1. Hypertension NICE CG127 August 2011

2. Hypertension is not a disease it is a risk factor for cardiovasuclar disease (CVD)-it is a modifiable risk factor

3. Key Changes Ambulatory blood pressure is suggested as the investigation of choice for all with suspected hypertension. Home readings are an alternative,. Clinic BP readings are no longer recommended for the diagnosis of hypertension, Hypertension is now defined as stage 1 and stage 2. This affects who we treat. The threshold blood pressure for offering drug therapy has changed, partly reflecting the move to ambulatory BP monitoring. Diuretics have moved to third line drugs after ACE inhibitors and calcium channel blockers The thiazide-like diuretic of choice is now indapamide or chlortalidone rather than bendroflumethiazide or hydrochlorothiazide. NICE say that those already established on bendroflumethiazide or hydrochlorothiazide need not be changed to chlortalidone or indapamide

4. Ambulatory BP readings Use a device that records at least 2 measurements/hour during waking hours. You need to have at least 14 readings to average. In the past we added 10/5 to ABPM before making decisions – there is no need to do this now, since the decision flow charts are based on ABPM not clinic readings.

5. Home BP monitoring (HBPM) Take readings morning and evening for at least 4d, preferably 7d. On each occasion take 2 readings≥1min apart, whilst seated. Discard the first day's readings, and average the remaining readings.

7. Care pathway CBPM ≥160/100 mmHg & ABPM/HBPM ≥ 150/95 mmHg Stage 2 hypertension Consider specialist referral Offer antihypertensive drug treatment Offer lifestyle interventions If younger than 40 years If target organ damage present or 10-year cardiovascular risk > 20% Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication Offer patient education and interventions to support adherence to treatment CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg Stage 1 hypertension

8. Assessing CV risk and target organ damage: updated recommendations Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension. For all people with hypertension offer to: – test urine for presence of protein – take blood to measure glucose, electrolytes, creatinine, eGFR and cholesterol – examine fundi for hypertensive retinopathy – arrange a 12-lead ECG.

9. Step 4 Summary of antihypertensive drug treatment Aged over 55 years or black person of African or Caribbean family origin of any age Aged under 55 years C2C2 A A + C 2 A + C + D Resistant hypertension A + C + D + consider further diuretic 3, 4 or alpha- or beta-blocker 5 Consider seeking expert advice Step 1 Step 2 Step 3 Key A – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB) 1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic See slide notes for details of footnotes 1-5

10. Drug therapy Aim for drugs to be taken once a day Do not use ACE inhibitors and Angiotensis receptor antagonists together (no additional benefit and increased risk of s/e) Treat women of child bearing age in line with NICE guidelines on hypertension in pregnancy Treat isolated systolic BP in same way as if both were raised SBP>160

11. NICE prefer Chlortalidone 12.5mg-25mg daily or indapamide 1.5mg MR od or 2.5mg od What are the cost differences? Based on drug tariff price (Dec 2010) monthly costs are: Bendroflumethiazide (2.5mg)£0.79 for 28 Chlortalidone (50mg)£1.77 for 28 Indapamide ordinary release 2.5mg £1.27 for 28 £2.01 for 56 cheapest. Indapamide slow release 1.5mg£3.40 for 30

12. Monitoring drug treatment (1) Use clinic blood pressure measurements to monitor response to treatment. Aim for target blood pressure below: 140/90 mmHg in people aged under 80 150/90 mmHg in people aged 80 and over

13. Monitoring drug treatment (2) For people identified as having a ‘white-coat effect’ consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor response to treatment. Aim for ABPM/HBPM target average of: below 135/85 mmHg in people aged under 80 below 145/85 mmHg in people aged 80 and over. White-coat effect: a discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.

14. Additional recommendations Lifestyle interventions Offer guidance and advice about: – diet (including sodium and caffeine intake) and exercise – alcohol consumption – smoking. Patient education and adherence Provide: – information about benefits of drugs and side effects – details of patient organisations – an annual review of care.

15. Summary Ambulatory blood pressure investigation of choice Clinic BP readings no longer recommended for diagnosis of hypertension Can be used to monitor treatment Hypertension defined as stage 1 and 2 Thresholds of treatments has changed reflecting ambulatory BP monitoring

16. Diuretics have moved to 3 rd line after ACE inhibitors and calcium channel blockers Thiazide-like diuretic of choice is indapamide or chlortalidone (no need to changed established)