hypertension treatment steps for hypertension

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Treatment steps forhypertension

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Treatment steps for hypertension NICE Pathways

Hypertension pathwayCopyright © NICE 2015.

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because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart

failure, offer a thiazide-like diuretic.

If diuretic treatment is to be initiated or changed, offer a thiazide like diuretic, such as

chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or

2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide

or hydrochlorothiazide.

For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide

and whose blood pressure is stable and well controlled, continue treatment with the

bendroflumethiazide or hydrochlorothiazide.

NICE has produced a pathway on chronic heart failure.

Resources

The following implementation tools are relevant to this part of the pathway.

Hypertension (drug treatment): audit support

Hypertension: (drug treatment): electronic audit tool

Hypertension: clinical case scenarios

5 Step 2

If blood pressure is not controlled by step 1 treatment, offer step 2 treatment with a CCB in

combination with either an ACE inhibitor or an ARB 1.

If a CCB is not suitable for step 2 treatment, for example because of oedema or intolerance, or

if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic,

such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once

daily or 2.5 mg once daily).

For black people of African or Caribbean family origin, consider an ARB in preference to an

ACE inhibitor, in combination with a CCB.

If therapy is initiated with a beta-blocker and a second drug is required, add a CCB rather than a

thiazide-like diuretic to reduce the person's risk of developing diabetes.



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1 Choose a low-cost ARB.


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Before considering step 3 treatment, review medication to ensure step 2 treatment is at optimal

or best tolerated doses.

NICE has produced a pathway on chronic heart failure.

Resources





6 Step 3

If treatment with three drugs is required, the combination of ACE inhibitor or ARB, CCB and

thiazide-like diuretic such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg

modified-release once daily or 2.5 mg once daily) should be used.

Regard clinic blood pressure that remains higher than 140/90 mmHg after treatment with theoptimal or best tolerated doses of an ACE inhibitor or an ARB plus a CCB plus a diuretic as

resistant hypertension, and consider adding a fourth antihypertensive drug and/or seeking

expert advice.

1

Quality standards

The following quality statement is relevant to this part of the pathway.

6. Referral to a specialist for people with resistant hypertension

Resources




1 Choose a low-cost ARB.


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7 Step 4 Resistant hypertension

For treatment of resistant hypertension at step 4:

Consider further diuretic therapy with low-dose spironolactone (25 mg once daily)1 if the

blood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a

reduced eGFR because they have an increased risk of hyperkalaemia.

Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher

than 4.5 mmol/l.

When using further diuretic therapy for resistant hypertension at step 4, monitor blood sodium

and potassium and renal function within 1 month and repeat as required thereafter.

If further diuretic therapy for resistant hypertension at step 4 is not tolerated, or is

contraindicated or ineffective, consider an alpha- or beta-blocker.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four

drugs, seek expert advice if it has not yet been obtained.

Interventional procedures

NICE has published interventional procedures guidance on percutaneous transluminal

radiofrequency sympathetic denervation of the renal artery for resistant hypertension with

special arrangements for clinical governance, consent, and audit or research.

NICE has published interventional procedures guidance that implanting a baroreceptor

stimulation device for resistant hypertension should be used only in the context of research.

Quality standards

The following quality statement is relevant to this part of the pathway.

6. Referral to a specialist for people with resistant hypertension


1 At the time of publication (August 2011), spironolactone did not have UK marketing authorisation for this

indication. Informed consent should be obtained and documented.


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http://www.nice.org.uk/Guidance/CG127/Resourceshttp://www.nice.org.uk/Guidance/CG127/Resourceshttp://www.nice.org.uk/guidance/IPG418http://www.nice.org.uk/guidance/IPG418http://www.nice.org.uk/guidance/IPG533http://www.nice.org.uk/guidance/IPG533http://www.nice.org.uk/guidance/IPG533http://www.nice.org.uk/guidance/IPG533http://www.nice.org.uk/guidance/IPG418http://www.nice.org.uk/guidance/IPG418http://www.nice.org.uk/Guidance/CG127/Resourceshttp://www.nice.org.uk/Guidance/CG127/Resources


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Resources





8 Monitoring drug treatment

Use clinic blood pressure measurements to monitor the response to antihypertensive treatment

with lifestyle modifications or drugs.

For people identified as having a white-coat effect, consider ABPM or HBPM as an adjunct to

clinic blood pressure measurements to monitor the response to antihypertensive treatment with

lifestyle modification or drugs.

Resources





9 Review annually

See Hypertension / Hypertension overview / Review annually



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Glossary

ACE inhibitor

angiotensin-converting enzyme inhibitor

ARB

angiotensin II receptor blocker

CCB

calcium-channel blocker

ABPM

ambulatory blood pressure monitoring

eGFR

estimated glomerular filtration rate

HBPM

home blood pressure monitoring

Severe hypertension

clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110

mmHg or higher

Stage 1 hypertension

clinic blood pressure 140/90 mmHg or higher and subsequent ambulatory blood pressure

monitoring daytime average or home blood pressure monitoring average blood pressure 135/85

mmHg or higher



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Stage 2 hypertension

clinic blood pressure 160/100 mmHg or higher and subsequent ambulatory blood pressure

monitoring daytime average or home blood pressure monitoring average blood pressure 150/95

mmHg or higher

White-coat effect

a discrepancy of more than 20/10 mmHg between clinic and average daytime ambulatory blood

pressure monitoring or average home blood pressure monitoring measurements at the time of

diagnosis

Sources

Hypertension (2011) NICE guideline CG127

Implanting a baroreceptor stimulation device for resistant hypertension (2015) NICE

interventional procedure guidance 533

Percutaneous transluminal radiofrequency sympathetic denervation of the renal artery for

resistant hypertension (2012) NICE interventional procedure guidance 418

Your responsibility

The guidance in this pathway represents the view of NICE, which was arrived at after careful

consideration of the evidence available. Those working in the NHS, local authorities, the wider

public, voluntary and community sectors and the private sector should take it into account when

carrying out their professional, managerial or voluntary duties. Implementation of this guidance

is the responsibility of local commissioners and/or providers. Commissioners and providers are

reminded that it is their responsibility to implement the guidance, in their local context, in light of

their duties to avoid unlawful discrimination and to have regard to promoting equality of

opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent

with compliance with those duties.

Copyright

Copyright © National Institute for Health and Care Excellence 2015. All rights reserved. NICE

copyright material can be downloaded for private research and study, and may be reproduced



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for educational and not-for-profit purposes. No reproduction by or for commercial organisations,

or for commercial purposes, is allowed without the written permission of NICE.

Contact NICE

National Institute for Health and Care Excellence

Level 1A, City Tower

Piccadilly Plaza

Manchester

M1 4BT

www.nice.org.uk

[email protected]

0845 003 7781



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