Training, technique and device maintenance

1.1.1.

Ensure that healthcare professionals taking blood pressure measurements have adequate initial training and periodic review of their performance. [2004]

1.1.2.

Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. [2011]

1.1.3.

Healthcare providers must ensure that devices for measuring blood pressure are properly validated, maintained and regularly recalibrated according to manufacturers’ instructions. See the British and Irish Hypertension Society’s website for a list of validated blood pressure monitoring devices. [2004]

1.1.4.

When measuring blood pressure in the clinic or in the home, standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. Use an appropriate cuff size for the person’s arm. [2011, amended 2019]

Postural hypotension

1.1.5.

In people with symptoms of postural hypotension, including falls or postural dizziness:

• measure blood pressure with the person lying on their back (or consider a seated position, if it is inconvenient to measure blood pressure with the person lying down)
• measure blood pressure again after the person has been standing for at least 1 minute. [2004, amended 2023]

1.1.6.

If the person’s systolic blood pressure falls by 20 mmHg or more, or their diastolic blood pressure falls by 10 mmHg or more, after the person has been standing for at least 1 minute:

• consider likely causes, including reviewing their current medication
• manage appropriately (for example, for advice on preventing falls in older people, see NICE’s guideline on falls in older people: assessing risk and prevention)
• measure subsequent blood pressures with the person standing
• consider referral to specialist care if symptoms of postural hypotension persist despite addressing likely causes. [2004, amended 2023]

1.1.7.

If the blood pressure drop is less than the thresholds in recommendation 1.1.6 despite suggestive symptoms and the baseline measurement was previously taken from a seated position, repeat the measurements this time starting with the person lying on their back. [2023]

1.1.8.

Consider referring the person for further specialist assessment if blood pressure measurements do not confirm postural hypotension despite suggestive symptoms. [2023]

Annual blood pressure measurement for people with type 2 diabetes

1.2.11.

Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed hypertension or renal disease. Offer and reinforce preventive lifestyle advice. [2009]

Specialist investigations for possible secondary causes of hypertension

1.2.12.

Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. [2004, amended 2011]

Lifestyle interventions

For guidance on the prevention of obesity and cardiovascular disease, see NICE’s guidelines on obesity prevention and cardiovascular disease prevention.

1.4.1.

Offer lifestyle advice to people with suspected or diagnosed hypertension, and continue to offer it periodically. [2004]

1.4.2.

Ask about people’s diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes. [2004]

1.4.3.

Ask about people’s alcohol consumption and encourage a reduced intake if they drink excessively, because this can reduce blood pressure and has broader health benefits. See the recommendations for practice in NICE’s guideline on alcohol-use disorders. [2004, amended 2019]

1.4.4.

Discourage excessive consumption of coffee and other caffeine-rich products. [2004]

1.4.5.

Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. Note that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease and people taking some antihypertensive drugs, such as ACE inhibitors and angiotensin II receptor blockers. Encourage salt reduction in these groups. [2004, amended 2019]

1.4.6.

Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure. [2004]

1.4.7.

Offer advice and help to smokers to stop smoking. See NICE’s guideline on tobacco. [2004]

1.4.8.

Inform people about local initiatives by, for example, healthcare teams or patient organisations that provide support and promote healthy lifestyle change, especially those that include group work for motivating lifestyle change. [2004]

Starting antihypertensive drug treatment

NICE has produced a patient decision aid on treatment options for hypertension to help people and their healthcare professionals discuss the different types of treatment and make a decision that is right for each person.

For advice on shared decision making for medicines, see the information on patient decision aids in NICE’s guideline on medicines optimisation.

To support adherence and ensure that people with hypertension make the most effective use of their medicines, see NICE’s guideline on medicines adherence.

1.4.9.

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity (see also NICE’s guideline on multimorbidity). [2019]

1.4.10.

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 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.
  Use clinical judgement for people with frailty or multimorbidity (see also NICE’s guideline on multimorbidity). [2019]

1.4.11.

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]

1.4.12.

Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 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]

1.4.13.

Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with stage 1 hypertension if their clinic blood pressure is over 150/90 mmHg. Use clinical judgement for people with frailty or multimorbidity (see also NICE’s guideline on multimorbidity). [2019]

1.4.14.

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]

Monitoring treatment and blood pressure targets

For specific recommendations on blood pressure control in people with other conditions or who are pregnant, see NICE’s guidelines on chronic kidney disease, type 1 diabetes and hypertension in pregnancy.

See also table 1 for clinic blood pressure targets for people aged under 80 and table 2 for clinic blood pressure targets for people aged 80 and over. The tables cover people with hypertension (with or without type 2 diabetes) as well as people with chronic kidney disease or type 1 diabetes.

Table 1

Clinic blood pressure targets for people aged under 80.

Table 2

Clinic blood pressure targets for people aged 80 and over.

1.4.15.

Use clinic blood pressure measurements to monitor the response to lifestyle changes or drug treatment in people with hypertension. [2019]

1.4.16.

Check for postural hypotension (see recommendation 1.1.5) in people with hypertension and:

• type 2 diabetes or
• symptoms of postural hypotension (see also recommendation 1.1.7) or
• aged 80 and over.
  In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure. [2019, amended 2023]

1.4.17.

Advise people with hypertension who choose to self-monitor their blood pressure to use HBPM. (NHS England is supporting the use of HBPM through the blood pressure@home scheme.) [2019]

1.4.18.

Consider ABPM or HBPM, in addition to clinic blood pressure measurements, for people with hypertension identified as having a white-coat effect or masked hypertension (in which clinic and non-clinic blood pressure results are conflicting). Be aware that the corresponding measurements for ABPM and HBPM are 5 mmHg lower than for clinic measurements (see recommendation 1.2.8 for diagnostic thresholds). [2019]

1.4.19.

For people who choose to use HBPM, provide:

• training and advice on using home blood pressure monitors
• information about what to do if they are not achieving their target blood pressure.
  Be aware that the corresponding measurements for HBPM are 5 mmHg lower than for clinic measurements (see recommendation 1.2.8 for diagnostic thresholds). [2019]

1.4.20.

For adults with hypertension aged under 80, reduce clinic blood pressure to below 140/90 mmHg and ensure that it is maintained below that level. See also table 1 for guidance on clinic blood pressure targets for people aged under 80 with type 1 diabetes or severe chronic kidney disease. [2019, amended 2022]

1.4.21.

For adults with hypertension aged 80 and over, reduce clinic blood pressure to below 150/90 mmHg and ensure that it is maintained below that level. Use clinical judgement for people with frailty or multimorbidity (see NICE’s guideline on multimorbidity). See also table 2 for guidance on clinic blood pressure targets for people aged 80 and over with type 1 diabetes or severe chronic kidney disease. [2019, amended 2022]

1.4.22.

When using ABPM or HBPM to monitor the response to treatment in adults with hypertension, use the average blood pressure level taken during the person’s usual waking hours (see recommendations 1.2.6 and 1.2.7). Reduce blood pressure and ensure that it is maintained:

• below 135/85 mmHg for adults aged under 80
• below 145/85 mmHg for adults aged 80 and over.
  Use clinical judgement for people with frailty or multimorbidity (see also NICE’s guideline on multimorbidity). [2019, amended 2022]

1.4.23.

Use the same blood pressure targets for people with and without cardiovascular disease. [2022]

1.4.24.

Provide an annual review of care for adults with hypertension to monitor blood pressure, provide people with support, and discuss their lifestyle, symptoms and medication. [2004]

Choosing antihypertensive drug treatment (for people with or without type 2 diabetes)

The recommendations in this section apply to people with hypertension with or without type 2 diabetes. They replace the recommendations on diagnosing and managing hypertension in NICE’s guideline on type 2 diabetes in adults. For guidance on choosing antihypertensive drug treatment in people with type 1 diabetes, see also the section on control of cardiovascular risk in NICE’s guideline on type 1 diabetes.

1.4.26.

