1. Implementing NICE guidance
Hypertension
Implementing NICE guidance
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on hypertension. This guideline has been written for healthcare professionals caring for adults with hypertension in secondary care (excluding emergency care) and community settings in which NHS care is received.
The guideline is available in a number of formats, including a quick reference guide. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. See the end of the presentation for ordering details.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
August 2011
NICE clinical guideline 127

2. Updated guidance
This guideline updates and replaces ‘Hypertension: management of hypertension in adults in primary care’ (NICE clinical guideline 34, 2006).
NICE clinical guideline 34 was a partial update of ‘Hypertension’ (NICE clinical guideline 18, 2004).
This update was produced in collaboration with the British Hypertension Society
NOTES FOR PRESENTERS:
This guidance updates and replaces NICE clinical guideline 34 (published in 2006). NICE clinical guideline 34 updated and replaced NICE clinical guideline 18 (published in 2004).
The original 2004 guideline was developed by the Newcastle Guideline Development and Research Unit. The guideline was updated by the National Collaborating Centre for Chronic Conditions [NCC-CC] (now the National Clinical Guideline Centre [NCGC]) in collaboration with the British Hypertension Society (BHS) in 2006 and by the NCGC in 2011.

3. Click here to go to NICE Pathways website
The NICE Hypertension pathway shows all the recommendations in the Hypertension guideline
Click here to go to NICE Pathways website
NOTES FOR PRESENTERS:
Key points to raise
The recommendations from this guideline have been incorporated into a NICE pathway, which is available from
If you are showing this presentation when connected to the internet, click on the orange button to go straight to the NICE Pathways website. The front page includes a two minute video giving an overview of the features and content within the site, as well as the list of topics covered.
NICE Pathways: guidance at your fingertips
Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended.

4. What this presentation covers
Background
Scope
Key priorities for implementation and updated areas
Areas not updated
Costs and savings
Discussion
Find out more
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background to the guideline and why it is important.
We will then present the key priorities for implementation. The NICE guideline contains 12 key priorities for implementation, which you can find on pages 7,8, and 9 of the NICE guideline.
We will then look at areas which that have not been identified as key priorities but where new recommendation have been added. We will then briefly summarise areas where the recommendations have not been updated.
Next, we will summarise the costs and savings that are likely to be incurred in implementing the guidance.
Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.
Finally, we will end the presentation with further information about the support provided by NICE.

5. Background High Blood Pressure:
Major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death.
Untreated hypertension can cause vascular and renal damage leading to a treatment-resistant state.
Each 2 mmHg rise in systolic blood pressure associated with increased risk of mortality:
7% from heart disease
10% from stroke.
NOTES FOR PRESENTERS:
Key points to raise:
Hypertension is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death.
Untreated hypertension is usually associated with a progressive rise in blood pressure. The vascular and renal damage that this may cause can culminate in a treatment-resistant state.
Blood pressure is normally distributed in the population and there is no natural cut-off point above which 'hypertension' definitively exists and below which it does not.
The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke.
Routine periodic screening for high blood pressure is now commonplace in the UK as part of National Service Frameworks for cardiovascular disease prevention. Consequently, the diagnosis, treatment and follow-up of people with hypertension is one of the most common interventions in primary care, accounting for approximately 12% of Primary Care consultation episodes and approximately £1billion in drug costs in 2006.

6. Epidemiology Hypertension is common in the UK population.
Prevalence influenced by age and lifestyle factors.
25% of the adult population in the UK have hypertension.
50% of those over 60 years have hypertension.
With an ageing population, the prevalence of hypertension and requirement for treatment will continue to increase.
NOTES FOR PRESENTERS:
Key points to raise:
Primary hypertension is remarkably common in the UK population and the prevalence is strongly influenced by age and lifestyle factors. Systolic and/or diastolic blood pressures may be elevated.
Systolic pressure elevation is the more dominant feature of hypertension in older patients and diastolic pressure is more commonly elevated in younger patients (those younger than 50 years).
At least one quarter of adults (and more than half of those older than 60) have hypertension (blood pressure ≥140/90mmHg).
As the demographics of the UK population shift towards an older, more sedentary and obese population, the prevalence of hypertension and its requirement for treatment will continue to rise.

