Management of hypertension: summary of NICE guidance
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4891 (Published 25 August 2011) Cite this as: BMJ 2011;343:d4891All rapid responses
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In its updated guidance on the management of hypertension, NICE
suggests that initial monotherapy for all black patients should be with a
calcium-channel blocker. If this is not tolerated, then a thiazide
diuretic should be tried[1,2]. This broadly continues the guidance of
starting black patients on C/D drugs given in NICE's 2006 guidelines[3],
which in turn were influenced by the British Hypertensive Society's 2004
guidelines[4].
There are, however, a number of issues with the evidence base used to
support this guidance which, if left unresolved, will perpetuate a
situation where the management of young (<55 years) black patients with
hypertension in the UK is less evidence based, and possibly less
efficacious, than for other ethnic groups. This has implications not only
for the 18% of the UK black population aged under 55 who suffer with
hypertension[5], but also for the validity of clinical guidelines tailored
to specific ethnic minorities.
The principal issue is that the evidence supporting the initial
monotherapeutic use of a calcium channel blocker for the management of
essential hypertension in younger black patients, is based, potentially
inappropriately, on the sub-group analysis of a single US-based study,
ALLHAT[6,7].
Whilst ALLHAT represents one of the largest antihypertensive trials
ever conducted, and specifically attempted to examine antihypertensive
response in different ethnicities, there are issues that limit its
usefulness in guiding treatment of young black patients in the UK. Most
importantly, it only recruited patients over the age of 55. As such, while
its findings do support NICE's recommendation that black patients aged 55
years and older should initially receive C or D monotherapy, it provides
no direct evidence for black patients younger than 55 years. In addition,
it did not control for socio-economic status of participants. This matters
because the relationship between race, socio-economic status and access to
healthcare in the US may differ considerably to that in the UK. As such,
the findings from studying the African-American population recruited in
ALLHAT may not be generalisable to the black British population.
We feel that ALLHAT does not provide sufficient evidence to support
the initial monotherapy advocated by NICE for all black patients. Indeed,
it is interesting that NICE has extrapolated ALLHAT's findings in this way
for young black patients, despite emphasising the relevance of age for
other ethnicities. Furthermore, despite explicitly stating its intention
to consider results relevant to younger black people, NICE has limited its
literature review to studies with over 1000 black patients, thus
potentially excluding smaller, well-designed studies that may have
provided some evidence to address this area of uncertainty.
Although we understand the pragmatic need to provide guidance in the
absence of perfect evidence, we feel that NICE has been remiss in failing
to specifically call for further research into the initial management of
young black hypertensive patients. At the very least, there should be a
clearer admission that the evidence base for managing hypertension in
young black patients is not as black and white as current guidance might
suggest.
References:
[1] Krause T, Lovibond K, Caulfield M, McCormack T, Williams B; on behalf
of the Guideline Development Group. Management of hypertension: summary of
NICE guidance. BMJ2011;343:d4891.
[2] National Institute for Health and Clinical Excellence. Hypertension:
clinical management of primary hypertension in adults (update). (Clinical
guideline 127.) 2011. http://guidance.nice.org.uk/CG127.
[3] National Collaborating Centre for Chronic Conditions. Hypertension:
management in adults in primary care: pharmacological update.
(Pharmacological update of CG18.) Royal College of Physicians, 2006.
www.nice.org.uk/nicemedia/live/10986/30111/30111.pdf.
[4] Williams B, Poulter NR, Brown MJ, Davies M, McInnes GT, Potter JP,
Sever PS and Thom S McG; The BHS Guidelines Working Party Guidelines for
Management of Hypertension: Report of the Fourth Working Party of the
British Hypertension Society, 2004 - BHS IV. J Hum Hypertens. 2004; 18:
139-185
[5]Health Survey for England 2004: The Health of Minority Ethnic Groups -
headline tables, National Statistics/Health and Social Care Information
Centre
http://www.ic.nhs.uk/webfiles/publications/hlthsvyeng2004ethnic/HealthSu...
