NICE guideline for management of hypertension in adults in 在成人的高血壓管理NICE指南

PAGE

NICEclinicalguideline34

DevelopedbytheNewcastleGuidelineDevelopmentandResearchUnit;thesectiononprescribingdrugshasbeenupdatedbytheBritishHypertensionSocietyandtheNationalCollaboratingCentreforChronicConditions

Hypertension

Managementofhypertensioninadultsinprimarycare

ThisisapartialupdateofNICEclinicalguideline18

Issuedate:June2006

NICEclinicalguideline34

Hypertension:managementofhypertensioninadultsinprimarycare(partialupdateofNICEclinicalguideline18)

Orderinginformation

Youcandownloadthefollowingdocumentsfrom

.uk/CG034

TheNICEguideline(thisdocument)–alltherecommendations.

Aquickreferenceguide,whichhasbeendistributedtohealthcareprofessionalsworkingintheNHSinEngland.

‘UnderstandingNICEguidance’–informationforpatientsandcarers.

Thefullguideline–alltherecommendations,detailsofhowtheyweredeveloped,andsummariesoftheevidenceonwhichtheywerebased.

Forprintedcopiesofthequickreferenceguideorinformationforthepublic,phonetheNHSResponseLineon0870

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455andquote:

N1050(quickreferenceguide)

N1051(‘UnderstandingNICEguidance’).

Thisguidanceiswritteninthefollowingcontext:

ThisguidancerepresentstheviewoftheInstitute,whichwasarrivedataftercarefulconsiderationoftheevidenceavailable.Healthcareprofessionalsareexpectedtotakeitfullyintoaccountwhenexercisingtheirclinicaljudgement.Theguidancedoesnot,however,overridetheindividualresponsibilityofhealthcareprofessionalstomakedecisionsappropriatetothecircumstancesoftheindividualpatient,inconsultationwiththepatientand/orguardianorcarer.

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PublishedbytheNationalInstituteforHealthandClinicalExcellence

June2006

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NationalInstituteforHealthandClinicalExcellence,June2006.Allrightsreserved.Thismaterialmaybefreelyreproducedforeducationalandnot-for-profitpurposes.Noreproductionbycommercialorganisations,orforcommercialpurposes,isallowedwithouttheexpresswrittenpermissionoftheInstitute.

Contents

Introduction 4

Patient-centredcare 6

Keyprioritiesforimplementation 7

1 Guidance 9

1.1 Measuringbloodpressure 9

1.2 Lifestyleinterventions 13

1.3 Estimatingcardiovascularrisk 16

1.4 Pharmacologicalinterventions 17

1.5 Continuingtreatment 23

2 Notesonthescopeoftheguidance 25

3 Researchrecommendations 26

4 Otherversionsofthisguideline 27

4.1 Fullguideline 27

4.2 Quickreferenceguide 27

4.3 UnderstandingNICEguidance:informationforpatientsandcarers 28

5 RelatedNICEguidance 28

6 Reviewdate 28

AppendixA:Gradingscheme 29

AppendixB:TheGuidelineDevelopmentGroup 33

AppendixB:TheGuidelineDevelopmentGroup 33

AppendixC:TheGuidelineReviewPanel 36

AppendixD:Technicaldetailonthecriteriaforaudit 38

AppendixE:Managementflowchartforhypertension 44

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15

NICEclinicalguideline34?hypertension

ThisisapartialupdateofNICEclinicalguideline18(publishedAugust2004).

TheupdatehasbeendevelopedbytheNationalCollaboratingCentreforChronicConditionsandtheBritishHypertensionSociety().TheoriginalguidelinewasdevelopedbytheNewcastleGuidelineDevelopmentandResearchUnit.Inthisupdate,onlytherecommendationsonprescribingdrugsforhypertension(section1.4)havebeenchanged;nootherrecommendationsareaffected.TheoriginalNICEguidelineandsupportingdocumentsareavailablefrom.uk/CG018

Introduction

ThisNICEguidelineprovidesrecommendationsfortheprimarycaremanagementofraisedbloodpressure(BP).