7. Definitions Stage 1 hypertension:
Clinic blood pressure (BP) is 140/90 mmHg or higher and
ABPM or HBPM average is 135/85 mmHg or higher.
Stage 2 hypertension:
Clinic BP 160/100 mmHg is or higher and
ABPM or HBPM daytime average is 150/95 mmHg or higher.
Severe hypertension:
Clinic BP is 180 mmHg or higher or
Clinic diastolic BP is 110 mmHg or higher.
NOTES FOR PRESENTERS:
Definitions
In this guideline the following definitions are used:
Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.
Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.
Additional information:
ABPM – ambulatory blood pressure monitoring
HBPM – home blood pressure monitoring

8. Scope
Clinical management of primary hypertension in adults who may, or may not, have pre-existing cardiovascular disease.
Groups not included are people with diabetes, secondary causes of hypertension, accelerated hypertension or acute hypertension, pregnant women, and children and young people aged under 18.
NOTES FOR PRESENTERS.
Key points to raise: This guidance and NICE clinical guideline 34 were developed in collaboration with the British Hypertension Society. This guideline is for the clinical management of primary hypertension in adults (aged 18 years and older) who may, or may not, have pre-existing cardiovascular disease.
Groups that have been covered
- Adults with hypertension (18 years and older).
- Particular consideration has been given to the needs of black people of African and Caribbean descent and minority ethnic groups where these differ from the needs of the general population.
- People aged 80 years or older.
Groups that have not been covered
- People with diabetes.
- Children and young people (younger than 18 years).
- Pregnant women.
- Secondary causes of hypertension (for example, Conn's adenoma, phaeochromocytoma and renovascular hypertension).
- People with accelerated hypertension (that is, severe acute hypertension associated grade III retinopathy and encephalopathy).
People with acute hypertension or high blood pressure in emergency care settings.
Additional information:
Primary hypertension: Primary hypertension was previously termed ‘essential hypertension’ because of a long-standing view that high blood pressure was sometimes ‘essential’ to perfuse diseased and sclerotic arteries. It is now recognised that the diseased and sclerotic arteries were most often the consequence of the hypertension and thus the term ‘essential hypertension’ is redundant and ‘primary hypertension’ is preferred. The majority of people (approximately 90%) with sustained high blood pressure encountered in clinical practice, for which there is no obvious, identifiable cause are said to have primary hypertension. The remaining 10% of cases are termed ‘secondary hypertension’, for which specific causes for the blood pressure elevation can be determined (for example, Conn's adenoma, renovascular disease, or phaeochromocytoma).
Drug recommendations in the guideline: The guideline will assume that prescribers will use a drug’s summary of product characteristics to inform decisions made with individual patients.
This guideline recommends drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. Where recommendations have been made for the use of drugs outside their licensed indications (‘off-label use’), these drugs are marked with an † in the presenters’ notes. If the drug does not have UK marketing authorisation for a particular use, informed consent should be obtained and documented.

9. Key priorities for implementation
Diagnosis.
Initiating and monitoring antihypertensive drug treatment.
Choosing antihypertensive drug treatment.
NOTES FOR PRESENTERS:
The NICE guideline contains 65 recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into two main areas of key priority and within these there are 12 recommendations that we will consider in turn.
Key points to raise:
Recommendations are marked as [2004], [2004, amended 2011], [2006], [2008], [2009], [2010] or [new 2011].
[2004] indicates that the evidence has not been updated and reviewed since 2004
[2004, amended 2011] indicates that the evidence has not been updated and reviewed since 2004 but a small amendment has been made to the recommendation. These amendments are likely to represent a change to clinical practice.
[2006] indicates that the evidence has not been updated and reviewed since 2006
[2008] applies to recommendations from ‘Lipid modification’ (NICE clinical guideline 67), published in 2008
[2009] applies to recommendations from ‘Medicines adherence’ (NICE clinical guideline 76), published in 2009
[2010] applies to recommendations from ‘Hypertension in pregnancy’ (NICE clinical guideline 107), published in 2010
[new 2011] indicates that the evidence has been reviewed and the recommendation has been updated or added.
Additional information:
All of the key priorities for implementation are labelled as [new 2011]
This slide set will focus upon presenting the recommendations which are new or amended and will signpost to the other relevant recommendations which have not been updated since 2004 and 2006.