For guidance on choice of hypertensive agent in people with chronic kidney disease, see NICE’s guideline on chronic kidney disease. If possible, offer treatment with drugs taken only once a day. [2004]

1.4.27.

Prescribe non-proprietary drugs if these are appropriate and minimise cost. [2004]

1.4.28.

Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure. [2004]

1.4.29.

Offer antihypertensive drug treatment to women of childbearing potential with diagnosed hypertension in line with the recommendations in this guideline. For women considering pregnancy or who are pregnant or breastfeeding, manage hypertension in line with the recommendations on management of pregnancy with chronic hypertension, and on antihypertensive treatment while breastfeeding in NICE’s guideline on hypertension in pregnancy. [2010, amended 2019]

1.4.30.

When choosing antihypertensive drug treatment for adults of Black African or African–Caribbean family origin, consider an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor. [2019]

Follow the MHRA safety advice on ACE inhibitors and angiotensin II receptor antagonists: not for use in pregnancy, how to use for breastfeeding and clarification on breastfeeding.

1.4.31.

For people with cardiovascular disease:

• Follow the recommendations for disease-specific indications in the NICE guideline on their condition (for example, when prescribing an ACE inhibitor or an ARB for secondary prevention of myocardial infarction). Relevant recommendations include:

  –

  drug therapy for secondary prevention in NICE’s guideline on acute coronary syndromes

  –

  treatment after stabilisation in NICE’s guideline on acute heart failure

  –

  treating heart failure with reduced ejection fraction in NICE’s guideline on chronic heart failure

  –

  drugs for secondary prevention of cardiovascular disease in NICE’s guideline on stable angina

  –

  blood pressure management in NICE’s guideline on type 1 diabetes in adults.

• If their blood pressure remains uncontrolled, offer antihypertensive drug treatment in line with the recommendations in this section. [2022]

Why the committee made the recommendations

Overall, there was limited new evidence on the accuracy of different methods of measuring blood pressure. Most of the studies identified were small, and the populations and protocols for measurement varied making interpretation difficult. However, the committee agreed that it was important to focus on the evidence from these more recent studies (post-2000) because the evidence should reflect the current use of electronic sphygmomanometers, which have replaced mercury-based sphygmomanometers.

The evidence did not show that changing the current blood pressure thresholds for clinic measurement or home blood pressure monitoring (HBPM) would improve diagnostic accuracy compared with ambulatory blood pressure monitoring (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.

Limited evidence suggested that clinic blood pressure measurement is less accurate than HBPM or ABPM when used to diagnose hypertension. The committee members acknowledged that these findings were in line with their clinical experience and agreed that clinic blood pressure measurement alone would not be an adequate method to diagnose hypertension.

The committee discussed repeat clinic blood pressure measurements when there is a difference in blood pressure between arms and noted that clinical practice varied. Based on their experience and knowledge, the committee members agreed that a cut-off of 15 mmHg would be more suitable than 20 mmHg, which was specified in the 2011 recommendations. This is in line with recent evidence that suggests a small difference in arm blood pressure is associated with an increased risk of cardiovascular events, possibly due to vascular damage.

ABPM correlates well with invasive blood pressure measurement and can identify both white-coat and masked hypertension. Based on the evidence in the 2011 guideline and the committee’s experience and knowledge, it was agreed that ABPM remains the gold standard for the accurate measurement of blood pressure in primary care. ABPM has therefore been retained as the preferred method for the diagnosis of hypertension. In addition, economic evidence obtained by updating the health economic model for the 2011 guideline confirmed that ABPM is still likely to be the most cost-effective method for diagnosis, even with the inclusion of new data for improved accuracy of home and clinic measurement.

The evidence showed that validated HBPM is an accurate method of diagnosing hypertension for people in sinus rhythm. The committee’s experience in clinical practice supported this, and the committee agreed that it is a suitable alternative when ABPM is unsuitable or not tolerated. The committee noted that the British and Irish Hypertension Society maintains a list of validated blood pressure devices for home use. The British and Irish Hypertension Society is an independent reviewer of published work and this does not imply any endorsement of specific devices by NICE.

