Return to recommendations Blood pressure targets for people without cardiovascular disease Why the committee made the recommendations No evidence was identified to determine whether cardiovascular risk or blood pressure targets should be used. The committee agreed that in the absence of evidence the focus should be on blood pressure targets, based on their expertise and experience of current practice. The evidence for blood pressure targets showed that there were both benefits and harms associated with a lower clinic systolic blood pressure target of 120 mmHg compared with 140 mmHg in people with primary hypertension without type 2 diabetes. Although the evidence suggested some benefit in reducing mortality and cardiovascular events, the lower blood pressure target was associated with a greater risk of harms, such as injury from falls and acute kidney injury. The committee agreed that the long-term implications of these adverse events were unclear and that further research is needed. This evidence came from the SPRINT trial, which was a large study undertaken in the US. The committee discussed concerns about the population included in the study and the applicability to UK practice of the methods used. The study used automated blood pressure devices with a time delay and an isolated rest period, which is not common practice in the UK. The committee considered that the use of these devices would lead to lower blood pressure readings than in routine UK clinical practice. They also had concerns that some medicines were stopped when blood pressure targets were achieved, which may have had an impact on the results. The committee also discussed concerns about applicability of the population; for example, the participants had high cardiovascular risk levels, including many with pre-existing cardiovascular disease or renal impairment, and were already receiving treatment before the study started. These concerns made the evidence difficult to interpret and use to inform the recommendations. Further details of the committee's discussion of this study is included in evidence review D: targets. Evidence from a smaller study also showed some benefit of lowering clinic systolic blood pressure targets to 130 mmHg. However, the committee noted that the study was based on people already receiving treatment and that it lacked information on adverse events. The committee agreed that there was no evidence to suggest that blood pressure targets should be different in people with type 2 diabetes. Evidence for lower targets in people with type 2 diabetes was also limited, with some evidence to suggest that lower blood pressure targets did not reduce the rate of cardiovascular events. Previous recommendations for people with type 2 diabetes (in NICE's guideline on type 2 diabetes in adults) suggested a blood pressure target below 130/80 mmHg in the presence of target organ damage such as kidney, cerebrovascular or eye disease. The committee noted that the evidence behind this recommendation was based on 2 small studies in people without hypertension. They also had concerns about the relevance of the study design. The committee were also aware of trial data showing less benefit in populations with type 2 diabetes with fewer additional risk factors. The committee therefore agreed that there was insufficient evidence to recommend a different blood pressure target for this subgroup. It was noted that people with later-stage chronic kidney disease are covered by other NICE guidelines. Overall, the committee agreed that the evidence was unclear and insufficient to determine whether a lower target would be beneficial and whether it would outweigh the associated harms. Therefore, the 2011 clinic blood pressure target of 140/90 mmHg for adults under 80 years was retained and applies to people with or without type 2 diabetes. The corresponding HBPM and ambulatory blood pressure monitoring (ABPM) targets were also retained at 135/85 mmHg. The recommendations emphasise the importance of achieving and maintaining a level consistently below the person's blood pressure target, whether this target be based on clinic blood pressure, HBPM or ABPM. Based on their experience, the committee members felt that people with postural hypotension are at risk of adverse events if a sitting or lying blood pressure is used for monitoring, because this measurement would overestimate daytime blood pressure and result in overtreatment. For example, a patient with a sitting systolic blood pressure of 140 mmHg might have a much lower blood pressure when standing and be at an increased risk of falls if treated based on their sitting blood pressure. The committee decided to recommend that 3 groups who are at risk of postural hypotension (people over 80 years, with type 2 diabetes and with symptoms of postural hypotension) should have their standing blood pressure measured, and their treatment modified accordingly if they have postural hypotension. The standing blood pressure should be used for future monitoring. How the recommendations might affect practice The recommendations should reinforce current good practice. However, the new recommendations place more emphasis on maintaining blood pressure consistently below the blood pressure targets. As a result, this could lead to a higher use of antihypertensive drugs and an increase in consultations to maintain target blood pressure. For people with type 2 diabetes