Intended for healthcare professionals

Rapid response to:

Practice Guidelines

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:d4891

Rapid Response:

Response on behalf of Guideline Development Group

We thank Dr. Taylor for his comments on the recent NICE guidance on
the management of primary hypertension in adults [1,2]. The guideline
recommends that when a diagnosis of hypertension is suspected on the basis
of a clinic blood pressure (BP) reading, the diagnosis should be confirmed
by using ambulatory blood pressure monitoring (ABPM). The guideline
development group (GDG) considered all data on the prognostic value of
ABPM compared to conventional clinic blood pressure monitoring (CBPM) and
home blood pressure monitoring (HBPM). This systematic review found ABPM
was the best predictor of clinical outcomes, i.e. major cardiovascular
events and mortality. For this reason the decision to use ABPM as the
reference standard for diagnosis in the subsequent analyses was considered
appropriate by the GDG. The systematic review and meta analysis of
diagnostic studies directly comparing the sensitivity and specificity of
clinic and home BP measurement strategies to a reference standard of ABPM
for diagnosis concluded that neither "had sufficient sensitivity or
specificity to be recommended as a single diagnostic test" and "might
result in substantial over-diagnosis" [3]. The GDG had the same concerns
as Dr. Taylor about whether it would be cost-effective to routinely deploy
ABPM to confirm the diagnosis of hypertension. Thus, the GDG requested a
detailed cost-effectiveness analysis which found ABPM to be the most cost-
effective diagnostic strategy, and indeed cost saving over the medium term
[4]. This conclusion remained robust across a wide range of sensitivity
analyses modelling a variety of extreme scenarios and when using a
probabilistic analysis which takes account of the uncertainty around model
inputs. We recognise that implementing this major change in practice will
be a challenge but the evidence suggests that it is the most accurate and
cost-effective way to ensure that those with hypertension are accurately
identified and treated.

In response to Dr. Cruickshank's comments about the exclusion of beta
-blockers as a preferred treatment of hypertension, unless there is a
compelling indication for beta-blockers beyond the need to lower blood
pressure, this decision was taken in the NICE hypertension guideline
update in 2006 [5]. Briefly, the analysis of data showed that for the
treatment of primary hypertension, beta-blockers were effective at
reducing the risk of major cardiovascular events but when compared to the
currently recommended treatments, they were significantly less effective
at reducing the risk of stroke and no more effective at preventing the
risk of myocardial infarction [5]. In the up-dated cost-effectiveness
analysis of the treatment of primary hypertension in the current guidance,
beta-blockers were the least cost-effective treatment option [1].
Furthermore, similar conclusions have been reached in other independent
analysis [6,7]. Dr. Cruickshank's assertion that the later generation of
more selective beta blockers may be more effective at reducing
cardiovascular risk than older generation beta blockers in people with
hypertension, cannot be substantiated by reference to evidence from
clinical outcome trials with these drugs in people with hypertension.

Drs. El Turabi and Payne raise important questions about the paucity
of data relating to the efficacy of different classes of BP-lowering drugs
in various ethnic groups, including people of Black African and Caribbean
origin. In particular, they note a lack of data for younger people, i.e.
under the age of 55 years. This latter point is addressed by the guideline
which recommends the need for further research regarding the treatment of
hypertension in all younger people. With regard to treatment outcomes, the
main available data comes from the ALLHAT study[8], which we acknowledge
does not specifically deal with treatment in younger people. However, it
does show that ACE-inhibition was significantly less effective at reducing
BP and the risk of stroke in Black Americans when compared to other
treatments, i.e. CCB or thiazide-type diuretic. It also showed a higher
incidence of angioedema associated with ACE-inhibition treatment, (albeit
low rates), in the Black American cohort when compared to the rest of the
study population. The recommendations with regard to people of Black
African or Caribbean descent in the current guidance are largely unchanged
from the recommendations in 2006, apart from the steer towards the
preferred use of CCB rather than thiazide-type diuretic as initial
therapy. We wholeheartedly agree that further data is needed in different
ethnic groups from future trials, especially for younger people but
believe that the current recommendations reflect the best available
evidence to date.

Bryan Williams MD

Taryn Krause

Kate Lovibond

Mark Caulfield

Terry McCormack

On behalf of the Guideline Development Group.

References:

1. 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.

2. Krause T, Lovibond K, Caulfield M, McCormack T, Williams B. on
behalf of the Guideline Development Group. Management of hypertension:
summary of NICE guidance. BMJ 2011; 343: d4891 [Full text]

3. Hodgkinson J, Mant J, Martin U, Guo B, Hobbs FDR, Deeks J,
Heneghan C, Roberts N, McManus RJ. Relative effectiveness of clinic and
home blood pressure monitoring compared with ambulatory blood pressure
monitoring in diagnosis of hypertension: systematic review, BMJ 2011;
342:d3621

4. Lovibond K, Jowett S, Barton P, Caulfield M, Heneghan C, Hobbs R,
Hodgkinson J, Mant J, Martin, U., Williams B, Wonderling D, McManus R,
2011. Cost-effectiveness of options for the diagnosis of high blood
pressure in primary care: a modelling study. The Lancet - 24 August 2011
DOI: 10.1016/S0140-6736(11)61184-7

5. National Collaborating Centre for Chronic Conditions.
Hypertension: management in adults in primary care: pharmacological
update. (Pharmacological update of CG18.) Royal College of Physicians,
2006.

6. Wiysonge C, Bradley H, Myose B, et al. Beta-blockers for
hypertension. Cochrane Database Syst Rev 2007; 1:CD002003.

7. Bangalore S, Messerli FH, Kostis JB, Pepine CJ. Cardiovascular
protection using beta-blockers: a critical review of the evidence. J Am
Coll Cardiol 2007;50: 563-72.

8. 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.

Competing interests: No competing interests

06 October 2011
Bryan Williams
Professor of Medicine
Taryn Krause, Kate Lovibond, Mark Caulfield, Terry McCormack, on behalf of the guideline development group
Department of Cardiovascular Sciences, University of Leicester