Hypertensionisamajorbutmodifiablecontributoryfactorincardiovasculardiseases(CVD)suchasstrokeandcoronaryheartdisease(CHD).Theobjectiveofthisguidelineistodecreasecardiovascularmorbidityandmortalityresultingfromthesediseases.ItisimportanttoassessriskinpeoplebeforeCVDdevelopsandmonitoringforpersistentlyraisedBPisoneaspectofCVriskassessment.

Thisguidelinemakesrecommendationsonprimarycaremanagementofhypertension.ItincludesrecommendationsonapproachestoidentifyingpatientswithpersistentlyraisedBP,andmanaginghypertension(includinglifestyleadviceanduseofBP-loweringdrugs).

Thisguidelinedoesnotaddressscreeningforhypertension,managementofhypertensioninpregnancyorthespecialistmanagementofsecondaryhypertension(whererenalorpulmonarydisease,endocrinecomplicationsorotherdiseaseunderlieraisedbloodpressure).Patientswithexistingcoronaryheartdiseaseordiabetesshouldbemanagedinlinewithcurrentnationalguidancefortheseconditions.

WhyaNICEguidelineonhypertension?

ThisNICEguidelineonthemanagementofhypertensionisbasedonthebestavailableevidence.AmultidisciplinaryGuidelineDevelopmentGroupcarefullyconsideredevidenceofboththeclinicaleffectivenessandcosteffectivenessoftreatmentandcareindevelopingtheserecommendations.Thedraftguidelinewasthenmodifiedinthelightoftworoundsofextensiveconsultationwiththerelevantstakeholdergroups,includingNHSorganisations,healthcareprofessionals,patient/carergroupsandmanufacturers.

Patient-centredcare

Thisguidelineoffersbestpracticeadviceonthecareofadultswithhypertension.

Treatmentandcareshouldtakeintoaccountpatients’individualneedsandpreferences.Peoplewithhypertensionshouldhavetheopportunitytomakeinformeddecisionsabouttheircareandtreatment.Wherepatientsdonothavethecapacitytomakedecisions,healthcareprofessionalsshouldfollowtheDepartmentofHealthguidelines–‘Referenceguidetoconsentforexaminationortreatment’(2001)(availablefrom.uk).

Goodcommunicationbetweenhealthcareprofessionalsandpatientsisessential.Itshouldbesupportedbytheprovisionofevidence-basedinformationofferedinaformthatistailoredtotheneedsoftheindividualpatient.Thetreatment,careandinformationprovidedshouldbeculturallyappropriateandinaformthatisaccessibletopeoplewhohaveadditionalneeds,suchaspeoplewithphysical,cognitiveorsensorydisabilities,andpeoplewhodonotspeakorreadEnglish.

Unlessspecificallyexcludedbythepatient,carersandrelativesshouldhavetheopportunitytobeinvolvedindecisionsaboutthepatient’scareandtreatment.

Carersandrelativesshouldalsobeprovidedwiththeinformationandsupporttheyneed.

Keyprioritiesforimplementation

Thefollowingrecommendationshavebeenidentifiedasprioritiesforimplementation.

Measuringbloodpressure

Toidentifyhypertension(persistentraisedbloodpressureabove140/90

mmHg),askthepatienttoreturnforatleasttwosubsequentclinicswherebloodpressureisassessedfromtworeadingsunderthebestconditionsavailable.

Routineuseofautomatedambulatorybloodpressuremonitoringorhomemonitoringdevicesinprimarycareisnotcurrentlyrecommendedbecausetheirvaluehasnotbeenadequatelyestablished;appropriateuseinprimarycareremainsanissueforfurtherresearch.

Lifestyleinterventions

Lifestyleadviceshouldbeofferedinitiallyandthenperiodicallytopatientsundergoingassessmentortreatmentforhypertension.

Cardiovascularrisk

Ifraisedbloodpressurepersistsandthepatientdoesnothaveestablishedcardiovasculardisease,discusswiththemtheneedtoformallyassesstheircardiovascularrisk.Testsmayhelpidentifydiabetes,evidenceofhypertensivedamagetotheheartandkidneys,andsecondarycausesofhypertensionsuchaskidneydisease.

