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The British Approach to Antihypertensive Therapy: Guidelines from the National Institute of Health and Clinical Excellence. Power Over Pressure www.poweroverpressure.com. Treatment guidelines provide a systematic approach to blood pressure (BP) management.

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The British Approach to Antihypertensive Therapy: Guidelines from the National Institute of Health and Clinical Excellence

Power Over Pressure

www.poweroverpressure.com

treatment guidelines provide a systematic approach to blood pressure bp management
Treatment guidelines provide a systematic approach to blood pressure (BP) management

In 2011, the National Institute of Health and Clinical Excellence (NICE) in the UK published a simple step-wise treatment algorithm for the initiation and optimization of antihypertensive therapy

National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

Power Over Pressure

www.poweroverpressure.com

a simple step wise algorithm to expedite bp control
A simple step-wise algorithm to expedite BP control

Patient ≥55 years old

OR

Any age black person of African or Caribbean origin

No

Initiate ACEI or ARB

Step 1

Yes

Initiate CCB

BP still above goal?

BP still above goal?

CCB + ACEI or ARB

Step 2

BP still above goal?

CCB + ACEI or ARB + thiazide-like diuretic

Step 3

BP still above goal?

  • Evaluate for treatment-resistant hypertension
  • Consider adding further diuretic or - or -blocker
  • Consider referral to a hypertension specialist

Step 4

ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin-receptor blocker; CCB = calcium channel blocker.

National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

Power Over Pressure

www.poweroverpressure.com

step 1 initiating treatment
Step 1: Initiating treatment
  • Initial treatment decisions should be based on patient’s age and race
    • Patients <55 years of age should start treatment with an ACEI oran ARB*
    • Patients 55 years of age and patients who are black of African or Caribbean origin, regardless of age, should initiate therapy with a CCB
    • In some cases, a CCB may not be suitable (eg, edema or intolerance)
      • If a CCB is not suitable or if there is evidence of heart failure or high risk of heart failure, a thiazide-like diuretic should be offered

Patient ≥55 years old

OR

Any age black person of African or Caribbean origin

No

Initiate ACEI or ARB

Step 1

Yes

Initiate CCB

BP still above goal?

BP still above goal?

CCB + ACEI or ARB

Step 2

BP still above goal?

CCB + ACEI or ARB + thiazide-like diuretic

Step 3

BP still above goal?

Practice Tip: Once drug therapy is initiated, patients should return for follow-up and adjustment of medications at least monthly until the BP goal is reached.

  • Evaluate for treatment-resistant hypertension
  • Consider adding further diuretic or - or -blocker
  • Consider referral to a hypertension specialist

Step 4

*Do not combine an ACEI with an ARB.

National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

Power Over Pressure

www.poweroverpressure.com

step 2 advancing therapy
Step 2: Advancing therapy
  • If single-drug therapy fails to control BP, patients should start combination therapy with a CCB in combination with either an ACEI or an ARB
  • If a CCB is not appropriate for step 2 treatment, offer a thiazide-like diuretic
  • For black people of African or Caribbean origin, consider an ARB rather than an ACEI in combination with a CCB

Patient ≥55 years old

OR

Any age black person of African or Caribbean origin

No

Initiate ACEI or ARB

Step 1

Yes

Initiate CCB

BP still above goal?

BP still above goal?

CCB + ACEI or ARB

Step 2

BP still above goal?

CCB + ACEI or ARB + thiazide-like diuretic

Step 3

BP still above goal?

Practice Tip: Thiazide-like diuretics such as chlortalidone or indapamide are preferred to conventional thiazide diuretics such as bendroflumethiazide or hydrochlorothiazide.

  • Evaluate for treatment-resistant hypertension
  • Consider adding further diuretic or - or -blocker
  • Consider referral to a hypertension specialist

Step 4

National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

Power Over Pressure

www.poweroverpressure.com

step 3 triple combination therapy
Step 3: Triple-combination therapy
  • If 2-drug combination therapy fails to control BP, the combination of an ACEI or an ARB + a CCB + a thiazide-like diuretic should be used

Patient ≥55 years old

OR

Any age black person of African or Caribbean origin

No

Initiate ACEI or ARB

Step 1

Yes

Initiate CCB

BP still above goal?

BP still above goal?

CCB + ACEI or ARB

Step 2

BP still above goal?

CCB + ACEI or ARB + thiazide-like diuretic

Step 3

BP still above goal?

Practice Tip: Treatment-resistant hypertension is frequently caused by suboptimal dosing. Before considering Step 3 treatment, review medication to ensure Step 2 treatment is at optimal or maximum tolerated doses.

  • Evaluate for treatment-resistant hypertension
  • Consider adding further diuretic or - or -blocker
  • Consider referral to a hypertension specialist

Step 4

National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

Power Over Pressure

www.poweroverpressure.com

step 4 treatment resistant hypertension
Step 4: Treatment-resistant hypertension
  • BP >140/90 mm Hg after treatment with the optimal or maximum tolerated doses of an ACEI or an ARB + a CCB + a diuretic should be regarded as treatment-resistant hypertension
  • Consider adding a fourth antihypertensive drug and/or seeking expert advice
    • An α- or β-blocker may be useful
    • Further diuretic therapy with low-dose spironolactone should be considered, depending on the patient’s blood potassium level

Patient ≥55 years old

OR

Any age black person of African or Caribbean origin

No

Initiate ACEI or ARB

Step 1

Yes

Initiate CCB

BP still above goal?

BP still above goal?

CCB + ACEI or ARB

Step 2

BP still above goal?

CCB + ACEI or ARB + thiazide-like diuretic

Step 3

BP still above goal?

  • Evaluate for treatment-resistant hypertension
  • Consider adding further diuretic or - or -blocker
  • Consider referral to a hypertension specialist

Practice Tip: If BP remains uncontrolled with the optimal or maximum tolerated doses of 4 drugs, seek the advice of a hypertension expert.

Step 4

National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

Power Over Pressure

www.poweroverpressure.com

summary
Summary
  • The NICE guidelines provide a systematic, stepwise approach to the treatment of hypertension
    • Start with single-drug therapy, either an ACEI or ARB, or a CCB, depending on the patient’s age and race
  • If BP remains uncontrolled, initiate combination therapy with a CCB in combination with either an ACEI or an ARB
    • Ensure that the regimen is titrated to optimal or maximum tolerated doses
  • If 2-drug combination therapy fails to control BP, add a thiazide-like diuretic to the regimen
  • If BP remains uncontrolled on a 3-drug regimen, the patient should be considered treatment resistant
    • Consider adding a fourth antihypertensive agent, either an α- or β-blocker or low-dose spironolactone
    • Seek the advice of a hypertension specialist

Power Over Pressure

www.poweroverpressure.com