New hypertension guidance from NICE criticised for being too conservative

The British and Irish Hypertension Society (BIHS) has criticised the newly updated NICE guidelines on hypertension for its conservative recommendations compared to recent international guidelines in the US and Europe that had reviewed the same evidence.

Professor Francesco P Cappuccio, Professor of Cardiovascular Medicine at the University of Warwick and President of the British and Irish Hypertension Society, also said in a statement on behalf of the Executive Committee that there had been few changes made to the 2011 version. 

He said: “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 and Wales there are currently about 6.5 million people with pre-existing CVD, of whom 89% have hypertension.

“Ninety-seven percent are treated for hypertension, and only six out of 10 have it controlled to target. 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.”

Key features of the new guidance are:

• Confirm the diagnosis with out-of-office measurements
• Systematically measure standing blood pressure in diabetics, those with postural symptoms and patients over 80 years of age
• Treat stage 1 hypertension (from 140/90 to 159/99mmHg) at an estimated absolute cardiovascular risk of 10%
• Keep blood pressure targets below 140/90mmHg for clinic blood pressure (below 150/90 mmHg over the age of 80 years)
• Use stepwise anti-hypertensive medications to reach targets
• Use thiazide-like diuretics rather than thiazidesdiscuss adherence
• Consider low-dose spironolactone as step 4 in resistant hypertension, after patient’s consent.

Cappuccio added: “Hypertension is the major cause of cardiovascular disease (CVD), responsible for over 10 million deaths worldwide every year and 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.”