The evidence did not suggest that there were any benefits of adding telemonitoring to HBPM. Therefore, the committee agreed that it could not make a recommendation on telemonitoring for the diagnosis of hypertension.

How the recommendations might affect practice

The recommendations reinforce current good practice. However, the committee noted that implementation of the 2011 recommendations on ABPM has been challenging and that there is still variation in practice. A change in practice and additional resources and training will be needed in areas where there is currently no access to ABPM devices. However, ABPM was found to be the most cost-effective method of diagnosis, and it is anticipated that the long-term benefits of accurate diagnosis and treatment (such as avoiding over diagnosis and unnecessary treatment) will outweigh any initial costs.

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Why the committee deleted the recommendation on relaxation therapies

The evidence on relaxation therapies was limited to a single small study. The study suggested some benefit in reducing angina and myocardial infarction, but it also suggested an increase in stroke. The committee agreed that the study was not adequate to assess the effectiveness of these therapies or to make a recommendation.

The 2011 guideline stated that relaxation therapies could reduce blood pressure, but it did not recommend their routine use in practice. The committee noted that this was based on evidence for reducing blood pressure only, and there was no evidence of a direct benefit to people with hypertension, such as improving quality of life or reducing cardiovascular events. The committee agreed there was insufficient evidence of benefit to recommend that people pursue this option themselves and agreed to remove this recommendation. It is not the intention of the committee to stop people from trying relaxation therapies if they wish to, but to make people aware that there is less evidence for benefit of this intervention compared with other lifestyle interventions or pharmacological treatment. The committee agreed that the clinical focus for non-pharmacological treatment of hypertension should be on encouraging people to make lifestyle changes, such as taking regular exercise and maintaining a healthy weight.

The committee agreed that further research would be useful to determine whether relaxation therapies are a clinically effective treatment for hypertension in terms of reducing cardiovascular events or improving quality of life (see the recommendation for research on relaxation therapies). They also noted that a larger study would be needed to obtain meaningful results.

How this might affect practice

Relaxation therapies were not recommended for routine use in the 2011 guideline, and they are not used in current practice for the management of primary hypertension in adults. The 2011 recommendation advised that people may try them as part of their treatment to reduce blood pressure, but committee consensus was that uptake has been low. Therefore, current practice will not be affected by the removal of the 2011 recommendation.

Why the committee made the recommendations

The evidence suggested that antihypertensive drug treatment was effective at reducing cardiovascular events in people with a clinic blood pressure of 160/100 mmHg or more (stage 2 hypertension).

A large study also suggested there was benefit of treating people with stage 1 hypertension. However, other studies in people with a low cardiovascular risk did not identify a benefit of treatment, and the committee agreed that the benefit of treatment across different cardiovascular risk groups was uncertain. The evidence was used to develop an economic model to compare the cost effectiveness of antihypertensive treatment with no treatment in people with stage 1 hypertension at different levels of cardiovascular risk. For people aged 60, the model showed that treatment was cost effective at a 10-year cardiovascular risk level of 10%, but there was some uncertainty at around 5% risk. Further analysis showed that it was cost effective to offer antihypertensive treatment to people aged 40 and 50 with stage 1 hypertension at a 5% risk and aged 70 and 75 at a 10% or 15% risk. QRISK was specified as the risk tool because it is recommended by NICE for risk calculation and most likely to be used in practice.

Taking into account the evidence and the results of the model, the committee were confident that people under 80 with stage 1 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.

The committee members were mindful of the additional population that would be affected by lowering the threshold and were aware that the decision to start drug treatment would depend on the person’s preferences and their individual risk of cardiovascular disease. The recommendations highlight the importance of discussing the person’s preferences for treatment and encouraging lifestyle changes.

Some studies investigated the benefits of treating hypertension in people with lower cardiovascular risk or people with blood pressure below 140/90 mmHg. However, some of these studies were not directly relevant because they included a high proportion of participants with chronic kidney disease and previous cardiovascular events. For this reason, several studies could not be used to inform the recommendations. For details of these studies see evidence review C: initiating treatment.

