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New NICE guideline will radically change how high blood pressure is diagnosed

NICE has today (Wednesday 24 August) published an updated guideline on the diagnosis and treatment of high blood pressure (hypertension). Developed in conjunction with the British Hypertension Society (BHS), it makes a number of new recommendations that are set to significantly improve the way health professionals diagnose and treat high blood pressure in the NHS in England and Wales.

In one of the biggest changes to NICE's previous guidance, published in 2006, the guideline recommends that a diagnosis of primary hypertension should be confirmed using 24-hour ambulatory blood pressure monitoring (ABPM)1, or home blood pressure monitoring (HBPM), rather than be based solely on measurements of blood pressure taken in the clinic. The recommendation draws on substantial new evidence, including that published in today's Lancet2, suggesting that ABPM is more accurate than both clinic and home monitoring in defining the presence of hypertension, and that implementation of a diagnostic strategy for hypertension using ambulatory monitoring following an initial raised clinic reading would reduce misdiagnosis and be cost saving for the NHS.

High blood pressure is one of the most important preventable causes of premature ill health and death in the UK. It is a major risk factor for stroke, heart attack, heart failure, chronic kidney disease and cognitive decline. Primary hypertension is diagnosed when there is no simple identifiable cause of the raised blood pressure: the hypertension may be related, in part, to obesity, dietary factors such as salt intake, physical inactivity or genetic inheritance. There are currently about 12 million people in the UK who have hypertension, (blood pressure ≥140/90mmHg) and more than half of those are over the age of 60 years. Around 5.7 million people have hypertension which is undiagnosed3. The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke. As a consequence of commonplace routine periodic screening for high blood pressure in the UK as part of National Service Frameworks for cardiovascular disease prevention, the diagnosis, treatment and follow-up of patients with hypertension is one of the most common interventions in primary care, accounting for approximately 12% of Primary Care consultation episodes and approximately £1 billion in drug costs in 2006.

Other recommendations that have been reviewed in this partial update of the guideline for the clinical management of primary hypertension in adults include; blood pressure targets for people receiving treatment; the pharmacological treatment of hypertension; the treatment of hypertension in the very elderly (people aged over 80); treatment of hypertension in younger adults (younger than 40); and the treatment of drug resistant hypertension.

Key priorities for implementation include:

  • If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.
  • When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person's usual waking hours (for example, between 08:00 and 22:00). Use the average value of these measurements to confirm a diagnosis of hypertension.
  • Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension (that is, initial clinic systolic blood pressure of 140/90 mmHg or higher and subsequent ABPM daytime average or HBPM average of 135/85 mmHg or higher) who have one or more of the following:
    • target organ damage
    • established cardiovascular disease
    • renal disease
    • diabetes
    • a 10-year cardiovascular risk equivalent to 20% or greater.
  • Offer antihypertensive treatment to people of any age with stage 2 hypertension, (that is, initial clinic systolic blood pressure exceeds ≥160 mmHg and/or diastolic blood pressure ≥100 mmHg and subsequent ABPM daytime average or HBPM average of 150/95 mmHg or higher).
  • For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people.

Professor Peter Littlejohns, Clinical and Public Health Director at NICE said: “Because the likelihood of hypertension increases with age, with more people living longer, the overall prevalence of hypertension is expected to continue to rise. Other potential risk factors such as diet and lifestyle may lead to further increases in the future prevalence of the disease. It's therefore vital that we have guidance which is based on the very latest evidence available, and has the potential to make a real improvement in how hypertension is diagnosed and treated.”

Professor Bryan Williams, Professor of Medicine, University of Leicester and University Hospitals NHS Trust, Leicester, and Guideline Development Group Chair said: “The important recommendations in this guideline will affect the treatment of millions of people in our country and change the way blood pressure is diagnosed for the first time for more than a century. It is a step-change that is likely to be replicated across the world, and means the diagnosis of hypertension will be more accurate. It will ensure that those who really need treatment get treated and those who don't need treatment don't get treated unnecessarily. I am under no illusions about the challenges to implement this but I believe this guideline will be well received by both doctors and patients not just in England and Wales, but worldwide.”

Professor Mark Caulfield, Professor of Clinical Pharmacology, Barts and the London School of Medicine, President of the British Hypertension Society and Guideline Development Group member said: “The British Hypertension Society is delighted to have partnered NICE in this new guideline which represents a major advance in the diagnosis and treatment of people with high blood pressure. For the first time, using this NICE guideline in the treatment of high blood pressure is cheaper than doing nothing. I am sure all those with an interest in hypertension will welcome these recommendations.”

Professor Richard McManus, Professor of Primary Care Cardiovascular Research, University of Birmingham, GP, Greenridge Surgery, Birmingham, and Guideline Development Group member, said: “These guidelines will mark a significant change in the way that we diagnose hypertension. The use of ambulatory monitoring will ensure quicker and more accurate diagnosis that will be better for patients and better for the NHS. This represents an exciting advance which I am sure will be taken up internationally.”