and target organ damage (not covered by other guidelines), the slightly higher target blood pressure compared to that recommended previously may reduce adverse events and may lead to fewer appointments and reduced drug use. Return to recommendations Blood pressure targets for people with cardiovascular disease Why the committee made the recommendation The evidence did not show a robust or consistent clinical benefit from using lower blood pressure targets for people with cardiovascular disease compared with standard blood pressure targets. The vast majority of people in the control arms of the studies achieved blood pressures well below 140/90 mmHg. In the committee's experience of practice, some people with hypertension can have their blood pressure maintained at 140/90 mmHg, rather than below this level. To address this issue, the committee amended the 2019 recommendations on blood pressure targets to emphasise the importance of reducing and maintaining blood pressure below 140/90 mmHg. The committee made recommendations for research for: People aged over 80, because there was no evidence specifically for this group. The only evidence was from mixed age groups, and the committee agreed that this evidence was too limited to support a new practice recommendation. People with aortic aneurysm, because there was no evidence for this group. People who have had a stroke, because there was limited evidence that lower blood pressure targets reduced the risk of future strokes, but there was also evidence on the possible harms of lower targets. Evidence for both potential benefit and harm was too limited to inform a recommendation. How the recommendations might affect practice The new recommendation reflects current practice for most types of cardiovascular disease, so there should be no change in practice or increase in resource use. The Royal College of Physicians Intercollegiate Stroke Working Party guideline recommends a lower blood pressure target for people after stroke. However, the national quality indicators used in primary care do not use a lower blood pressure target for people with cardiovascular disease (including stroke and transient ischaemic attack). Return to recommendation Choosing antihypertensive drug treatment for people with cardiovascular disease Why the committee made the recommendation New evidence in this area was not reviewed as part of the 2022 update. Instead, the evidence from previous versions of the guideline was reassessed to look at outcomes for people with cardiovascular disease. Only evidence up to 2010 was re-analysed, because the 2019 update did not review evidence for people with cardiovascular disease. There was no difference in clinically relevant outcomes between people with and without cardiovascular disease. Evidence was limited for people with stroke, transient ischaemic attack, or coronary artery disease. This evidence did not cover enough treatment comparisons to allow the committee to draw any firm conclusions. There are NICE guidelines on acute coronary syndromes and chronic heart failure, and these guidelines make recommendations on drug treatment that overlap with treatment for hypertension. To avoid confusion over the treatment pathway, the committee highlighted that these condition-specific recommendations should be applied first (for example, when prescribing an ACE inhibitor or an ARB for secondary prevention of myocardial infarction). How the recommendations might affect practice The recommendation reflects current practice for most types of cardiovascular disease. The committee were aware that, after a stroke, the thiazide-like diuretic indapamide is sometimes used first, rather than a calcium channel blocker. However, it is unclear how common this is. As people with cardiovascular disease are commonly prescribed more than 1 antihypertensive drug, any impact on prescribing would be limited. Return to recommendation Step 1 treatment Why the committee made the recommendations The committee reviewed the evidence for starting treatment for primary hypertension with a single antihypertensive medicine compared with starting with 2 antihypertensive medicines at once (dual therapy). Additionally, the committee reviewed the evidence on whether specific subgroups of people with hypertension might benefit from starting on dual therapy, for example people with type 2 diabetes, older people, or those of particular family origins. Some limited evidence from a single study showed that initial dual therapy may reduce cardiovascular events in people with hypertension and type 2 diabetes, but the committee members were disappointed that more comprehensive data was not available. The committee discussed the benefits of optimising treatment for hypertension early and agreed that this can substantially improve quality of life. However, there was not enough evidence to determine confidently the benefits or harms of starting treatment with dual therapy. In response to the lack of available evidence, the committee developed a recommendation for research on step 1 treatment to determine if particular subgroups would benefit from starting dual therapy, to inform future guidance. In the absence of compelling new evidence on step 1 dual therapy, the committee agreed that the previous recommendations for step 1 treatment should be retained (with minor changes for clarity), because they were based on robust clinical and