10. Diagnosis (1)
If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.
NOTES FOR PRESENTERS:
Recommendation [new 2011] in full: shown on the slide.
Related new recommendations
When considering a diagnosis of hypertension, measure blood pressure in both arms. If the difference in readings between arms is more than 20 mmHg, repeat the measurements. If the difference in readings between arms remains more than 20 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading. [new 2011] [1.2.1]
If blood pressure measured in the clinic is 140/90 mmHg or higher take a second measurement during the consultation. If the second measurement is substantially different from the first, take a third measurement. Record the lower of the last two measurements as the clinic blood pressure. [new 2011] [1.2.2]
If a person is unable to tolerate ABPM, home blood pressure monitoring (HBPM) is a suitable alternative to confirm the diagnosis of hypertension. [new 2011] [1.2.4]
If the person has severe hypertension, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM. [new 2011] [1.2.5]
While waiting for confirmation of a diagnosis of hypertension, carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy) (see recommendation 1.3.3, slide 19) and a formal assessment of cardiovascular risk using a cardiovascular risk assessment tool (see recommendation 1.3.2, slide 19). [new 2011] [1.2.6]
Additional information
See slide 18 for recommendations about measuring blood pressure.

11. Diagnosis (2) When using the following to confirm diagnosis, ensure:
ABPM:
at least two measurements per hour during the person’s usual waking hours, average of at least 14 measurements to confirm diagnosis
HBPM:
two consecutive seated measurements, at least 1 minute apart
blood pressure is recorded twice a day for at least 4 days and preferably for a week
measurements on the first day are discarded – average value of all remaining is used.
NOTES FOR PRESENTERS:
Recommendations in full:
When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension. [new 2011] [1.2.9]
When using HBPM to confirm a diagnosis of hypertension, ensure that:
for each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated and
blood pressure is recorded twice daily, ideally in the morning and evening and
blood pressure recording continues for at least 4 days, ideally for 7 days.
Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. [new 2011] [1.2.10]
Related new recommendations
If hypertension is not diagnosed but there is evidence of target organ damage such as left ventricular hypertrophy, albuminuria or proteinuria, consider carrying out investigations for alternative causes of the target organ damage. [new 2011] [1.2.7]
If hypertension is not diagnosed, measure the person’s clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person’s clinic blood pressure is close to 140/90 mmHg. [new 2011] [1.2.8]
Additional information:
An extensive review of the evidence by the guideline development group has identified that ABPM multiple blood pressure measurements away from the clinic setting are the best predictor of blood pressure-related clinical outcomes. They concluded that ABPM appeared to provide the best method of confirming a diagnosis of hypertension. They stated that ABPM would not only be a more effective means of diagnosis but also, a more cost-effective means of establishing the diagnosis of hypertension.
Recommendations and covering specialist assessment and investigation have been amended since the previous guideline in It is possible that this amendment may reflect a change in practice.

12. Initiating drug treatment
Offer antihypertensive drug treatment to people:
who have stage 1 hypertension, are aged under 80 and meet identified criteria
who have stage 2 hypertension at any age.
If aged under 40 with stage 1 hypertension and without evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider:
specialist evaluation of secondary causes of hypertension
further assessment of potential target organ damage.
NOTES FOR PRESENTERS:
Recommendations in full:
Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following:
target organ damage
established cardiovascular disease
renal disease
diabetes
a 10-year cardiovascular risk equivalent to 20% or greater. [new 2011] [1.5.1]
Offer antihypertensive drug treatment to people of any age with stage 2 hypertension. [1.5.2] [new 2011].
For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people. [new 2011] [1.5.3]
Additional information
See slide 20 for recommendations about lifestyle interventions and patient education and adherence to treatment.