The committee discussed the lack of evidence to inform a threshold for starting treatment in people aged under 40. It was agreed that this is an important area for future research and the recommendation for research was carried forward from the 2011 guideline (see the recommendation for research on thresholds for interventions in adults aged under 40).

The committee agreed that there was no evidence to suggest that thresholds for starting treatment should be different in people with type 2 diabetes. The previous recommendations for people with type 2 diabetes (in NICE’s guideline on type 2 diabetes in adults) suggested starting antihypertensive drug treatment if lifestyle interventions alone did not reduce blood pressure to below 140/80 mmHg or 130/80 mmHg in the presence of kidney, cerebrovascular or eye disease. However, this was based on evidence from 2 small studies in which the participants did not have hypertension. Further evidence for lower treatment thresholds in people with type 2 diabetes was limited within this review, with the committee aware of some evidence to suggest that lower blood pressure thresholds did not reduce the rate of cardiovascular events in people without additional risk factors. The committee therefore agreed that there was insufficient evidence to recommend a different threshold for starting treatment for this subgroup.

There was no evidence identified on thresholds for people aged over 80, and no prior recommendation for this age group with hypertension below stage 2; therefore, the committee agreed that the threshold for starting treatment in people aged over 80 should be consistent with the target for treatment in this population (150/90 mmHg or lower).

The committee discussed the additional risks of starting treatment in older people, particularly those who are frail or have multiple comorbidities. Based on their expertise and experience, they agreed that the use of clinical judgement should be highlighted in decision making for people with frailty or multimorbidity, and that it should apply to people of any age. The committee agreed that a number of factors should be considered when discussing treatment options in this group and noted that healthcare professionals should refer to NICE’s guideline on multimorbidity for further advice.

How the recommendations might affect practice

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. However, it is believed, based on some recently published UK data, that potentially around 50% of people with stage 1 hypertension and risk below 20% are already being treated with antihypertensive drugs (Association of guideline and policy changes with incidence of lifestyle advice and treatment for uncomplicated mild hypertension in primary care. Sheppard et al. 2018).

People with stage 1 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.

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Monitoring treatment

Blood pressure targets for people without cardiovascular disease

Recommendations 1.4.15 to 1.4.22

Blood pressure targets for people with cardiovascular disease

Recommendation 1.4.23

Why the committee made the recommendation

New evidence in this area was not reviewed as part of the 2022 update. Instead, the evidence from previous versions of the guideline was reassessed to look at outcomes for people with cardiovascular disease. Only evidence up to 2010 was re-analysed, because the 2019 update did not review evidence for people with cardiovascular disease.

There was no difference in clinically relevant outcomes between people with and without cardiovascular disease.

Evidence was limited for people with stroke, transient ischaemic attack, or coronary artery disease. This evidence did not cover enough treatment comparisons to allow the committee to draw any firm conclusions.

There are NICE guidelines on acute coronary syndromes and chronic heart failure, and these guidelines make recommendations on drug treatment that overlap with treatment for hypertension. To avoid confusion over the treatment pathway, the committee highlighted that these condition-specific recommendations should be applied first (for example, when prescribing an ACE inhibitor or an ARB for secondary prevention of myocardial infarction).

How the recommendations might affect practice

The recommendation reflects current practice for most types of cardiovascular disease.

The committee were aware that, after a stroke, the thiazide-like diuretic indapamide is sometimes used first, rather than a calcium channel blocker. However, it is unclear how common this is. As people with cardiovascular disease are commonly prescribed more than 1 antihypertensive drug, any impact on prescribing would be limited.

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Why the committee made the recommendations

The committee reviewed the evidence for starting treatment for primary hypertension with a single antihypertensive medicine compared with starting with 2 antihypertensive medicines at once (dual therapy). Additionally, the committee reviewed the evidence on whether specific subgroups of people with hypertension might benefit from starting on dual therapy, for example people with type 2 diabetes, older people, or those of particular family origins.

