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Changes to NICE hypertension guidelines to go ahead despite workload concerns

Amendments to NICE guidance for the management of blood pressure in patients at risk of CVD will go ahead despite GP concerns about increasing workload. 

NICE has recognised the new guidelines will have a ‘significant impact’ on GP practices. 

Earlier this year, NICE announced draft plans to lower the threshold for considering treatment for the under-80s with a stage one of hypertension and a risk of cardiovascular disease (CVD) of 10% or more. 

The plans were confirmed today in a final version of the guidance, which NICE said had no significant changes as a result of the consultation. 

GPs previously said they were ‘already working flat out‘ managing patients’ CVD risk and that extra funding would be required to cope with any additional workload.

Under the new guidelines, which replace the 2011 version, NICE has recommended offering anti-hypertensive drug treatment to stage one hypertension patients under the age of 80 who have an estimated 10-year risk of CVD of 10% or more – a reduction on the previous ‘20% or greater’ threshold.

NICE has said the move will have ‘a significant impact’ on practices as more people will be eligible for treatment. 

The guidelines state: ‘The committee were confident that people under 80 with stage one hypertension and a cardiovascular risk above 10% should have a discussion with their healthcare professional about starting antihypertensive treatment, alongside lifestyle changes, and that this would be a clinically and cost effective use of NHS resources.

‘The committee also agreed that antihypertensive treatment should be considered for people under 60 with a risk below 10%, with the degree of uncertainty in treating people at low risk reflected in the strength of the recommendation.’

At the moment, it is estimated that around 50% of people diagnosed with stage one hypertension and risk below 20% are already being treated with antihypertensive drugs.  

NICE said the changes will result in an increasing number of people needing treatment but could not estimate the extent of the impact on practices. 

The guidelines said: ‘The recommendations will have a significant impact on practice because more people will now be eligible for treatment. It is difficult to predict the extent of the impact because there is variability in how the 2011 recommendation with a threshold of 20% is being implemented in practice.

‘People with stage one hypertension should already be monitored every year, but reducing the threshold will increase the number of people being prescribed antihypertensive drugs and increase staff time and consultations involved in starting and monitoring their drug treatment. However, there will be a reduction in cardiovascular events resulting in savings, although it is acknowledged that the costs and savings may fall in different sectors of the NHS.’

Despite a number of studies acknowledging there are benefits of treating people with stage one hypertention, NICE pointed out that evidence is still lacking, saying the benefit of treatment across different cardiovascular risk groups remains ‘uncertain’. 

BMA GP committee executive team clinical and prescribing lead Dr Farah Jameel said: ‘It’s important that patients with hypertension are diagnosed as early as possible, and that the latest clinical guidelines for managing high blood pressure are evidence-based – so in many ways these refreshed guidelines are helpful.

‘GPs treat patients as individuals, rather than as a whole population, and there is a fine balance between aiming for targets across population groups and allowing doctors to take into account the personal situation of the patient in front of them. It is therefore positive that the new guidelines take this into consideration, where for those less at risk, a discussion about pros and cons rather than an offer of treatment is encouraged.’

She added: ‘As we have said before, GPs are already working flat-out treating patients with increased cardiovascular risk, and as NICE itself recognises, these changes have significant workload implications – with potentially hundreds of thousands more patients now in scope for treatment who weren’t before. Any additional workload created as a result must be fully resourced.

‘Of course, we should always avoid overmedicalisation and discuss management plans – including a range of non-pharmacological options – with the patient, based on their individual circumstances.’

A study published in 2017, which analysed nearly 40,000 low-risk patients across England, found not only that there was no benefit to treating such patients with anti-hypertensive medication but also it had the potential to cause ‘harm’.

Treatment recommendations  

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage two hypertension. Use clinical judgement for people of any age with frailty or multimorbidity, (see also NICE’s guideline on multimorbidity). [2019]

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with 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.

Discuss with the person their individual cardiovascular disease risk and their preferences for treatment, including no treatment, and explain the risks and benefits before starting antihypertensive drug treatment. Continue to offer lifestyle advice and support them to make lifestyle changes (see the section on lifestyle interventions) whether or not they choose to start antihypertensive drug treatment. [2019]

Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage one hypertension and an estimated 10-year risk below 10%. Bear in mind that 10-year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease. [2019]

Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with a clinic blood pressure of over 150/90 mmHg. Use clinical judgement for people with frailty or multimorbidity (see also NICE’s guideline on 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