cost-effectiveness evidence. One exception to this was the 2006 recommendation for considering beta- blockers in certain groups of younger people. The committee discussed this recommendation and agreed that beta-blockers are rarely used as step 1 antihypertensive treatment in current practice and there is no established relationship between beta- blocker use in primary hypertension and a reduction in cardiovascular events. For these reasons, the committee decided that the recommendation should not be retained. The committee noted that this is consistent with most international guidelines. This guideline also updates and replaces the section on blood pressure management from NICE's guideline on type 2 diabetes in adults. That guideline recommended that adults with type 2 diabetes of any age should start on an angiotensin-converting enzyme (ACE) inhibitor as step 1 treatment (except women with a possibility of becoming pregnant and people of Black African or African Caribbean family origin). The committee discussed the evidence for this and agreed that it was sufficient to support and retain this recommendation. The committee agreed it should be broadened to include the choice of an ACE inhibitor or an angiotensin II receptor blocker (ARB; also referred to as A-type drugs), because they are now cost equivalent, and the committee also agreed they are clinically equivalent. For people of Black African or African Caribbean family origin with type 2 diabetes, the previous recommendation was to offer step 1 dual therapy with an ACE inhibitor and either a diuretic (D-type drug) or a calcium channel blocker (CCB; C-type drug). However, these recommendations were based on monotherapy studies and when the committee looked at this evidence alongside the new dual therapy evidence review, they concluded that it was insufficient to recommend starting dual therapy in any subgroup of people with type 2 diabetes. The committee noted that people with type 2 diabetes who are older or are of Black African or African Caribbean family origin may not achieve their target blood pressure on ACE inhibitor or ARB monotherapy and may need to start step 2 drug therapy in the short term. How the recommendations might affect practice Overall, the recommendations for step 1 treatment reflect current practice for people who do not have type 2 diabetes. For people of Black African or African Caribbean family origin who have type 2 diabetes, the recommendation to start antihypertensive monotherapy rather than dual therapy may result in an extra clinical appointment if the dose needs to be adjusted. However, it may also reduce potential harms from initial overtreatment of blood pressure. Return to recommendations Step 2 and 3 treatment Why the committee made the recommendations No evidence for step 2 or step 3 treatment was identified that was relevant to determining the best sequence for step 2 and step 3 antihypertensive treatment. Some of the studies available on drug treatments for hypertension were not included in this review because they were designed to inform step 1 treatment. Others did not reflect UK clinical practice. For details of these studies see evidence review F: step 2 and step 3 treatment. Based on evidence from the previous version of the guideline and their clinical expertise, the committee members agreed to retain the same choice of drugs from the 2011 guideline, which reflect current best practice. The committee agreed that, in the absence of evidence of which treatment(s) are most effective for step 2 or step 3, the recommendation should be to offer any of these treatments based on an individualised approach informed by risks and benefits of each treatment and the person with hypertension's preference. The committee noted that the changes to the step 1 recommendations for some people with type 2 diabetes do not necessitate a change in the step 2 recommendations since the same options for combination treatment at step 2 are available. The committee agreed that the choice of drug should be discussed and agreed with the person, based on the person's step 1 treatment, the risks and benefits of each treatment option, and taking into account the person's preferences and other clinical factors. The updated recommendations reflect this, giving the choice of possible treatment options. A NICE patient decision aid on treatment choices for high blood pressure has been developed to support healthcare professionals and people with hypertension to discuss their treatment options and make informed decisions. How the recommendations might affect practice The recommendations are unlikely to alter current practice. The options for drug treatment remain the same and most step 2 or 3 treatment decisions are already based on an individualised approach. Return to recommendations Step 4 treatment Why the committee made the recommendations No evidence on step 4 treatment was identified that could be used to formulate new recommendations. However, the committee reviewed the 2011 recommendations and agreed that they should be retained and updated to reflect current best practice. The committee discussed the importance of confirming resistant hypertension before starting step 4 treatment. Based on their clinical experience and knowledge of best current practice, the committee members agreed that a recommendation to highlight this would help prevent overtreatment and ensure that people receive the