Considertheneedforspecialistinvestigationofpatientswithsignsandsymptomssuggestingasecondarycauseofhypertension.Accelerated(malignant)hypertensionandsuspectedphaeochromocytomarequireimmediatereferral.

Pharmacologicalinterventions

Drugtherapyreducestheriskofcardiovasculardiseaseanddeath.Offerdrugtherapyto:

patientswithpersistenthighbloodpressureof160/100

mmHgormore

patientsatraisedcardiovascularrisk(10yearriskofCVDof20%ormore,orexistingCVDortargetorgandamage)withpersistentbloodpressureofmorethan140/90

mmHg.

Inhypertensivepatientsaged55orolderorblackpatientsofanyage,thefirstchoiceforinitialtherapyshouldbeeitheracalcium-channelblockerorathiazide-typediuretic.Forthisrecommendation,blackpatientsareconsideredtobethoseofAfricanorCaribbeandescent,notmixed-race,AsianorChinese.

Inhypertensivepatientsyoungerthan55,thefirstchoiceforinitialtherapyshouldbeanangiotensin-convertingenzyme(ACE)inhibitor(oranangiotensin-IIreceptorantagonistifanACEinhibitorisnottolerated).

Continuingtreatment

Provideanannualreviewofcaretomonitorbloodpressure,providepatientswithsupportanddiscusstheirlifestyle,symptomsandmedication.

Patientsmaybecomemotivatedtomakelifestylechangesandwanttostopusingantihypertensivedrugs.Ifatlowcardiovascularriskandwithwellcontrolledbloodpressure,thesepatientsshouldbeofferedatrialreductionorwithdrawaloftherapywithappropriatelifestyleguidanceandongoingreview.

Thefollowingguidanceisevidencebased.Theevidencesupportingeachrecommendationisprovidedinthefullguideline(seeSection5).Recommendationsareclassifiedaccordingtothetypeofevidencetheyarebasedon(seeappendixA).

Guidance

Measuringbloodpressure

Healthcareprofessionalstakingbloodpressuremeasurementsneedadequateinitialtrainingandperiodicreviewoftheirperformance.D

Healthcareprovidersmustensurethatdevicesformeasuringbloodpressureareproperlyvalidated,maintainedandregularlyrecalibratedaccordingtomanufacturers’instructions.D

Wherepossible,standardisetheenvironmentwhenmeasuringbloodpressure:providearelaxed,temperatesetting,withthepatientquietandseatedandwiththeirarmoutstretchedandsupported*.D

*Theprinciplesofgoodtechniqueformeasuringbloodpressurearepresentedinbox

1.

Ifthefirstmeasurementexceeds140/90

mmHg*,ifpractical,takeasecondconfirmatoryreadingattheendoftheconsultation.D

*Bloodpressureisrecordedassystolic/diastolicbloodpressuremeasuredinmillimetresofmercury(mmHg).Raisedbloodpressureisnotedwheneithersystolicpressureexceeds140

mmHgordiastolicbloodpressureexceeds90

mmHg.

Measurebloodpressureonbothofthepatient’sarmswiththehighervalueidentifyingthereferencearmforfuturemeasurement.D

Inpatientswithsymptomsofposturalhypotension(fallsorposturaldizziness)measurebloodpressurewhilepatientisstanding.Inpatientswithsymptomsordocumentedposturalhypotension(fallinsystolicBPwhenstandingof20

mmHgormore)considerreferraltoaspecialist.D

Referimmediatelypatientswithaccelerated(malignant)hypertension(BPmorethan180/110

mmHgwithsignsofpapilloedemaand/orretinalhaemorrhage)orsuspectedphaeochromocytoma(possiblesignsincludelabileorposturalhypotension,headache,palpitations,palloranddiaphoresis).D

Toidentifyhypertension(persistentraisedbloodpressure,above140/90

mmHg),askthepatienttoreturnforatleasttwosubsequentclinicswherebloodpressureisassessedfromtworeadingsunderthebestconditionsavailable.D

