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NICE Hypertension Guidelines for adults: what is new? Professor Francesco Cappuccio comments

Press comment by Professor Francesco P Cappuccio, Professor of Cardiovascular Medicine at the University of Warwick and President of the British and Irish Hypertension Society, on the new NICE Hypertension Guidelines for adults

"Hypertension is the major cause of cardiovascular disease (CVD), responsible for over 10 million deaths worldwide every year. Its prevention and management is a proven cost-effective way to reduce the burden of CVD (fatal and non-fatal). Therefore, achieving good blood pressure control is a priority of every healthcare system, including the NHS.

"The long awaited revision of the NICE Guideline: Hypertension in adults: diagnosis and management (NG136) is finally out. It comes after the publication of the American[1] and the European[2] Guidelines in 2018, with the benefit of having had access to the latest evidence.

"Key features are: (1) confirm the diagnosis with out-of-office measurements; (2) systematically measure standing BP in diabetics, those with postural symptoms and patients over 80 years of age; (3) treat Stage 1 hypertension (from 140/90 to 159/99 mmHg) at an estimated absolute cardiovascular risk of 10%; (4) keep BP targets below 140/90 mmHg for clinic blood pressure (below 150/90 mmHg over the age of 80 years); (5) use stepwise anti-hypertensive medications to reach targets; (6) use thiazide-like diuretics rather than thiazides; (7) discuss adherence; (8) consider low-dose spironolactone as Step 4 in resistant hypertension, after patient’s consent.

"The British and Irish Hypertension Society, whilst welcoming the new Guideline, notes that few changes have been made to the 2011 version, and finds the recommendations rather conservative compared to recent international guidelines in the US and Europe, that had reviewed the same evidence. This is in part due toan important limitation in the scoping of the NICE evidence review – and therefore the identification of the beneficiaries of their recommendations. The new NICE Guideline is directed to the management of adults with hypertension, with or without diabetes, but excludes patients with established CVD (like prior myocardial infarction, stroke and heart failure). The latter group represents up to one third of patients with hypertension seen daily in primary and secondary care. In England & Wales there are currently about 6.5 million people with pre-existing CVD[3], of whom 89% have hypertension[4]. Ninety-seven percent are treated for hypertension, and only 6 out of 10 have it controlled to target 4,[5]. To them the guideline does not apply. This is not only a missed opportunity to improve the management of hypertension in people with the highest risk, but a challenge for the implementation of the guideline in primary care."

Professor Francesco P Cappuccio, Professor of Cardiovascular Medicine at the University of Warwick and President of the British and Irish Hypertension Society

[1] Whelton PK et al. Hypertension 2018; 71: e13-e115
[2] Williams B et al. Eur Heart J 2018; 39: 3021-104
[3] British Heart Foundation. England and Wales Factsheets (2019)
[4] Falaschetti E et al. Lancet 2014; 383; 1912-9
[5] McDonnell BJ et al. Eur Heart J 2019; 21 (suppl. D): D121-3
28 August 2019

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