13. Monitoring drug treatment (1)
Use clinic blood pressure measurements to monitor response to treatment. Aim for target blood pressure below:
140/90 mmHg in people aged under 80
150/90 mmHg in people aged 80 and over
NOTES FOR PRESENTERS:
These recommendations are not key priorities but have been included as they direct the management of hypertension.
Recommendations in full:
Use clinic blood pressure measurements to monitor the response to antihypertensive treatment with lifestyle modifications or drugs. [new 2011] [1.5.4]
Aim for a target clinic blood pressure below 140/90 mmHg in people aged under 80 years with treated hypertension. [new 2011] [1.5.5]
Aim for a target clinic blood pressure below 150/90 mmHg in people aged 80 years and over, with treated hypertension. [new 2011] [1.5.6]

14. Monitoring drug treatment (2)
For people identified as having a ‘white-coat effect’ consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor response to treatment.
Aim for ABPM/HBPM target average of:
below 135/85 mmHg in people aged under 80
below 145/85 mmHg in people aged 80 and over.
NOTES FOR PRESENTERS:
Recommendation in full:
For people identified as having a ‘white-coat effect’ (a discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis) consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor the response to antihypertensive treatment with lifestyle modification or drugs. [new 2011]
Related recommendation:
When using ABPM or HBPM to monitor the response to treatment (for example, in people identified as having a ‘white-coat effect’ and people who choose to monitor their blood pressure at home), aim for a target average blood pressure during the person’s usual waking hours of:
below 135/85 mmHg for people aged under 80 years
below 145/85 mmHg for people aged 80 years and over. [new 2011] [1.5.8]
White-coat effect: a discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.

15. Care pathway CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg
Stage 1 hypertension
CBPM ≥160/100 mmHg & ABPM/HBPM ≥ 150/95 mmHg
Stage 2 hypertension
Care pathway
If target organ damage present or 10-year cardiovascular risk > 20%
Offer antihypertensive drug treatment
Consider specialist referral
If younger than 40 years
Offer lifestyle interventions
NOTES FOR PRESENTERS. Key priority recommendations are identified with [KPI] in these notes
Step 1 treatment:
Offer people aged under 55 years step 1 antihypertensive treatment with an angiotensin-converting enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB). If an ACE inhibitor is prescribed and is not tolerated (for example, because of cough), offer a low-cost ARB. [new 2011] [1.6.6]
Do not combine an ACE inhibitor with an ARB to treat hypertension. [new 2011] [1.6.7]
Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged over 55 years and to black people of African or Caribbean family origin of any age. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. [new 2011] [1.6.8] [KPI]
If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.9] [KPI]
For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.10] [KPI]
Related recommendations:
Recommendations and have not been updated and reviewed since ‘Hypertension’ (NICE clinical guideline 34, 2006).
Step 2 treatment
If blood pressure is not controlled by step 1 treatment, offer step 2 treatment with a CCB in combination with either an ACE inhibitor or an *ARB. [new 2011] [1.6.13]
If a CCB is not suitable for step 2 treatment, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. [new 2011] [1.6.14]
For black people of African or Caribbean family origin, consider an ARB* in preference to an ACE inhibitor, in combination with a CCB. [new 2011] [1.6.15]
*Choose a low-cost ARB
Additional information: the pathway above focuses on stage 1 and 2 hypertension. For the full care pathway see page 35 of the NICE guideline.
Offer patient education and interventions to support adherence to treatment
Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