[6] Leenen FH, Nwachuku CE, Black HR, Cushman WC, Davis BR, Simpson LM,
Alderman MH, Atlas SA, Basile JN, Cuyjet AB, Dart R, Felicetta JV, Grimm
RH, Haywood LJ, Jafri SZ, Proschan MA, Thadani U, Whelton PK, Wright JT,
Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack
Trial Collaborative Research Group. Clinical events in high-risk
hypertensive patients randomly assigned to calcium channel blocker versus
angiotensin-converting enzyme inhibitor in the antihypertensive and lipid-
lowering treatment to prevent heart attack trial. Hypertension. 2006;
48(3):374-384.
[7] Piller LB, Ford CE, Davis BR, Nwachuku C, Black HR, Oparil S, Retta
TM, Probstfield JL, ALLHAT Collaborative Research Group. Incidence and
predictors of angioedema in elderly hypertensive patients at high risk for
cardiovascular disease: a report from the Antihypertensive and Lipid-
Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Journal of
Clinical Hypertension. 2006; 8(9):649-656.
Competing interests: No competing interests
Dear Sir
Thank you for the informative summary on the recent NICE guideline on
the management of hypertension1. Publicising new NICE guidelines in this
way is a useful way of disseminating the information to those who are
unlikely to have the time to read either the full guideline or the summary
on the NICE website.
It is a shame that the summary in the BMJ (which will be read by many
doctors in the UK) does not mention that women of child bearing potential
should not be treated with either ACE inhibitors or ARBs without a
detailed discussion of the teratogenic potential of these drugs, and
advice to discontinue them preferably prior to conception. It is
recognised that over 20% of ongoing pregnancies are unintended2 and thus
the woman's current intentions may be insufficient protection against the
unwanted affects of ACE inhibitors in early pregnancy.
The NICE summary3 does direct the clinicians to the NICE guideline on
management of hypertension in pregnancy4 for all women in whom this needs
to be considered. Sadly this line was omitted from the BMJ summary.
Kate Harding
Consultant Obstetrician
Guy's and St Thomas' Foundation Trust
Andrew Shennan
Professor of Obstetrics
Cathy Nelson Piercy
Professor of Obstetric Medicine
References
1 BMJ September 3rd 2011
2 Unintended pregnancy in the united States. Henshaw SK Fam Plann Perspect
1998 jan-feb:30(1)
3 NICE Hypertension: management of hypertension in adults in primary care
2011
4 NICE The management of hypertensive disorders during pregnancy 2010
Competing interests: No competing interests
This is an excellent and up to date summary for clinicians. Not only
will it save money for the NHS, but it will help to provide a framework
for both the reliable diagnosis and effective treatment for hypertension.
Patients would value the use of new guidelines to improve diagnostic
accuracy as treatment is lifelong. Target organ damage and mortality could
both be reduced from effective treatment of hypertension, and services
could be concentrated on those in need of therapy. Well done NICE, on
providing a refreshingly easy to read document for this important
condition.
Competing interests: No competing interests
Poorly evidenced key recommendation of Hypertension guidance
A key recommendation of these new NICE guidelines is that 24 hour
Ambulatory Blood Pressure Monitoring should be used to confirm the
diagnosis of hypertension.Its is claimed that this would be cost effective
for the NHS.A single review is referenced in support of this conclusion
(BMJ 2011 342 d3621)
This review describes the paucity of evidence available to the
reviewers with only one study comparing clinic, ambulatory and home BP
measurement. The authors conclude that the three methods give differing
results.
The authors only justification for ABPM being the most appropriate
measure is that since it is used in situations of uncertainty it "
arguably has become the reference standard for the diagnosis of
hypertension."
"Arguably" is not good enough.
Routine introduction of ABPM, with its costs in equipment and staff
time is not yet justified
Competing interests: No competing interests