Choice of antihypertensive drug in hypertension

The guidance regarding combination treatment of systemic hypertension has been updated (1):

BP targets in adults:

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• in people with CKD and diabetes, and also in people with an ACR of 70 mg/mmol or more, aim to keep the systolic blood pressure below 130 mmHg (target range 120-129 mmHg) and the diastolic blood pressure below 80 mmHg

Starting antihypertensive drug treatment

Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity.

Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:

• target organ damage
• established cardiovascular disease
• renal disease
• diabetes
• an estimated 10-year risk of cardiovascular disease of 10% or more
• use clinical judgement for people with frailty or multimorbidity

Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%

• note that 10-year cardiovascular risk may underestimate the lifetime probability of developing cardiovascular disease

Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with a clinic blood pressure of over 150/90 mmHg

• use clinical judgement for people with frailty or multimorbidity

Measure standing as well as seated blood pressure in people with hypertension and:

• with type 2 diabetes or
• with symptoms of postural hypotension or
• aged 80 and over.
• in people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure

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

For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks

Choosing antihypertensive drug treatment

• recommendations in this section apply to people with hypertension with or without type 2 diabetes
• for guidance on choice of hypertensive agent in people with chronic kidney disease, see CKD and hypertension linked item
• people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) should be offered the same treatment as people with both raised systolic and diastolic blood pressure
• offer antihypertensive drug treatment to women of childbearing potential with diagnosed hypertension in line with guidance below. For women considering pregnancy or who are pregnant or breastfeeding, manage hypertension in line with the recommendations on management of pregnancy
• when choosing antihypertensive drug treatment for adults of black African or African-Caribbean family origin (and not diabetic), consider an angiotensin II receptor blocker (ARB), in preference to an angiotensin-converting enzyme (ACE) inhibitor

Step 1 treatment

Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:

• have type 2 diabetes and are of any age or family origin or
• are aged under 55 but not of black African or African-Caribbean family origin.

If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB to treat hypertension.

Do not combine an ACE inhibitor with an ARB to treat hypertension

Offer a calcium-channel blocker (CCB) to adults starting step 1 antihypertensive treatment who:

• are aged 55 or over and do not have type 2 diabetes or
• are of black African or African-Caribbean family origin and do not have type 2 diabetes (of any age)

If a CCB is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension.

If there is evidence of heart failure, offer a thiazide-like diuretic and follow NICE guidance on management of heart failure

If starting or changing diuretic treatment for hypertension, offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide

For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment

Step 2 treatment

If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step 1 treatment:

• a CCB or
• a thiazide-like diuretic

If hypertension is not controlled in adults taking step 1 treatment of a CCB, offer the choice of 1 of the following drugs in addition to step 1 treatment:

• an ACE inhibitor or
• an ARB
• or a thiazide-like diuretic

If hypertension is not controlled in adults of black African or African-Caribbean family origin who do not have type 2 diabetes taking step 1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step 1 treatment

Step 3 treatment

If hypertension is not controlled in adults taking step 2 treatment, offer a combination of:

• an ACE inhibitor or ARB and
• a CCB and
• a thiazide-like diuretic

Step 4 treatment

If hypertension is not controlled in adults taking the optimal tolerated doses of an ACE inhibitor or an ARB plus a CCB and a thiazide-like diuretic, regard them as having resistant hypertension.

Before considering further treatment for a person with resistant hypertension:

• confirm elevated clinic blood pressure measurements using ambulatory or home blood pressure recordings.
• assess for postural hypotension.
• discuss adherence

For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice

Consider further diuretic therapy with low-dose spironolactone for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of 4.5 mmol/l or less. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia

When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium and potassium and renal function within 1month of starting treatment and repeat as needed thereafter

Consider an alpha-blocker or beta-blocker for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4.5mmol/l.

If blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4 drugs, seek specialist advice

Notes:

Stage 1 hypertension

• clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg

Stage 2 hypertension

• clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher

Stage 3 or severe hypertension

• clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.

Reference:

1. NICE (August 2019). Clinical management of primary hypertension in adults