Some limited evidence from a single study showed that initial dual therapy may reduce cardiovascular events in people with hypertension and type 2 diabetes, but the committee members were disappointed that more comprehensive data was not available. The committee discussed the benefits of optimising treatment for hypertension early and agreed that this can substantially improve quality of life. However, there was not enough evidence to determine confidently the benefits or harms of starting treatment with dual therapy. In response to the lack of available evidence, the committee developed a recommendation for research on step 1 treatment to determine if particular subgroups would benefit from starting dual therapy, to inform future guidance.

In the absence of compelling new evidence on step 1 dual therapy, the committee agreed that the previous recommendations for step 1 treatment should be retained (with minor changes for clarity), because they were based on robust clinical and cost-effectiveness evidence. One exception to this was the 2006 recommendation for considering beta-blockers in certain groups of younger people. The committee discussed this recommendation and agreed that beta-blockers are rarely used as step 1 antihypertensive treatment in current practice and there is no established relationship between beta-blocker use in primary hypertension and a reduction in cardiovascular events. For these reasons, the committee decided that the recommendation should not be retained. The committee noted that this is consistent with most international guidelines.

This guideline also updates and replaces the section on blood pressure management from NICE’s guideline on type 2 diabetes in adults. That guideline recommended that adults with type 2 diabetes of any age should start on an angiotensin-converting enzyme (ACE) inhibitor as step 1 treatment (except women with a possibility of becoming pregnant and people of Black African or African–Caribbean family origin). The committee discussed the evidence for this and agreed that it was sufficient to support and retain this recommendation. The committee agreed it should be broadened to include the choice of an ACE inhibitor or an angiotensin II receptor blocker (ARB; also referred to as A-type drugs), because they are now cost equivalent, and the committee also agreed they are clinically equivalent.

For people of Black African or African–Caribbean family origin with type 2 diabetes, the previous recommendation was to offer step 1 dual therapy with an ACE inhibitor and either a diuretic (D-type drug) or a calcium channel blocker (CCB; C-type drug). However, these recommendations were based on monotherapy studies and when the committee looked at this evidence alongside the new dual therapy evidence review, they concluded that it was insufficient to recommend starting dual therapy in any subgroup of people with type 2 diabetes. The committee noted that people with type 2 diabetes who are older or are of Black African or African–Caribbean family origin may not achieve their target blood pressure on ACE inhibitor or ARB monotherapy and may need to start step 2 drug therapy in the short term.

How the recommendations might affect practice

Overall, the recommendations for step 1 treatment reflect current practice for people who do not have type 2 diabetes. For people of Black African or African–Caribbean family origin who have type 2 diabetes, the recommendation to start antihypertensive monotherapy rather than dual therapy may result in an extra clinical appointment if the dose needs to be adjusted. However, it may also reduce potential harms from initial overtreatment of blood pressure.

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Why the committee made the recommendations

No evidence for step 2 or step 3 treatment was identified that was relevant to determining the best sequence for step 2 and step 3 antihypertensive treatment. Some of the studies available on drug treatments for hypertension were not included in this review because they were designed to inform step 1 treatment. Others did not reflect UK clinical practice. For details of these studies see evidence review F: step 2 and step 3 treatment.

Based on evidence from the previous version of the guideline and their clinical expertise, the committee members agreed to retain the same choice of drugs from the 2011 guideline, which reflect current best practice. The committee agreed that, in the absence of evidence of which treatment(s) are most effective for step 2 or step 3, the recommendation should be to offer any of these treatments based on an individualised approach informed by risks and benefits of each treatment and the person with hypertension’s preference.

The committee noted that the changes to the step 1 recommendations for some people with type 2 diabetes do not necessitate a change in the step 2 recommendations since the same options for combination treatment at step 2 are available.

The committee agreed that the choice of drug should be discussed and agreed with the person, based on the person’s step 1 treatment, the risks and benefits of each treatment option, and taking into account the person’s preferences and other clinical factors. The updated recommendations reflect this, giving the choice of possible treatment options. A NICE patient decision aid on treatment choices for high blood pressure has been developed to support healthcare professionals and people with hypertension to discuss their treatment options and make informed decisions.