Measurementsshouldnormallybemadeatmonthlyintervals.However,patientswithmoreseverehypertensionshouldbereevaluatedmoreurgently.D

Routineuseofautomatedambulatorybloodpressuremonitoringorhomemonitoringdevicesinprimarycareisnotcurrentlyrecommendedbecausetheirvaluehasnotbeenadequatelyestablished;appropriateuseinprimarycareremainsanissueforfurtherresearch.C

Readingsfromclinicandambulatorybloodpressuredevices,whenusedside-by-side,maydifferfromoneanotherandfromtruearterialpressurebecausetheyusedifferentmethodsandassumptions.

Averageambulatoryreadingsfromaseriesofpatients,takenover24

hours,arecommonlylowerthanclinicreadingsbybetween10/5and20/10

mmHg.However,anindividualpatientmayhaveambulatoryreadingshigherorlowerthanclinicreadings.Studiescomparingclinicandambulatorymeasurementvaryintheirdesign,setting,conductofmeasurementandanalysis:estimateddifferencesbetweenambulatoryandclinicvaluesvarywiththesefactors.

Clinicandambulatoryreadingsmayalsodifferbecauseofa‘whitecoat’effect?thatis,aresponsetothesettingorclinician.

Epidemiologicalstudiesareinconsistentindemonstratingtheadditionalprognosticvalueofambulatorybloodpressuremonitoringtopredictcardiovasculardiseaseinunselectedpatients.

Considertheneedforspecialistinvestigationofpatientswithunusualsignsandsymptoms,orofthosewhosemanagementdependscriticallyontheaccurateestimationoftheirbloodpressure.D

BOX1Estimationofbloodpressurebyauscultation

Standardisetheenvironmentasmuchaspossible:

?relaxedtemperatesetting,withthepatientseated

?armout-stretched,inlinewithmid-sternum,andsupported.

Correctlywrapacuffcontaininganappropriatelysizedbladderaroundtheupperarmandconnecttoamanometer.Cuffsshouldbemarkedtoindicatetherangeofpermissiblearmcircumferences;thesemarksshouldbeeasilyseenwhenthecuffisbeingappliedtoanarm.

Palpatethebrachialpulseintheantecubitalfossaofthatarm.

Rapidlyinflatethecuffto20

mmHgabovethepointwherethebrachialpulsedisappears.

Deflatethecuffandnotethepressureatwhichthepulsere-appears:theapproximatesystolicpressure.

Re-inflatethecuffto20

mmHgabovethepointatwhichthebrachialpulsedisappears.

Usingonehand,placethestethoscopeoverthebrachialarteryensuringcompleteskincontactwithnoclothinginbetween.

Slowlydeflatethecuffat2–3

mmHgpersecondlisteningforKorotkoffsounds.

PhaseI: Thefirstappearanceoffaintrepetitivecleartappingsoundsgraduallyincreasinginintensityandlastingforatleasttwoconsecutivebeats:notethesystolicpressure.

PhaseII: Abriefperiodmayfollowwhenthesoundssoftenor‘swish’.

Auscultatorygap: Insomepatients,thesoundsmaydisappearaltogether.

PhaseIII: Thereturnofsharpersoundsbecomingcrisperforashorttime.

PhaseIV: Thedistinct,abruptmufflingofsounds,becomingsoftandblowinginquality.

PhaseV: Thepointatwhichallsoundsdisappearcompletely:notethediastolicpressure.

Whenthesoundshavedisappeared,quicklydeflatethecuffcompletelyifrepeatingthemeasurement.

Whenpossible,takereadingsatthebeginningandendofconsultations.

Lifestyleinterventions

Ascertainpatients’dietandexercisepatternsbecauseahealthydietandregularexercisecanreducebloodpressure.Offerappropriateguidanceandwrittenoraudiovisualmaterialstopromotelifestylechanges.B

Educationaboutlifestyleonitsownisunlikelytobeeffective.

