NICE planning to reduce threshold for hypertension treatment

NICE has today published a draft update to its guideline on the diagnosis and treatment of high blood pressure in adults for public consultation.

“The guideline effectively shifts the focus to earlier intervention with lifestyle or drug treatment”

Anthony Wierzbicki

In the biggest change to the existing guidance drawn up in 2011, NICE has proposed reducing the threshold for cardiovascular risk at which treatment for hypertension should be started by clinicians.

The new draft recommends that blood pressure lowering drugs should be offered to people aged under 80 with stage 1 hypertension who have an estimated 10-year risk of CVD of 10% or more.

In contrast, the current 2011 guidance states that anti-hypertensive treatment should be started in those with an estimated 10-year CVD risk of 20% or more.

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.

It is estimated that around 450,000 men and 270,000 women would fall into the category of having stage 1 hypertension and a CVD risk of between 10% and 20%, said NICE.

However, it said it was difficult to predict what impact using the lower risk threshold would have in practice because there was variability in how the 2011 guidance was being implemented in practice.

“High blood pressure is the country’s leading cause of heart attacks and strokes”

Jamie Waterall

For example, NICE highlighted that some estimates suggested around 50% of patients in this group were already being treated with blood pressure lowering drugs.

NICE also considered new studies suggesting those with blood pressure below 140/90mmHg might also benefit from medication and what the effect would be of lowering the target for people on treatment.

However, some of these studies, which formed a key part of the evidence reviewed in other recent international hypertension guidelines, were difficult to interpret, according to the institute.

Although they recruited people with raised blood pressure who had increased CVD risk, they also included people who had other CVD risk factors, it said.

Therefore, these studies could not be directly used to inform the recommendations in this draft guidance, noted NICE.

Dr Anthony Wierzbicki, chair of the NICE committee that developed the draft guideline, said: “A rigorous evaluation of new evidence has resulted in updated recommendations around when to treat raised blood pressure that have the potential to make a real difference to the lives of many thousands of people.

“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,” he said. “This would keep people well for longer and reduce the long-term need for multiple medications.”

Professor Jamie Waterall, national lead for CVD prevention at Public Health England, said: “High blood pressure is the country’s leading cause of heart attacks and strokes yet millions remain undiagnosed.

“Diagnosing high blood pressure earlier and managing it in line with NICE guidance will save thousands of lives and years spent in ill-health,” he said.

“That’s why we’ve set new national ambitions to improve the detection and management of high blood pressure within the next decade,” he added.

In 2015, it was reported that hypertension affected 31% of men and 26% of women in England – around 13.5 million people – and contributed to 75,000 deaths.

In addition, the clinical management of hypertension accounts for 12% of visits to primary care and up to £2.1bn of healthcare expenditure.

NICE noted that, over the last decade, progress has been made to improve the diagnosis and management of hypertension.

The average blood pressure in England has fallen by about 3mmHg systolic and the proportion of adults with untreated high blood pressure has decreased.

However, Public Health England’s 2015 blood pressure action plan called for further measures to reduce average blood pressure by a further 5mmHg through improved prevention, detection and management.

The draft NICE guideline is open for public consultation until 23 April 2019. Final guidance is expected to be published in August 2019.