How the recommendations might affect practice

The recommendations are unlikely to alter current practice. The options for drug treatment remain the same and most step 2 or 3 treatment decisions are already based on an individualised approach.

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Why the committee made the recommendations

No evidence on step 4 treatment was identified that could be used to formulate new recommendations. However, the committee reviewed the 2011 recommendations and agreed that they should be retained and updated to reflect current best practice.

The committee discussed the importance of confirming resistant hypertension before starting step 4 treatment. Based on their clinical experience and knowledge of best current practice, the committee members agreed that a recommendation to highlight this would help prevent overtreatment and ensure that people receive the right care.

Despite the lack of evidence formally reviewed, the committee discussed the recommendation based on their clinical experience, taking the 2011 recommendations into account. The committee agreed that although the evidence for spironolactone did not meet the criteria for inclusion in the updated review for the guideline because the key study had a very short follow up and did not report any of the cardiovascular outcomes specified in this review protocol, the use of an aldosterone antagonist is now common clinical practice. Therefore, there was no reason to suggest that this recommendation should be changed.

In the 2011 guideline, high-dose thiazide diuretics were recommended as a potential step 4 treatment in people with high blood potassium levels. The committee felt that there was a lack of evidence for this approach and noted that the studies did not show an improvement in cardiovascular outcomes at higher doses, albeit in people without resistant hypertension. The committee agreed that the recommendation for considering alpha- or beta-blockers should be retained based on significant clinical experience of their safe and effective use and because adding a further drug is likely to have a greater effect on blood pressure than increasing the thiazide diuretic dose.

How the recommendations might affect practice

The recommendations represent current good practice and so should not change practice. High-dose thiazide diuretics are not commonly used as step 4 therapy and so removing this should not change practice.

There might be a small reduction in step 4 treatment with more thorough checks to confirm resistant hypertension. However, this may also result in an increase in blood pressure measurements to appropriately confirm resistant hypertension where this is not already being done.

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Why the committee made the recommendations

There was no evidence identified to inform recommendations on this topic. The committee reviewed the 2011 recommendations and agreed that they should be updated by consensus based on their clinical expertise. In particular they agreed it would be helpful to clarify which features warranted same-day referral, which would need further investigation and when repeat blood pressure measurement should be taken.

The committee noted that it can be difficult to differentiate between accelerated hypertension and severe hypertension. They discussed the advantages and disadvantages of broader criteria for same-day referral, which would increase referrals to hospital but reduce the risk of missing people who need urgent treatment. The committee decided it would be beneficial to add some emergency symptoms to the existing recommendation, which will help healthcare professionals to decide when to refer.

Based on their experience, the committee members agreed that some people with severe hypertension could be receiving unnecessary treatment because the 2011 guideline recommended treatment based on severe hypertension alone. The committee agreed that this could be prevented if investigations for target organ damage were carried out quickly before offering treatment in people with severely raised blood pressure and no other symptoms of concern. The committee also agreed that checking blood pressure again within 7 days in people with no target organ damage would ensure that people with severe hypertension are followed up and offered suitable treatment.

The committee agreed that further research is needed in this area, particularly for people with extreme hypertension (220/120 mmHg or higher) or emergency symptoms. The committee members developed a recommendation for research on same-day hospital specialist assessment to help inform future recommendations.

How the recommendations might affect practice

The emergency symptoms listed in the recommendation may lead to more referrals to hospital. However, people with emergency symptoms will benefit from urgent treatment because accelerated hypertension can be fatal if untreated.

There may be some additional resource use from doing target organ damage tests more quickly and re-measuring blood pressure within 7 days. However, the number of people started on treatment immediately may be reduced because of undertaking investigations first.

The population with severe hypertension is very small, and the proportion with severe hypertension and additional symptoms that suggest accelerated hypertension is even smaller; therefore, resource impact is unlikely to be substantial.

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