Healthy,low-caloriedietshadamodesteffectonbloodpressureinoverweightindividualswithraisedbloodpressure,reducingsystolicanddiastolicbloodpressureonaveragebyabout5?6

mmHgintrials.However,thereisvariationinthereductioninbloodpressureachievedintrialsanditisunclearwhy.About40%ofpatientswereestimatedtoachieveareductioninsystolicbloodpressureof10

mmHgsystolicormoreintheshortterm,upto1

year.

Takingaerobicexercise(briskwalking,joggingorcycling)for30–60minutes,threetofivetimeseachweek,hadasmalleffectonbloodpressure,reducingsystolicanddiastolicbloodpressureonaveragebyabout2–3

mmHgintrials.However,thereisvariationinthereductioninbloodpressureachievedintrialsanditisunclearwhy.About30%ofpatientswereestimatedtoachieveareductioninsystolicbloodpressureof10

mmHgormoreintheshortterm,upto1

year.

Interventionsactivelycombiningexerciseanddietwereshowntoreducebothsystolicanddiastolicbloodpressurebyabout4–5

mmHgintrials.Aboutone-quarterofpatientsreceivingmultiplelifestyleinterventionswereestimatedtoachieveareductioninsystolicbloodpressureof10

mmHgsystolicormoreintheshortterm,upto1

year.

Ahealthierlifestyle,byloweringbloodpressureandcardiovascularrisk,mayreduce,delayorremovetheneedforlong-termdrugtherapyinsomepatients.

Relaxationtherapies*canreducebloodpressureandindividualpatientsmaywishtopursuetheseaspartoftheirtreatment.However,routineprovisionbyprimarycareteamsisnotcurrentlyrecommended.B

*Examplesinclude:stressmanagement,meditation,cognitivetherapies,musclerelaxationandbiofeedback.

Overall,structuredinterventionstoreducestressandpromoterelaxationhadamodesteffectonbloodpressure,reducingsystolicanddiastolicbloodpressureonaveragebyabout3–4

mmHgintrials.Thereisvariationinthereductioninbloodpressureachievedintrialsanditisunclearwhy.Aboutone-thirdofpatientsreceivingrelaxationtherapieswereestimatedtoachieveareductioninsystolicbloodpressureof10

mmHgsystolicormoreintheshortterm,upto1

year.

Thecurrentcostandfeasibilityofprovidingtheseinterventionsinprimarycarehasnotbeenassessedandtheyareunlikelytoberoutinelyprovided.

Ascertainpatients’alcoholconsumptionandencourageareducedintakeifpatientsdrinkexcessively,becausethiscanreducebloodpressureandhasbroaderhealthbenefits.B

Excessivealcoholconsumption(men:morethan21

units/week;women:morethan14

units/week)isassociatedwithraisedbloodpressureandpoorercardiovascularandhepatichealth.

Structuredinterventionstoreducealcoholconsumption,orsubstitutelowalcoholalternatives,hadamodesteffectonbloodpressure,reducingsystolicanddiastolicbloodpressureonaveragebyabout3–4

mmHgintrials.Thirtypercentofpatientswereestimatedtoachieveareductioninsystolicbloodpressureof10

mmHgsystolicormoreintheshortterm,upto1

year.

Briefinterventionsbycliniciansof10–15

minutes,assessingintakeandprovidinginformationandadviceasappropriate,havebeenreportedtoreducealcoholconsumptionbyone-quarterinexcessivedrinkerswithorwithoutraisedbloodpressure,andtobeaseffectiveasmorespecialistinterventions.

Briefinterventionshavebeenestimatedtocostbetween￡40and￡60perpatientreceivingintervention.Thestructuredinterventionsusedintrialsofpatientswithhypertensionhavenotbeencosted.

Discourageexcessiveconsumptionofcoffeeandothercaffeine-richproducts.C

Excessiveconsumptionofcoffee(fiveormorecupsperday)isassociatedwithasmallincreaseinbloodpressure(2/1

mmHg)inparticipantswithorwithoutraisedbloodpressureinstudiesofseveralmonthsduration.