16. Summary of antihypertensive drug treatment
Aged over 55 years or black person of African or Caribbean family origin of any age
Aged under 55 years
Summary of antihypertensive drug treatment A C2
Step 1
Key
A – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1
C – Calcium-channel blocker (CCB)
D – Thiazide-like diuretic
A + C2
Step 2
A + C + D
Step 3
NOTES FOR PRESENTERS. Key priority recommendations are identified with [KPI] in these notes.
Step 3 treatment
Before considering step 3 treatment, review medication to ensure step 2 treatment is at optimal or best tolerated doses. [new 2011] [1.6.16]
If treatment with three drugs is required, the combination of ACE inhibitor (or angiotensin-II receptor blocker), calcium-channel blocker and thiazide-like diuretic should be used. [2006] [1.6.17]
Step 4 treatment
Regard clinic blood pressure that remains higher than 140/90 mmHg after treatment with the optimal or best tolerated doses of an ACE inhibitor or an ARB plus a CCB plus a diuretic as resistant hypertension, and consider adding a fourth antihypertensive drug and/or seeking expert advice. [new 2011] [1.6.18]
For treatment of resistant hypertension at step 4:
Consider further diuretic therapy with low-dose spironolactone4 (25 mg once daily) if the blood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia.
Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5 mmol/l. [new 2011] [1.6.19] [KPI]
When using further diuretic therapy for resistant hypertension at step 4, monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter. [new 2011] [1.6.20]
If further diuretic therapy for resistant hypertension at step 4 is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker. [new 2011] [1.6.21]
If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained. [new 2011] [1.6.22]
Footnotes
(1) Choose a low-cost ARB. (2) A CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has oedema, evidence of heart failure or a high risk of heart failure. (3) Consider a low dose of spironolactone4 or higher doses of a thiazide-like diuretic. (4) At the time of publication (August 2011), spironolactone did not have a UK marketing authorisation for this indication. Informed consent should be obtained and documented. (5) Consider an alpha- or beta-blocker if further diuretic therapy is not tolerated, or is contraindicated or ineffective.
Resistant hypertension
A + C + D + consider further diuretic3, 4 or alpha- or beta-blocker5
Consider seeking expert advice
Step 4
See slide notes for details of footnotes 1-5

17. Drug treatment Choosing antihypertensive drug treatment
Offer people aged 80  and over the same antihypertensive drug treatment as people aged over 55, taking into account any comorbidities.
NOTES FOR PRESENTERS:
Key points to raise:
Recommendation [1.6.4] [new 2011] in full on the slide
Related recommendations
Where possible, recommend treatment with drugs taken only once a day. [2004] [1.6.1]
Prescribe non-proprietary drugs where these are appropriate and minimise cost. [2004] [1.6.2]
Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure. [2004] [1.6.3]
Offer antihypertensive drug treatment to women of child-bearing potential in line with the recommendations on Management of pregnancy with chronic hypertension and Breastfeeding in ‘Hypertension in pregnancy’ (NICE clinical guideline 107). [1.6.5] [2010]
Related recommendations from ‘Hypertension in pregnancy’ (NICE clinical guideline 107, 2010).
The recommendations from CG107 on Management of pregnancy with chronic hypertension are available here:
The recommendations from CG107 on Breastfeeding are available here:

18. Measuring blood pressure: updated recommendations
Standardise the environment and provide a relaxed, temperate setting with the person quiet and seated.
When using an automated device:
palpate the radial or brachial pulse before measuring blood pressure. If pulse if irregular measure blood pressure manually
ensure that the device is validated* and an appropriate cuff size for the person’s arm is used.
NOTES FOR PRESENTERS:
These are not key priorities for implementation in this area however this has been included as it is considered an important part of the treatment pathway. Please note these recommendations would be applied during the person’s initial blood pressure measurement and diagnosis stages of the patient pathway.
Recommendations in full:
Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. [new 2011] [1.1.2]
When measuring blood pressure in the clinic or in the home, standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. [new 2011] [1.1.4]
If using an automated blood pressure monitoring device, ensure that the device is validated* and an appropriate cuff size for the person’s arm is used. [new 2011] [1.1.5]
Related recommendations
These have been amended since 2004 and may represent a change in practice.
In people with symptoms of postural hypotension (falls or postural dizziness):
measure blood pressure with the person either supine or seated
measure blood pressure again with the person standing for at least 1 minute prior to measurement. [2004, amended 2011] [1.1.6]
If the systolic blood pressure falls by 20 mmHg or more when the person is standing:
review medication
measure subsequent blood pressures with the person standing
consider referral to specialist care if symptoms of postural hypotension persist. [2004, amended 2011] [1.1.7]
Additional information:
*A list of validated blood pressure monitoring devices is available on the British Hypertension Society’s website (see or The British Hypertension Society is an independent reviewer of published work. This does not imply any endorsement by NICE.
Recommendations and have not been updated and reviewed since ‘Hypertension’ (NICE clinical guideline 18)
* See notes

