2 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

2.1 Out-of-office monitoring

In adults with primary hypertension, does the use of out-of-office monitoring (HBPM or ABPM) improve response to treatment?

Why this is important

There is likely to be increasing use of HBPM and for the diagnosis of hypertension as a consequence of this guideline update. There are, however, very few data regarding the utility of HBPM or ABPM as means of monitoring blood pressure control or as indicators of clinical outcome in treated hypertension, compared with clinic blood pressure monitoring. Studies should incorporate HBPM and/or ABPM to monitor blood pressure responses to treatment and their usefulness as indicators of clinical outcomes.

2.2 Intervention thresholds for people aged under 40 with hypertension

In people aged under 40 years with hypertension, what are the appropriate thresholds for intervention?

Why this is important

There is uncertainty about how to assess the impact of blood pressure treatment in people aged under 40 years with stage 1 hypertension and no overt target organ damage or cardiovascular disease (CVD). In particular, it is not known whether those with untreated hypertension are more likely to develop target organ damage and, if so, whether such damage is reversible. Target organ damage and CVD as surrogate or intermediate disease markers are the only indicators that are likely to be feasible in younger people because traditional clinical outcomes are unlikely to occur in sufficient numbers over the timescale of a typical clinical trial. The data will be important to inform treatment decisions for younger people with stage 1 hypertension who do not have overt target organ damage.

2.3 Methods of assessing lifetime cardiovascular risk in people aged under 40 years with hypertension

In people aged under 40 years with hypertension, what is the most accurate method of assessing the lifetime risk of cardiovascular events and the impact of therapeutic intervention on this risk?

Why this is important

Current short-term (10-year) risk estimates are likely to substantially underestimate the lifetime cardiovascular risk of younger people (aged under 40 years) with hypertension, because short-term risk assessment is powerfully influenced by age. Nevertheless, the lifetime risk associated with untreated stage 1 hypertension in this age group could be substantial. Lifetime risk assessments may be a better way to inform treatment decisions and evaluate the cost effectiveness of earlier intervention with pharmacological therapy.

2.4 Optimal systolic blood pressure

In people with treated hypertension, what is the optimal systolic blood pressure?

Why this is important

Data on optimal blood pressure treatment targets, particularly for systolic blood pressure, are inadequate. Current guidance is largely based on the blood pressure targets adopted in clinical trials but there have been no large trials that have randomised people with hypertension to different systolic blood pressure targets and that have had sufficient power to examine clinical outcomes.

2.5 Step 4 antihypertensive treatment

In adults with hypertension, which drug treatment (diuretic therapy versus other step 4 treatments) is the most clinically and cost effective for step 4 antihypertensive treatment?

Why this is important

Although this guideline provides recommendations on the use of further diuretic therapy for treatment at step 4 (resistant hypertension), they are largely based on post-hoc observational data from clinical trials. More data are needed to compare further diuretic therapies, for example a potassium-sparing diuretic with a higher-dose thiazide-like diuretic, and to compare diuretic therapy with alternative treatment options at step 4 to define whether further diuretic therapy is the best option.

2.6 Automated blood pressure monitoring in people with atrial fibrillation

Which automated blood pressure monitors are suitable for people with hypertension and atrial fibrillation?

Why this is important

Atrial fibrillation may prevent accurate blood pressure measurement with automated devices. It would be valuable to know if this can be overcome.

More information

You can also see this guideline in the NICE pathway on hypertension.

To find out what NICE has said on topics related to this guideline, see our web page on cardiovascular conditions.

See also the guideline committee's discussion and the evidence reviews (in the full guideline), and information about how the guideline was developed, including details of the committee.

  • National Institute for Health and Care Excellence (NICE)