March 8, 2019

expert reaction to new draft NICE guidance on blood pressure treatment

Reactions to new guidance published by the National Institute for Health and Care Excellence (NICE) on how to identify and treat high blood pressure.

Prof Stephen MacMahon FMedSci, Professor of Medicine & Oxford Martin Senior Fellow, and Principal Director, The George Institute for Global Health, University of Oxford, said:

“The new draft guidance from NICE is surprisingly conservative.  For example, there is strong evidence that greater reductions in blood pressure produce greater reductions in stroke and heart attack.  Yet the draft guidance recommends blood pressure targets that are only slightly lower than the starting level for treatment.  This will almost certainly result in large numbers of patients not achieving the full potential benefits of treatment as a consequence of inadequate reduction in blood pressure.

“Similarly, the draft guidance recommends a stepped approach to treatment that involves slowly adding drugs one at a time over an extended period until the target is reached.  This is an approach that has not been updated for several decades, despite evidence showing that it doesn’t work in practice.  Many patients remain on a single antihypertensive drug long-term despite inadequate blood pressure control, even by the conservative standard proposed by the new guidance.

“Much lower blood pressure targets are required and multiple drugs need to be used right from the start, if patients are to achieve the largest reduction in the risks of stroke and heart attack.”

Professor Rhian Touyz, BHF Professor of Cardiovascular Medicine, said:

“This evidence-based research is solid and I support the new NICE guidelines.  If more people who are at risk of high blood pressure are identified and treated appropriately with good blood pressure monitoring, that can only be a good thing.

“Regarding choice of drugs for therapy, it’s good to see that beta blockers have been removed, as there’s little evidence to suggest they are beneficial as initial therapy for hypertension in the absence of heart disease.

“However, despite the new guidelines, it’s important that doctors continue to use their clinical judgement with each patient.  While the new guidelines suggest that people over the age of 80 with stage 1 hypertension should be treated, in those patients over 80 who are frail and prone to falls or who have other chronic diseases, drug treatment for hypertension may not be suitable.  For this reason, clinicians are still encouraged to use their judgement during consultations.”

Dr Sonya Babu-Narayan, Associate Medical Director at the British Heart Foundation, said:

“This new guidance reflects the latest research, which shows that many more people could lower their risk of heart and circulatory disease by healthy lifestyle choices and taking prescribed medication to lower their blood pressure.

“We have a long way to go in improving the diagnosis of high blood pressure across the UK.  Our estimates show that as many as 5 million people are living with undiagnosed high blood pressure, putting them at unnecessary high risk of a deadly heart attack or stroke.  BHF are now testing new and innovative ways of allowing people to have their blood pressure checked in the community for example providing access to blood pressure testing in pharmacies or even train stations.

“A focus on prevention is rightly at the heart of the NHS’ long term plan.  By diagnosing and treating more people with high blood pressure we could prevent thousands of heart attacks and strokes across the UK each year.”

Prof Liam Smeeth, Head of the Department of Non-Communicable Disease, London School of Hygiene & Tropical Medicine, said:

“This draft guidance from NICE is a welcome step forward towards high blood pressure being viewed as one important part of peoples’ overall risk of cardiovascular disease.  However, the guidance remains reliant on somewhat arbitrary thresholds that divides people into those with “hypertension” and those without.  The evidence we have tells us that the risk of heart attack and strokes is related to blood pressure values across the spectrum.  There is higher risk at higher blood pressure levels, but no evidence to support a distinct threshold above which people need treatment and below which they don’t need treatment.

“A more rational approach would be to base the management of blood pressure on peoples’ overall risk of cardiovascular disease: targeting blood pressure reduction among people at higher risk of heart attacks and strokes.  This guideline does recognise the importance of risk of vascular disease, but continues to suggest that treatment should largely be determined by blood pressure thresholds.  I would suggest we should be moving towards a more unified approach to cardiovascular disease prevention, identifying people at high risk and targeting all their major risk factors rather than seeing blood pressure in isolation.  The NICE guidance on statins recommends basing therapeutic choices largely on the risk of cardiovascular disease: such an approach could be usefully adopted for blood pressure too.”

Prof Francesco Cappuccio, President of the British and Irish Hypertension Society, and Professor of Cardiovascular Medicine at the University of Warwick, said:

“The present release of the draft document of the revised NICE Guidelines for the diagnosis and management of hypertension was eagerly expected.  At a glance, the recommendations, whilst conservative compared to recent international guidelines in the US and Europe, are a step forward in the intensification of the diagnosis, management and control of the first cause of cardiovascular disease in our country and globally.

“In particular, the current proposal recommends treating Stage 1 hypertension (from 140/90 to 159/99 mmHg) earlier, even at an estimated absolute cardiovascular risk to 10%, potentially increasing the number of individuals requiring drug therapy to start with.  However, targets are maintained at below 140/90 mmHg for clinic blood pressure (below 150/90 mmHg over the age of 80 years), at variance with the European guidelines that – reviewing the same evidence – recommend targets below 130/80 mmHg and 140/80 mmHg, respectively.  NICE draft also suggests a stepwise incremental use of anti-hypertensive medications, as in 2011, whilst the European guidelines already embrace the concept of dual therapy as first step in most cases of hypertension, with or without co-morbidities.

“The next 6 weeks will offer the opportunity to discuss and refine these recommendations that promise to be a progress from those issued in 2011, in line with the clinical evidence accumulated in the last few years.”

Prof Peter Sever, Professor of Clinical Pharmacology & Therapeutics, Imperial College London, said:

“One of the major changes in the new Nice Guidelines for blood pressure management is to reduce the threshold for intervention in patients with Stage 1 hypertension (BP >140/90 mmHg).  Formerly the threshold was set at a 10 year risk of a cardiovascular event of more than 20%.  The new guidelines have lowered this threshold to 10%.

“Many patients in this new risk group are currently being treated with blood pressure lowering drugs based on clear evidence of benefit from randomised controlled trials.  Now the guidelines (in parallel with the lipid lowering guidelines) have formalised this approach to a reduction in risk thresholds, thereby confirming that a substantial increase in hypertensive patients should now be treated at an earlier stage of their disease, with antihypertensive drugs, and will benefit in the longer term from a reduction in cardiovascular events including myocardial infarction and stroke.”

‘National Institute for Health and Care Excellence Guideline: Hypertension in adults: diagnosis and management, Draft for consultation, March 2019’ was published by NICE at 00:01 UK time on Friday 8 March 2019.

Declared interests

Prof Liam Smeeth: “Professor Smeeth reports grants from Wellcome, MRC, NIHR, BHF, Diabetes UK, ESRC and the EU; grants and personal fees for advisory work from GSK, and personal fees for advisory work from AstraZeneca. He is a Trustee of the British Heart Foundation and a member of the steering committee for UK Biobank. He is the principal investigator of the NIHR funded StatinWise trial established to investigate whether statins cause muscle symptoms.”

Prof Francesco Cappuccio: “I have no conflict of interest except the fact that I am unpaid Trustee and President of the British and Irish Hypertension Society, a stakeholder in the consultation.”

Prof Peter Sever: “I’ve received grant funding, honoraria for speaking and consultancies from Pfizer, Amgen and Servier.”

None others received.