1. BY
DR IJAZ HUSSAIN

2. AIM
• To discuss with colleagues the recent
changes in NICE guide lines for
management of Hypertension
• To share mutual knowledge and
experiences on the subject.

3. OBJECTIVE
• After this activity the colleagues will be able
to register latest changes in guide lines for
management of Hypertension and then
apply it in their day to day clinical life.

4. INTRODUCTION
• This guidance is a partial update of NICE clinical guideline 34
(published June 2006) and will replace it. NICE clinical
guideline 34 partially updated and replaced NICE clinical
guideline 18 (published August 2004).
• In this update new recommendations have been added on
blood pressure measurement, the use of ambulatory and
home blood pressure monitoring, blood pressure targets and
antihypertensive drug treatment.

5. • High blood pressure (hypertension) is one of the most important preventable
causes of premature morbidity and mortality in the UK. Hypertension is a
major risk factor for
– Stroke (ischaemic and haemorrhagic)
– Myocardial infarction
– Heart failure
– Chronic kidney disease
– Cognitive decline
– Premature death
• Untreated hypertension is usually associated with progressive rise in blood
pressure. The vascular and renal damage that may cause treatment-resistant
state.
INTRODUCTION

6. MOST IMP MODIFIABLE RISK FACTOR
• coronary heart disease (the leading cause of
death in North America)
• Stroke (the third leading cause)
• Congestive heart failure
• End-Stage renal disease
• Peripheral vascular disease.

7. BACKGROUND
• 50 million people are affected in USA alone
• 30 % of the adults are still unaware of their
hypertension
• 40 % of the diagnosed Pts are not using
adequate treatment
• 67 % of those who are being treated, do not
have their hypertension controlled under 140/
80 mm Hg.

8. Q: 52 Years old man seen in hypertension clinic. He
was diagnosed around three weeks ago and
started on Tab Ramipril. This has been titrated up
to 10 mg OD. His blood pressure remains around
156/92 mm Hg. What is most appropriate next step
in management.
• Add Bendroflumethiazide
• Add Bisoprolol
• Switch Ramipril to Prindopril
• Add Amlodipine
• Add Losartan

9. KEY POINTS
• Treatment and care should take into account
people’s needs and preferences. People with
hypertension should have the opportunity to make
informed decisions about their care and treatment,
in partnership with their healthcare professionals. If
people do not have the capacity to make decisions.

10. KEY POINTS
• Good communication between healthcare professionals and people
with hypertension is essential. It should be supported by evidence-
based written information tailored to the person’s needs.
Treatment, care, and the information being given, should be
culturally appropriate. It should also be accessible to people with
additional needs such as physical, sensory or learning
disabilities, and to people who do not speak or read English.
• If the person agrees, families and care givers should have the
opportunity to be involved in decisions about treatment and care.

11. DIAGNOSING HYPERTENSION
• If the first and second blood pressure
measurements taken during a consultation are
140/90 mmHg or higher, offer 24-hour ambulatory
blood pressure monitoring (ABPM) to confirm the
diagnosis of hypertension.
• If ambulatory blood pressure monitoring (ABPM) is
not acceptable to the patient then home BP
monitoring is advised

12. AMBULATORY BLOOD PRESSURE
MONITORING (ABPM)
• Blood pressure is measured for a total of 24 hours.
• At least two measurements per hour are taken
during the day (08:00 to 22:00).
• At least one measurement per hour is taken during
the night (22:00 to 08:00).
• Use the average daytime blood pressure
measurement, calculated using a minimum of 14
daytime measurements, to confirm a diagnosis of
hypertension.
When using ABPM to confirm a diagnosis of
hypertension, ensure that:

13. HOME BLOOD PRESSURE
MONITORING (HBPM)
• When using home blood pressure monitoring (HBPM) to confirm a
diagnosis of hypertension, ensure that:
• For each blood pressure measurement, two consecutive
measurements are taken, at least 1 minute apart and with the person
seated
• Blood pressure measurements are taken twice daily, ideally in the
morning and evening. Blood pressure measurement continues for at
least 4 days, ideally for 7 days.
• Discard the measurements taken on the first day and use the average
value of all the remaining measurements to confirm a diagnosis of
hypertension.

