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NICE set to lower hypertension treatment thresholds for CVD patients

NICE is to reduce thresholds for considering high blood pressure treatment, including for patients with a risk of CVD, according to new draft guidelines.

However it will not lower thresholds for diagnosing hypertension – a move that was being considered and which could have seen a large proportion of the population assessed as having the condition.

GPs have said they are ‘already working flat out’ managing patients’ CVD risk and that additional funding would be required to deal with the any resulting extra workload.

The latest draft guidelines from NICE, which will replace the 2011 version, include a number of updates as to when patients should start treatment, including reducing the threshold for considering high blood pressure treatment for patients with a risk of CVD.

The draft said blood pressure lowering drugs should be offered to stage one hypertension patients under 80, who have an estimated 10-year risk of CVD of 10% or more, a reduction on the previous ‘20% or greater’ threshold.

Around 450,000 men and 270,000 women would fall into this category and could therefore require medication, NICE said.

However, due to ‘variability in how the 2011 recommendation with a threshold of 20% is being implemented in practice’, it’s estimated around 50% of people in this group are already being treated with blood pressure lowering drugs, NICE added.

Meanwhile, the new draft guidance said that despite recent studies showing the apparent benefit of reducing thresholds for diagnosing hypertension, the evidence was lacking and ‘difficult to interpret’.

NICE previously said it was considering the same evidence that led to drastically lowered hypertension thresholds in the US, and an additional 14% of the population classed as having high blood pressure.

The US guidance was updated last year, and included a sharp reduction in the threshold for stage one hypertension from an average systolic blood pressure of 140 to 130 mmHg, and from ≥160 to ≥140 mmHg for stage two.

The change was prompted by the 2015 SPRINT study, which showed that by treating patients with a target blood pressure of 120 mmHg, rather than the 140 mmHg target, mortality and cardiovascular events were significantly reduced.

But today’s draft NICE guidelines said: ‘The evidence did not show that changing the current blood pressure thresholds for clinic measurement or home blood pressure measurement (HBPM) would improve diagnostic accuracy compared with ambulatory measurement pressure measurement (ABPM), so the committee agreed the 2011 thresholds for diagnosis should be retained.

‘The committee noted that these are in line with most international guidance.’

NICE explained that while the committee considered the same studies as the US – which said people with blood pressure below 140/90mmHg might also benefit from medication – they were ‘difficult to interpret because although they recruited people with raised blood pressure who had increased CVD risk, they also included people who had other CVD risk factors such as established blood pressure-related organ damage from previous CVD, or chronic kidney disease’.

Professor Anthony Wierzbicki, guideline committee chair and consultant in metabolic medicine/chemical pathology, said: ‘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.

BMA GP committee clinical and prescribing lead Dr Andrew Green said: ‘This is an important consultation as it has enormous implications both for GP workload and also for individual patients.

‘It is extremely challenging for GPs to translate studies that show benefits to populations into advice for individuals, many of whom will not see any benefit from lifelong pharmacological intervention.

‘GPs are already working flat out on managing patients’ cardiovascular risk and recognise the impact that poorly managed blood pressure can have on individuals’ health, and any additional activity will need to be funded with extra resources. The BMA will consider this document carefully and contribute to the consultation in due course.’

RCGP chair Professor Helen Stokes-Lampard said: ‘Taking steps to prevent cardiovascular disease in patients is vital to help safeguard their long-term health and wellbeing, and it is a key pledge in the NHS long-term plan. But many GPs do also have concerns about overdiagnosis and the unintended harms of prescribing medication to groups of patients when the benefits may be limited.

‘Lowering the [cardiovascular] threshold for treating hypertension, or high blood pressure – a condition that already affects a very large number of patients in the UK – is likely to affect thousands, if not millions of patients, so this decision must not be taken lightly and must be evidence-based.’

A study published last November, which analysed nearly 40,000 low-risk patients across England, found not only was there no benefit to treating such patients with anti-hypertensive medication, it also had the potential to cause ‘harm’.

Treatment recommendations in full

Discuss with the person their preferences for treatment before starting antihypertensive drug treatment. Continue to offer lifestyle advice and support them to make lifestyle changes whether or not they choose to start antihypertensive drug treatment. [2019]

Offer antihypertensive drug treatment in addition to lifestyle advice to adults aged under 80 with persistent stage one hypertension who have one or more of the following:

  • target organ damage
  • established cardiovascular disease
  • renal disease
  • diabetes
  • an estimated 10-year risk of cardiovascular disease of 10% or more. [2019]

Offer antihypertensive drug treatment to adults of any age with persistent stage two hypertension. Use clinical judgement for people with frailty or multimorbidity. [2019]

Consider antihypertensive drug treatment in addition to lifestyle advice for 10 younger adults with stage one hypertension and an estimated 10-year risk 11 below 10%. Bear in mind that 10-year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease. [2019]

Consider starting antihypertensive drug treatment for people aged over 80 with stage one hypertension. Use clinical judgement for people with frailty or multimorbidity. [2019]

For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks. [2019]

Source: NICE hypertension in adults diagnosis and management