated cost-effectiveness analysis
both favored A + C over A + D
Step 3 Treatment
 ACEi/ARB + CCB + Thiazide-like diuretic
 Based on the recommendations and analyses performed in the
first two steps.
 Thiazide diuretic examples: chlorthalidone (Hygroton),
indapamide (Lozol), hydrochlorothiazide (Hydrodiuril),
metolazone (Zaroxolyn)
Resistant Hypertension: Step 4
treatment
 Person with confirmed hypertension in whom blood pressure
is not controlled (<140/90mmHg) despite treatment with
combination of optimum or best tolerated doses of three
antihypertensive drugs (generally A+C+D).
Recommendations for Step 4
 Addition of low-dose Spironolactone
 Considered when potassium level is <4.5 mmol/L
 Potassium, sodium, creatinine: checked 2 weeks after initiation and
periodically thereafter.
 Higher-dose thiazide-like diuretic treatment
 Considered when potassium level is >4.5 mmol/L
 Other options for add-on therapy: alpha blockers or beta
blockers
Blood Pressure Goals
 People aged < 80 years with treated hypertension: <140/90
(home: 135/85)
 People aged > 80 years with treated hypertension: <150/90
(home: 145/85)
 For people with “white coat effect”—difference of 20/10
mmHg between clinic and average daily reading—consider
adjunt ambulatory or home BP measurement to monitor BP.
Comparing NICE with JNC7 (U.S.):
Diagnosis
 NICE
 JNC 7 (U.S.)
 Hypertension signaled
 Mainly based on office BP
from clinic reading
(>140/90 mm Hg).
 Officially diagnosed using
Ambulatory Blood
Pressure Monitoring
(>135/85 mm Hg)
reading (>140/90)
 Ambulatory or Home
Blood Pressure Monitoring
mainly used for selfmonitoring.
Comparing NICE with JNC7: Initiation
of Medication Therapy
 NICE:
 Stage 1 (>135/85mmHg
Ambulatory or Home BP)
 Offer antihypertensive to
patients under 80 years if the
patient has: Target organ
damage, established
cardiovascular disease, renal
disease, diabetes, and 10-year
CV risk equivalent to 20% or
greater.
 Stage 2 (150/95 mmHg
ABPM).

Offer antihypertensive
therapy to patients of any age
with Stage 2 hypertension
 JNC7:
 After attempt of lifestyle
modifications to lower BP, if
still not at goal:
 Stage 1: diuretic or medication
for compelling indication
 Stage 2: diuretic + additional
medication considering
compelling indication.
Comparing NICE with JNC7 (U.S.): First
Medication Therapy Used.
 NICE:
 < 55 years: ACE inhibitor
or ARB
 > 55 years: Calcium
Channel Blocker
 If CCB not tolerated or
contraindicated, use diuretic.
 JNC 7:
 Thiazide diuretic for most
 Unless diuretic cannot be
used or if compelling
indication requires use of
another class of
antihypertensive.
Comparing NICE with JNC7: Additional
medication treatment
 NICE:
 Step 2: ACEi/ARB +
Calcium Channel Blocker
 Step 3: ACEi/ARB +
Calcium Channel Blocker
+ diuretic
 Step 4: add spironolactone
if K < 4.5 mmol/L or
increase doses of diuretic if
K > 4.5 mmol/L.
 Also can add alpha blocker or
beta blocker
 JNC 7:
 Stage 2 (>160/100
mmHg):
 Thiazide diuretic + ACEi or
ARB or CCB or BB.
Level of Evidence: Class I, Level A
References
 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL,
Jones DW, Materson BJ, Oparil S, Wright JT, Rocella EJ, and National
High Blood Pressure Education Program Coordinating Committee.
Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure. 2003.
Amer Heart Assoc
 National Institute for Health and Clinical Excellence. Hypertension:
clinical management of primary hypertension in adults. CG127. 2011.
http://guidance.nice.org.uk/CG127/Guidance/pdf/English
 Medscape Cardiology. New Approaches to Managing Dyslipidemia: Risk
Reduction Beyond LDL-C (Slides with Transcript). 2008. Available at:
http://www.medscape.org/viewarticle/577753. Accessed on April 12,
2012.