Encouragepatientstokeeptheirdietarysodiumintakelow,eitherbyreducingorsubstitutingsodiumsalt,asthiscanreducebloodpressure.B

Advicetoreducedietarysaltintaketolessthan6.0

g/day(equivalentto2.4

g/daydietarysodium)wasshowntoachieveamodestreductioninsystolicanddiastolicbloodpressureof2–3

mmHginpatientswithhypertension,atupto1

yearintrials.Aboutone-quarterofpatientswereestimatedtoachieveareductioninsystolicbloodpressureof10

mmHgsystolicormoreintheshortterm,upto1

year.

Long-termevidenceover2–3

yearsfromstudiesofnormotensivepatientsshowsthatreductionsinbloodpressuretendtodiminishovertime.

Onetrialsuggeststhatreducedsodiumsalt,whenusedasareplacementinbothcookingandseasoning,isaseffectiveinreducingbloodpressureasrestrictingtheuseoftablesalt.

Donotoffercalcium,magnesiumorpotassiumsupplementsasamethodforreducingbloodpressure.B

Thebestcurrentevidencedoesnotshowthatcalcium,magnesiumorpotassiumsupplementsproducesustainedreductionsinbloodpressure.

Thebestcurrentevidencedoesnotshowthatcombinationsofpotassium,magnesiumandcalciumsupplementsreducebloodpressure.

Offeradviceandhelptosmokerstostopsmoking.A

Thereisnostrongdirectlinkbetweensmokingandbloodpressure.However,thereisoverwhelmingevidenceoftherelationshipbetweensmokingandcardiovascularandpulmonarydiseases,andevidencethatsmokingcessationstrategiesarecosteffective.

See:Guidanceontheuseofnicotinereplacementtherapy(NRT)andbupropionforsmokingcessation,NICEtechnologyappraisalno.39,March2002..uk/TA039

Acommonaspectofstudiesformotivatinglifestylechangeistheuseofgroupworking.Informpatientsaboutlocalinitiativesby,forexample,healthcareteamsorpatientorganisationsthatprovidesupportandpromotehealthylifestylechange.D

Estimatingcardiovascularrisk

Ifraisedbloodpressurepersistsandthepatientdoesnothaveestablishedcardiovasculardisease,discusswiththemtheneedtoformallyassesstheircardiovascularrisk.Testsmayhelpidentifydiabetes,evidenceofhypertensivedamagetotheheartandkidneys,andsecondarycausesofhypertensionsuchaskidneydisease.D

Testforthepresenceofproteininthepatient’surine.Takeabloodsampletoassessplasmaglucose,electrolytes,creatinine,serumtotalcholesterolandHDLcholesterol.Arrangefora12-leadelectrocardiographtobeperformed.D

Considertheneedforspecialistinvestigationofpatientswithsignsandsymptomssuggestingasecondarycauseofhypertension.Accelerated(malignant)hypertensionandsuspectedphaeochromocytomarequireimmediatereferral.D

Anidentifiablecauseofhypertensionismorelikelywhenhypertensionoccursinyoungerpatients(lessthan30

yearsofage),worsenssuddenly,presentsasaccelerated(malignant)hypertension(BPmorethan180/110

mmHgwithsignsofpapilloedemaand/orretinalhaemorrhage)orrespondspoorlytotreatment.

Anelevatedcreatininelevelmayindicaterenaldisease.Labileorposturalhypotension,headache,palpitations,palloranddiaphoresisarepotentialsignsofphaeochromocytoma.Hypokalaemia,abdominalorflankbruits,orasignificantriseinserumcreatininewhenstartinganACE-inhibitormayindicaterenovascularhypertension.Isolatedhypokalaemiamaybeduetohyperaldosteronism.PotentialsignsofCushingsyndromeincludeosteoporosis,truncalobesity,moonface,purplestriae,muscleweakness,easybruising,hirsutism,hyperglycaemia,hypokalaemiaandhyperlipidaemia.

Usethecardiovascularriskassessmenttodiscussprognosisandhealthcareoptionswithpatients,bothforraisedbloodpressureandothermodifiableriskfactors.D

Riskmodelsprovideausefulprognostictoolforcliniciansandpatientsinprimarycare.Theyreinforcetheneedtooffertreatmenttopatientsbasedontheirprofileofcardiovascularriskratherthanfocusingonbloodpressureinisolation.