19. Assessing cardiovascular risk and target organ damage: updated recommendations
Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension.
For all people with hypertension offer to:
test urine for presence of protein
take blood to measure glucose, electrolytes, creatinine, estimated glomerular filtration rate and cholesterol
examine fundi for hypertensive retinopathy
arrange a 12-lead ECG.
NOTES FOR PRESENTERS:
These are not key priorities for implementation in this area, however this has been included as it is considered an important part of the treatment pathway. Please note these recommendations would be applied during the person’s initial blood pressure measurement and at the diagnosis stages of the patient pathway.
Key points to raise:
Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension, both for raised blood pressure and other modifiable risk factors. [2004] [1.3.1]
Estimate cardiovascular risk in line with the recommendations on Identification and assessment of CVD risk in ‘Lipid modification’ (NICE clinical guideline 67)*. [2008] [1.3.2]
*Clinic blood pressure measurements must be used in the calculation of cardiovascular risk.
For all people with hypertension offer to:
test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip
take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol
examine the fundi for the presence of hypertensive retinopathy
arrange for a 12-lead electrocardiograph to be performed. [2004, amended 2011] [1.3.3]
Additional information:
The recommendations in identification and assessment of CVD risk in ‘lipid modification’ are available here:
For NICE guidance on the early identification and management of chronic kidney disease see ‘Chronic kidney disease’ (NICE clinical guideline 73, 2008).

20. Additional recommendations
Lifestyle interventions
Offer guidance and advice about:
diet (including sodium and caffeine intake) and exercise
alcohol consumption
smoking.
Patient education and adherence
Provide:
information about benefits of drugs and side effects
details of patient organisations
an annual review of care.
NOTES FOR PRESENTERS:
These are not key priorities for implementation in this area however this has been included as it is considered an important part of the treatment pathway. Note these recommendations did not require updating in Please note these recommendations should be applied throughout the patient pathway.
Key points to raise:
Lifestyle interventions
Recommendations 1.4.1–1.4.8 in the NICE guideline have not been updated and reviewed since ‘Hypertension’ (NICE clinical guideline 18, 2004).
Patient education and adherence
Recommendations 1.7.1–1.7.3 in the NICE guideline cover recommendations concerning patient education and adherence to treatment. These have not been updated and reviewed since ‘Hypertension’ (NICE clinical guideline 18, 2004).
Because evidence supporting interventions to increase adherence is inconclusive, only use interventions to overcome practical problems associated with non-adherence if a specific need is identified. Target the intervention to the need. Interventions might include:
suggesting that patients record their medicine-taking
encouraging patients to monitor their condition
simplifying the dosing regimen
using alternative packaging for the medicine
using a multi-compartment medicines system.
This recommendation is taken from ‘Medicines adherence’ (NICE clinical guideline 76). [2009] [1.7.4]
Additional information
For NICE guidance on the prevention of obesity and cardiovascular disease see ‘Obesity’ (NICE clinical guideline 43, 2006) and ‘Prevention of cardiovascular disease at population level’ (NICE public health guidance 25, 2010).

