Revised NICE advice on hypertension a 'missed opportunity'

A revised NICE guideline on hypertension could see hundreds of thousands more people offered BP-lowering drugs - but experts have called the advice a 'missed opportunity' for some high-risk patients.

BP check (Photo: stockvisual/Getty Images)
BP check (Photo: stockvisual/Getty Images)

Guidance on diagnosis and management of hypertension in adults published on Wednesday halves the CVD risk threshold for prescribing BP-lowering medication, in what NICE called the 'biggest change' to its hypertension advice.

Patients with stage 1 hypertension who have an estimated 10-year CVD risk of 10% should now be offered BP-lowering drugs according to the revamped advice, which ditches the previous 20% threshold.

The move could see hundreds of thousands more people offered medication to lower BP - with an estimated 450,000 men and 270,000 women in the 10-20% risk range. Although research suggests that as many as half of these patients may already be receiving BP-lowering drugs, the new advice is still expected to trigger a significant change.

Hypertension guideline

However, responding to the revamped guideline, the British and Irish Hypertension Society (BIHS) called it 'rather conservative' compared with the latest advice in the US and Europe.

BIHS president Professor Francesco P Cappuccio, professor of cardiovascular medicine at the University of Warwick, 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.'

He cited figures showing that around 6.5m people in England and Wales have pre-existing CVD 'of whom 89% have hypertension'.

Overdiagnosis

Professor Cappucio added: 'Ninety-seven percent are treated for hypertension, and only 6 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.'

The RCGP has urged caution over a potential large increase in prescribing of BP-lowering drugs. The college warned earlier this year that GPs 'have concerns about overdiagnosis and the unintended harms of prescribing medication to groups of patients when the benefits may be limited'.

High BP affects around 13.5m people in England and contributes to around 75,000 deaths a year. Clinical management of hypertension accounts for 12% of visits to primary care and up to £2.1bn of healthcare expenditure, NICE said.

Anthony Wierzbicki, consultant in metabolic medicine/chemical pathology and chair of the guideline committee, has said of the updated guidance: 'The guideline effectively shifts the focus to earlier intervention with lifestyle or drug treatment because this may slow the age-related deterioration of blood pressure. This would keep people well for longer and reduce the long-term need for multiple medications.

'It unifies and simplifies the advice given to GPs in implementing the NHS health check and it supports the NHS long-term plan’s aim to improve chronic disease prevention. The guideline also places a greater emphasis on achieving and maintaining blood pressure targets as many people with high blood pressure are undertreated.'

Stage 1 hypertension is defined as a clinic blood pressure reading of 140/90 mmHg or higher, or an ambulatory blood pressure daytime average or home blood pressure monitoring average of 135/85 mmHg or higher.

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