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NICE to look at lowering blood pressure targets in guidance overhaul



NICE has given the green light for a full update of its guidance on hypertension – including the potential introduction of lower blood pressure targets that could see GPs treating many more people with antihypertensive drugs.

It comes despite recent RCGP advice for GPs to only treat hypertension if blood pressure is consistently above the current NICE-recommended threshold of 140/90 mmHg, as part of the Choosing Wisely campaign aimed at cutting down on unnecessary treatments.

Pulse previously revealed that NICE experts were considering new evidence on lowering blood pressure to a target of 120mmHg in high-risk patients, as part of a review of the current guidance published in 2011.

Having concluded the review, NICE has now announced that it will carry out a full update of the guidelines and confirmed to Pulse that this will consider new evidence on blood pressure targets as part of revisions to the guidelines section on ‘initiating and monitoring antihypertensive drug treatment, including blood pressure targets’.

The update will also take in new evidence on management of blood pressure in people with type 2 diabetes, previously covered in the condition-specific NICE guidelines on diabetes.

Dr Terry McCormack, secretary of the British Hypertension Society and a GP in Whitby, North Yorkshire, was involved in the reappraisal of the guidelines in his role as NICE topic expert advisor.

He told Pulse that the full update ‘will include targets, fourth line therapy, lifestyle and diabetes’ and that the review of blood pressure targets ‘will specifically evaluate SPRINT’.

But he noted it was unlikely to reduce the target to as low as 120mmHg and would likely included recommendations on more intensive drug treatment, and adherence. 

Dr McCormack said: ‘The actual achieved target was closer to 130mmHg. The average number of drugs in each arm were 2.8 and 1.8 which is more significant in my mind.’

He added: ‘They also stopped drugs in the “standard” treatment arm, mostly diuretics.’

As Pulse reported, the SPRINT trial was a large US study that reported that treating high-risk patients with hypertension to a systolic target of 120mmHg cut mortality and cardiovascular events, when compared with treatment to the usual 140mmHg goal.

At the time, GP cardiovascular experts said the trial could ‘fundamentally change’ GPs’ practice, and academics who carried out a meta-analysis of new trials evidence including SPRINT have since called on NICE to introduce the lower target in guidelines.

Currently NICE recommends GP should offer antihypertensive treatment to people with stage 1 hypertension (140-159mmHg) if they have an additional risk factor such as existing heart disease or diabetes, and to aim for a target clinic blood pressure below 140/90 mmHg in those aged under 80 years.

A NICE spokesperson said: ‘A full scoping exercise will be carried out on this topic, so the exact recommendations to be updated will be identified during that process based primarily on the areas for update we identified during surveillance. One of those areas was initiating and monitoring which includes blood pressure targets.’

The guidelines update could also see the introduction of new recommendations on self-management, following evidence showing that getting patients to self-titrate their blood pressure medications can help high-risk groups improve control of their blood pressure.

Other areas that will be updated include lifestyle recommendations, with new evidence emerging for specific interventions, choice of antihypertensive – in particular, fourth-line options – and the optimal timing of treatment, after studies showed evening doses may improve patient outcomes.

NICE is also extending the scope of the guidelines to take in management of blood pressure in people with type 2 diabetes – previously considered under the condition specific guidance – and secondary care of malignant hypertension.

The RCGP declined to comment until the updated NICE guidance is published.

Emerging evidence on hypertension

SPRINT was a randomised controlled trial included more than 9,000 patients, typically aged around 70 and with at least one cardiovascular risk factor – but not diabetes – and an average baseline blood pressure of 139/78mmHg.

Results – unveiled provisionally last year and subsequently published in the New England Journal of Medicine – showed that, on average, patients who received an intensive treatment regimen got their systolic blood pressure down to around 121mmHg, compared with around 136mmHg in the standard treatment group.

Cardiovascular events or death were reduced 25% in the intensive treatment group compared with standard treatment.

GP experts previously told Pulse the new evidence could have ‘major implications’ for general practice.

However, the RCGP recently reinforced the current NICE target, calling for GPs to only treat hypertension in people with drugs if blood pressure is consistently above 140/90 mmHg and they have additional risk factors.

According to RCGP leads on Choosing Wisely, there is a tendency for people to be treated more aggressively than this owing to the legacy of earlier, lower targets – such as previous audit blood pressure levels in QOF that have now been retired.