MostriskmodelsderivefromtheFraminghamHeartStudy:acohortofover5000menandwomenaged30–62yearsfromFramingham,Massachusettsfollowedupfrom1971toassessthedeterminantsofcardiovasculardisease.

LimitationsofcommonlyusedriskmodelsincludepoorvalidationinUKethnicminoritiesandyoungerpopulations.

Framinghamriskcalculatorcomputerprogrammescurrentlyprovidethebestassessmentofriskofcoronaryheartdiseaseandstrokeover10

years.ThelatestversiondevelopedbytheJointBritishSocieties*givestheriskofacardiovasculareventover10

years(acombinedscoreincludingtheriskofcoronaryheartdiseaseandstroke).

Riskchartsmayberelativelyimprecise,placingpatientsinbandsofrisks,althoughthevisualpresentationmaybehelpfultosomepatients.EvidencesuggeststheJointBritishSocietieschartadheresmostcloselytoFraminghamriskcalculators.

WhenonlytheCHDriskscoreisknown,CVDriskscorecanbeapproximatedbymultiplyingby4/3.WhenCHDandstrokeriskarereported,theCVDriskcanbeapproximatedbyaddingthesetwoscorestogether.

*JointBritishSocietiesCardiovascularRiskChartsareavailablefromtheBritishNationalFormulary.

Pharmacologicalinterventions

ForthisupdatedguidelineissuedbyNICEandtheBritishHypertensionSociety(),newstudiespublishedsinceJuly2004wereappraisedandthedataconsideredtogetherwiththosefromtheearlierstudies,usingmeta-analysiswhereappropriate.TheGuidelineDevelopmentGroup(GDG)consideredthisevidenceinthecontextofotheravailableevidence.Adverseeventsdataandissuesofpatientconcordancewereparticularlynoted,andtheGDGalsohadaccesstoadetailedhealtheconomicanalysiscomparingthecost-effectivenessofthemaindrugclasses.Considerationwasalsogiventothepathogenesisofhypertensionandthemechanismofactionofthedifferentclassesofdrugsusedtolowerbloodpressure,takingageandethnicityintoaccount.Finally,wheretheevidencedidnotprovedefinitive,theGDGtookintoaccountexistingguidelinesandconstructedrecommendationsmostcompatiblewithcurrentgoodpractice.

Informulatingitsrecommendations,theGDGhasassumeda’drugclasseffect’unlesstherewasclearevidencetothecontrary.However,clinical-outcometrialsinvolvingthiazide-typediureticshaveusedavarietyofdifferentdrugsatdifferentdoses.Moreover,theGDGfeltthatthebenefitsfromACEinhibitorsandangiotensin-IIreceptorantagonistswerecloselycorrelatedandthattheyshouldbetreatedasequalintermsofefficacy(although,becauseofcostdifferences,ACEinhibitorsshouldbeinitiatedfirst).

Oneclassofdrugsthatcausedparticulardebatewasthebeta-blockers.Inhead-to-headtrials,beta-blockerswereusuallylesseffectivethanacomparatordrugatreducingmajorcardiovascularevents,inparticularstroke.Atenololwasthebeta-blockerusedinmostofthesestudiesand,intheabsenceofsubstantialdataonotheragents,itisunclearwhetherthisconclusionappliestoallbeta-blockers.

Theevidenceshowedcalcium-channelblockersorthiazide-typediureticstobethedrugsmostlikelytoconferbenefitasfirst-linetreatmentformostpatients.Thehealtheconomicmodelslightlyfavouredcalcium-channelblockers,withthiazide-typediureticsasthenextmostcost-effectiveoption.Onbalance,theGDGdecidedthatcalcium-channelblockersandthiazide-typediureticsshouldbeofferedasequalalternativesforcliniciansandpatientstoconsiderasinitialtreatment.Considerationshouldbegiventothepatient’sriskofadverseeffectsandpreferences.

Thisconclusionislesscertainforyoungerpatients(definedpragmaticallyasthose