21. Costs and savings for total population of England
Costs and savings of using ABPM to confirm diagnosis of hypertension
Year
Change in diagnosis cost (£m)
Change in treatment cost (£m)
Net resource impact (£m)
Year 1
£5.1
− £2.5
£2.6
Year 2
− £5.8
− £0.7
Year 3
− £9.1
− £4.0
Year 4
−£12.4
− £7.3
Year 5
−£15.7
−£10.5
ADAPTING THIS SLIDE FOR LOCAL USE: We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact recommendation will have locally. We encourage you to calculate the local impact of this recommendation by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues.
NOTES FOR PRESENTERS: NICE has worked closely with people within and outside the NHS to look at the major costs and savings related to implementing recommendation 1.2.3:
If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new 2011] [1.2.3]
Implementing recommendation could lead to a significant recurrent saving for the NHS. However, in the first year following implementation it is expected to need additional funding.
In year 1 it is estimated the recommendation will cost the NHS around £2.6 million
In future years, as more people benefit from more accurate diagnoses using ABPM, a cumulative effect of people not receiving antihypertensive drugs inappropriately starts to be seen. Savings from reduced treatment costs will start to outweigh the additional costs of diagnoses. Expected savings are £4.0 million in year 3 and £10.5 million in year 5. Saving may increase further from a continuation of this cumulative effect.
Difficulties with modeling:
Unable to model future trends and practice for example people previously diagnoses as not hypertensive (using ABPM) may start to re-attend for testing. This makes estimating patient numbers and impact complex.
Calculation does not include potential savings from a reduction in adverse events, such as strokes and myocardial infarction, resulting from more accurate diagnosis and appropriate treatment. Owing to their long term nature these are difficult to calculate.
Estimated savings assume population and demographic remain unchanged over time. In practice the incidence of suspected hypertension is increasing. Total spending in real terms may therefore not decrease over time as described. However, the use of ABPM will provide savings compared with continued use of clinic blood pressure monitoring to confirm hypertension diagnoses.
For further information please refer to the costing template and costing report for this guideline on the NICE website. The costing report provides detailed estimates on the national costs and savings associated with implementing recommendation 1.2.3

22. Discussion
How do our diagnosis and treatment pathways for people with hypertension need to change in order to bring them in line with this guidance?
What innovative ways can we think of to enhance our capacity to deliver ABPM to people who need it?
What action do we need to take to ensure our blood pressure monitoring devices are properly validated, maintained and regularly calibrated?
Who within our team needs briefing or training to ensure consistent implementation?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.
Additional questions
What information can we develop for people who require ABPM and HBPM?
Further information:
A list of validated blood pressure monitoring devices is available on the British Hypertension Society’s website (see Please note the British Hypertension Society is an independent reviewer of published work. This does not imply any endorsement by NICE.

23. Click here to go to the NHS Evidence website
Visit NHS Evidence for the best available evidence on all aspects of cardiovascular disease
Click here to go to the NHS Evidence website
NOTES FOR PRESENTERS:
If you are showing this presentation when connected to the internet, click on the blue button to go straight to the NHS Evidence website topic page for Hypertension.
For the home page go to

24. Find out more Visit www.nice.org.uk/guidance/CG127 for: audit support
Visit to access the hypertension NICE pathway (see slide 3)
audit support
baseline assessment tool
clinical case scenarios
implementation advice
podcast
the guideline
the quick reference guide
‘Understanding NICE guidance’
costing report and template
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The NICE guideline – all the recommendations.
A quick reference guide – a summary of the recommendations for healthcare professionals.
‘Understanding NICE guidance’ – information for patients and carers.
The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.
For online copies of the quick reference guide or ‘Understanding NICE guidance’, visit the NICE website (quick reference guide) and/or (‘Understanding NICE guidance’).
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved.
Audit support – for monitoring local practice.
Baseline assessment tool – to help you identify which areas of practice may need more support, decide on clinical audit topics and prioritise implementation activities.
Clinical case scenarios – illustrate how the recommendations from the guideline can be applied to the care of patients presenting to primary care.
Implementation advice – on how to increase capacity for ABPM in order to facilitate implementation of the ABPM recommendations in practice.
Podcast – with Professor Bryan Williams discussing implementing the ABPM recommendations in practice
For access to the British Hypertension Society website please visit

25. What do you think?
Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice?
We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form.
If you are experiencing problems accessing or using this tool, please
NOTES FOR PRESENTERS:
Additional information:
This final slide is not intended to be part of the presentation. It asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice: your opinion would be appreciated.
To open the links in this slide set, right click over the link and choose ‘open link’.
To open the links in this slide set right click over the link and choose ‘open link’