Intended for healthcare professionals

Rapid response to:

Practice Guidelines

Management of hypertension: summary of NICE guidance

BMJ 2011; 343 doi: (Published 25 August 2011) Cite this as: BMJ 2011;343:d4891

Rapid Response:

Poorly evidenced key recommendations of Hypertension guidance

I too would agree that the new NICE Hypertension guidance, despite
being well-intended, is poorly evidenced and impractical for the NHS GP.

Despite the constant revisions of treatment algorithms, diuretics are
still well-evidenced for outcomes. Indications for other treatment
preferences offer small benefits compared to each other, which can be
dealt with by looking at 'clear contraindications' versus 'pressing
indications'. In practice, whichever initial drug is chosen, most
hypertensives quickly end up on middling doses of many drugs !

I am not sure that loss of GP QOF income will be an issue. White-
coat patients would still be declared 'hypertensive' on the usual
criteria, but exempted from drug treatment and encouraged to self-manage
and avoid white-coats.

Referral for ABPM seems a care pathway to hell.

In our 6000-patient list we loan out validated home BP monitors
whenever the diagnosis of sustained hypertension is in doubt. This, as
NICE acknowledges, has some evidence in its favour, and has several
advantages over referral for ABPM :-

1. there is no need for secondary-care involvement
2. the patient has less inconvenience
3. the patient becomes engaged and educated
4. the NHS avoids unnecessary added costs

in the longer term, the 'white-coat patients' are encouraged either
to purchase their own machine, or borrow on of ours periodically - thus
giving added and ongoing reassurance to both patient and doctor.

Let us hope that NICE's new role in guiding General Practitioners
through QOF does not repeat such ex-cathedra impracticalities. QOF
prevalencereturns testify that 20-25% of patients are hypertensive !!
The GPs on the committee will need to earn their salt if they are to
sustain the respect and compliance of jobbing GPs.

Competing interests: No competing interests

11 September 2011
L Sam Lewis
GP Trainer
Surgery, Newport, Pembrokeshire, SA42 oTJ