15. JNC - VII CLASSIFICATION
• Normal
– Systolic lower than 120, diastolic lower than 80
• Pre-hypertension
– Systolic 120-139, diastolic 80-90
• Stage 1
– Systolic 140-159, diastolic 90-99
• Stage 2
– Systolic equal to or more than 160, diastolic equal to or
more than 100

16. CLASSIFICATION
• Stage 1 hypertension:
Initial clinic blood pressure 140/90 mmHg or higher and subsequent
ambulatory blood pressure monitoring (ABPM) daytime average or
home blood pressure monitoring (HBPM) average blood pressure
135/85 mmHg or higher.
• Stage 2 hypertension:
Initial clinic blood pressure 160/100 mmHg or higher and subsequent
ABPM daytime average or HBPM average blood pressure 150/95
mmHg or higher.
• Severe hypertension:
Clinic blood pressure 180/110 mmHg or higher.

17. DIAGNOSIS PROTOCOL
Clinic BP Reading
– If a BP reading is >= 140 / 90 mmHg patients should be
offered ABPM to confirm the diagnosis.
– Patients with a BP reading of >= 180/110 mmHg should be
considered for immediate treatment.
Ambulatory blood pressure monitoring (ABPM)
– At least 2 measurements per hour during the person’s
usual waking hours (for example, between 08:00 and
22:00)
– Use the average value of at least 14 measurements

18. DIAGNOSIS PROTOCOL
If ABPM is not tolerated or declined HBPM should be offered.
• For each BP recording, two consecutive measurements need to
be taken, at least 1 minute apart and with the person seated
• BP should be recorded twice daily, ideally in the morning and in
the evening
• BP should be recorded for at least 4 days, ideally for 7 days
• Discard the measurements taken on the first day and use the
average value of all the remaining measurements

19. MANAGEMENT PROTOCOL
ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)
• Treat if < 80 years of age and any of the following apply;
– Target organ damage
– Established cardiovascular disease
– Renal disease,
– Diabetes Mellitus
– 10-year cardiovascular risk equivalent to 20% or greater
ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension)
• Offer drug treatment regardless of age
• For patients < 40 years consider specialist referral to exclude
secondary causes.

20. MANAGEMENT PROTOCOL
Step 1 treatment
• Patients < 55-years-old: ACE inhibitor (A)
• Patients > 55-years-old or of Afro-Caribbean origin: calcium channel
blocker
Step 2 treatment
• ACE inhibitor + calcium channel blocker (A + C)
Step 3 treatment
• Add a Thiazide Diuretic (D, i.e. A + C + D)
Note:
NICE now advocate using either Chlortalidone (12.5–25.0 mg once daily)
or Indapamide (1.5 mg modified-release once daily or 2.5 mg once daily)
in preference to a conventional Thiazide diuretic such as
Bendroflumethiazide

21. MANAGEMENT PROTOCOL
NICE define a clinic BP >= 140/90 mmHg after step 3 treatment with
optimal or best tolerated doses as Resistant Hypertension. They
suggest step 4 treatment or seeking expert advice
Step 4 treatment
• consider further diuretic treatment,
– If potassium < 4.5 mmol/l add Spironolactone 25mg od
– If potassium > 4.5 mmol/l add higher-dose Thiazide-like diuretic
treatment
• If further diuretic therapy is not tolerated, or is
contraindicated or ineffective, consider an alpha- or
beta-blocker
• If BP still not controlled seek specialist advice.

22. BLOOD PRESSURE TARGET
Clinic BP/ ABPM / HBPM
• Age < 80 years140/90 mmHg135/85
mmHg
• Age > 80 years150/90 mmHg145/85
mmHg Age < 80 Yrs 140/90 mm Hg
135/85 mm Hg
Age > 80 Yrs 150/90 mm Hg
145/85 mm Hg

23. NEW DRUG
• Direct Renin inhibitors e.g. Aliskiren (branded as Rasilez)
• by inhibiting renin blocks the conversion of angiotensinogen to
angiotensin I
• no trials have looked at mortality data yet. Trials have only investigated
fall in blood pressure. Initial trials suggest aliskiren reduces blood
pressure to a similar extent as angiotensin converting enzyme (ACE)
inhibitors or angiotensin-II receptor antagonists
• Adverse effects were uncommon in trials although diarrhoea was
occasionally seen
Only current role would seem to be in patients who are intolerant of more
established antihypertensive drugs