Shelly Mason, Patient and carer representative and Guideline Development Group member, said: “The new guideline will ensure a variety of treatment options are available to patients. Patients will feel engaged and empowered, and be confident they are receiving the best possible care to manage their hypertension.”

Michaela Watts, Hypertension Nurse Specialist, Addenbrooke's Hospital, Cambridge and Guideline Development Group member, said: “As a nurse specialist working in secondary care, I have seen first-hand the very real effects of hypertension. This guideline will serve to streamline the consultation process enabling a more accurate diagnosis which both the patient and clinician can have greater confidence in. Provision of this more individualised care will improve ‘the patient experience'. I was very pleased to have been involved in its development.”

Ends

Notes to Editors

About the guideline

1. The guideline for the clinical management of primary hypertension in adults, is available from Wednesday 24 August on the NICE website.

2. Clinical case scenarios have been developed alongside the guideline to illustrate how the recommendations can be applied to the diagnosis and management of people with hypertension in primary care. Available on the NICE website as a PowerPoint presentation to help facilitate group learning and as a PDF document more suited to individual use, they are relevant to a wide range of healthcare professionals. Following the course of realistic patients from first presentation to stabilisation, they will help to improve users' knowledge of the clinical guideline on hypertension and its application in primary care. Suitable for practice and community nurses, this resource should update those responsible for measuring and interpreting blood pressure, diagnosing hypertension and monitoring the response to treatment.

3. In addition, the following implementation support tools are also available on the NICE website:

  • Slides highlighting key messages for local discussion.
  • Costing tools:
    • costing report to estimate the national savings and costs associated with implementing the ABPM recommendations
    • costing template to estimate the local costs and savings involved in implementing the ABPM recommendations.
  • Audit support, including an electronic audit tool for monitoring local practice.
  • Baseline assessment tool to help you identify which areas of practice may need more support, decide on clinical audit topics and prioritise implementation activities.
  • Implementation advice provides suggested actions on how to increase capacity for ABPM in order to facilitate implementation of the ABPM recommendations in practice.

3. NICE has also incorporated the guideline into its hypertension Pathway. NICE Pathways are online tools for health and social care professionals that bring together all related NICE guidance and associated products in a set of interactive topic-based diagrams. The NICE Pathway on hypertension is available at http://pathways.nice.org.uk/pathways/hypertension

About hypertension

1. Primary hypertension is remarkably common in the UK population, its prevalence being strongly influenced by age and lifestyle factors. At least one quarter of the UK population have blood pressure greater than or equal to 140/90mmHg - the threshold used for diagnosis - and more than half of those over the age of 60 years.

2. Because this guideline update recommends using the ABPM daytime average BP (calculated using a minimum of 14 daytime measurements) to confirm the diagnosis of hypertension for initiating treatment, it was necessary to define the ABPM daytime average pressures that are equivalent to the thresholds for stages 1 and 2 hypertension, previously defined according to CBPM readings alone. Thus:

Blood pressure measurement method Threshold for Stage 1 hypertension Threshold for Stage 2 hypertension
Clinic blood pressure reading 140/90mmHg 160/100mmHg
Ambulatory blood pressure reading 135/85mmHg 150/95mmHg

3. Healthcare providers must ensure that devices for measuring blood pressure are properly validated, maintained and regularly recalibrated according to manufacturers' instructions

4. White Coat Hypertension (WCH) is reported to occur in as many as 25% of the population with hypertension (about 2 million people), especially where their BP is close to the threshold for diagnosis. It is more common in pregnancy and with increasing age. Failing to identify WCH makes inappropriate treatment for hypertension in normotensive patients a possibility. Similarly, hypertensive individuals can also exhibit WCH and may receive inappropriate dose titrations or additional antihypertensive agents. Patients have historically been enrolled in trials using clinic BP values, and these trials will almost certainly have included a proportion of patients with WCH. It is unknown whether benefits of treatment differ substantially in those with or without WCH.

5. The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke.

6. As the demographics of the UK shift towards an older, more sedentary and obese population, the prevalence of hypertension and its requirement for treatment will continue to rise.

7. Routine periodic screening for high blood pressure is now commonplace in the UK as part of the National Service Frameworks for cardiovascular disease prevention. Consequently, the diagnosis, treatment and follow-up of patients with hypertension is one of the most common interventions in primary care, accounting for approximately 12% of Primary Care consultation episodes and approximately £1 billion in drug costs in 2006.

About NICE

1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health

2. NICE produces guidance in three areas of health:

  • public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
  • health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
  • clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

3. NICE produces standards for patient care:

  • quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
  • Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients

4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.

About the British Hypertension Society

The British Hypertension Society provides a medical and scientific research forum to enable sharing of cutting edge research in order to understand the origin of high blood pressure and improve its diagnosis and treatment.

References

1. Devices that are programmed to allow blood pressure to be measured repeatedly during the day and night.

2. The Lancet, Early Online publication, Wed 24 Aug 2011

3. UK Blood Pressure Association

This page was last updated: 07 September 2012

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.