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

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 Treatment guidelines provide a systematic approach to blood pressure (BP) management National Institute for Health and Clinical Excellence Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. Power Over Pressure

A simple step-wise algorithm to expedite BP control Patient ≥55 years old OR Any age black person of African or Caribbean origin Patient ≥55 years old OR Any age black person of African or Caribbean origin Initiate ACEI or ARB Step 1 Step 2 Step 3 Step 4 Initiate CCB CCB + ACEI or ARB CCB + ACEI or ARB + thiazide-like diuretic Evaluate for treatment-resistant hypertension Consider adding further diuretic or  - or  -blocker Consider referral to a hypertension specialist Evaluate for treatment-resistant hypertension Consider adding further diuretic or  - or  -blocker Consider referral to a hypertension specialist Yes BP still above goal? No BP still above goal? National Institute for Health and Clinical Excellence Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. Power Over Pressure ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin-receptor blocker; CCB = calcium channel blocker.

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 or an 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 *Do not combine an ACEI with an ARB. National Institute for Health and Clinical Excellence Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. 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. Power Over Pressure Patient ≥55 years old OR Any age black person of African or Caribbean origin Patient ≥55 years old OR Any age black person of African or Caribbean origin Initiate ACEI or ARB Step 1 Step 2 Step 3 Step 4 Initiate CCB CCB + ACEI or ARB CCB + ACEI or ARB + thiazide-like diuretic Evaluate for treatment-resistant hypertension Consider adding further diuretic or  - or  -blocker Consider referral to a hypertension specialist Evaluate for treatment-resistant hypertension Consider adding further diuretic or  - or  -blocker Consider referral to a hypertension specialist Yes BP still above goal? No BP still above goal?

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 National Institute for Health and Clinical Excellence Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. Practice Tip: Thiazide-like diuretics such as chlortalidone or indapamide are preferred to conventional thiazide diuretics such as bendroflumethiazide or hydrochlorothiazide. Power Over Pressure Patient ≥55 years old OR Any age black person of African or Caribbean origin Patient ≥55 years old OR Any age black person of African or Caribbean origin Initiate ACEI or ARB Step 1 Step 2 Step 3 Step 4 Initiate CCB CCB + ACEI or ARB CCB + ACEI or ARB + thiazide-like diuretic Evaluate for treatment-resistant hypertension Consider adding further diuretic or  - or  -blocker Consider referral to a hypertension specialist Evaluate for treatment-resistant hypertension Consider adding further diuretic or  - or  -blocker Consider referral to a hypertension specialist Yes BP still above goal? No BP still above goal?

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 National Institute for Health and Clinical Excellence Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. 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. Power Over Pressure Patient ≥55 years old OR Any age black person of African or Caribbean origin Patient ≥55 years old OR Any age black person of African or Caribbean origin Initiate ACEI or ARB Step 1 Step 2 Step 3 Step 4 Initiate CCB CCB + ACEI or ARB CCB + ACEI or ARB + thiazide-like diuretic Evaluate for treatment-resistant hypertension Consider adding further diuretic or  - or  -blocker Consider referral to a hypertension specialist Evaluate for treatment-resistant hypertension Consider adding further diuretic or  - or  -blocker Consider referral to a hypertension specialist Yes BP still above goal? No BP still above goal?

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 National Institute for Health and Clinical Excellence Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. Practice Tip: If BP remains uncontrolled with the optimal or maximum tolerated doses of 4 drugs, seek the advice of a hypertension expert. Power Over Pressure Patient ≥55 years old OR Any age black person of African or Caribbean origin Patient ≥55 years old OR Any age black person of African or Caribbean origin Initiate ACEI or ARB Step 1 Step 2 Step 3 Step 4 Initiate CCB CCB + ACEI or ARB CCB + ACEI or ARB + thiazide-like diuretic Evaluate for treatment-resistant hypertension Consider adding further diuretic or  - or  -blocker Consider referral to a hypertension specialist Evaluate for treatment-resistant hypertension Consider adding further diuretic or  - or  -blocker Consider referral to a hypertension specialist Yes BP still above goal? No BP still above goal?

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