right care. Despite the lack of evidence formally reviewed, the committee discussed the recommendation based on their clinical experience, taking the 2011 recommendations into account. The committee agreed that although the evidence for spironolactone did not meet the criteria for inclusion in the updated review for the guideline because the key study had a very short follow up and did not report any of the cardiovascular outcomes specified in this review protocol, the use of an aldosterone antagonist is now common clinical practice. Therefore, there was no reason to suggest that this recommendation should be changed. In the 2011 guideline, high-dose thiazide diuretics were recommended as a potential step 4 treatment in people with high blood potassium levels. The committee felt that there was a lack of evidence for this approach and noted that the studies did not show an improvement in cardiovascular outcomes at higher doses, albeit in people without resistant hypertension. The committee agreed that the recommendation for considering alpha- or beta-blockers should be retained based on significant clinical experience of their safe and effective use and because adding a further drug is likely to have a greater effect on blood pressure than increasing the thiazide diuretic dose. How the recommendations might affect practice The recommendations represent current good practice and so should not change practice. High-dose thiazide diuretics are not commonly used as step 4 therapy and so removing this should not change practice. There might be a small reduction in step 4 treatment with more thorough checks to confirm resistant hypertension. However, this may also result in an increase in blood pressure measurements to appropriately confirm resistant hypertension where this is not already being done. Return to recommendations Identifying who to refer for same-day specialist review Why the committee made the recommendations There was no evidence identified to inform recommendations on this topic. The committee reviewed the 2011 recommendations and agreed that they should be updated by consensus based on their clinical expertise. In particular they agreed it would be helpful to clarify which features warranted same-day referral, which would need further investigation and when repeat blood pressure measurement should be taken. The committee noted that it can be difficult to differentiate between accelerated hypertension and severe hypertension. They discussed the advantages and disadvantages of broader criteria for same-day referral, which would increase referrals to hospital but reduce the risk of missing people who need urgent treatment. The committee decided it would be beneficial to add some emergency symptoms to the existing recommendation, which will help healthcare professionals to decide when to refer. Based on their experience, the committee members agreed that some people with severe hypertension could be receiving unnecessary treatment because the 2011 guideline recommended treatment based on severe hypertension alone. The committee agreed that this could be prevented if investigations for target organ damage were carried out quickly before offering treatment in people with severely raised blood pressure and no other symptoms of concern. The committee also agreed that checking blood pressure again within 7 days in people with no target organ damage would ensure that people with severe hypertension are followed up and offered suitable treatment. The committee agreed that further research is needed in this area, particularly for people with extreme hypertension (220/120 mmHg or higher) or emergency symptoms. The committee members developed a recommendation for research on same-day hospital specialist assessment to help inform future recommendations. How the recommendations might affect practice The emergency symptoms listed in the recommendation may lead to more referrals to hospital. However, people with emergency symptoms will benefit from urgent treatment because accelerated hypertension can be fatal if untreated. There may be some additional resource use from doing target organ damage tests more quickly and re-measuring blood pressure within 7 days. However, the number of people started on treatment immediately may be reduced because of undertaking investigations first. The population with severe hypertension is very small, and the proportion with severe hypertension and additional symptoms that suggest accelerated hypertension is even smaller; therefore, resource impact is unlikely to be substantial. Return to recommendations Context High blood pressure (hypertension) is one of the most important, treatable causes of premature morbidity and mortality in the world. It is a major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. In 2015, it was reported that high blood pressure affected more than 1 in 4 adults in England (31% of men; 26% of women) around 13.5 million people and contributed to 75,000 deaths. The clinical management of hypertension accounts for 12% of visits to primary care and up to 2.1 billion of healthcare expenditure. Managing the cardiovascular events caused by hypertension also consumes considerable resources. The guideline covers adults (over 18 years) with suspected or diagnosed hypertension, including those with type 2 diabetes. Between 2010 and 2020, progress has been made to improve the diagnosis and management of hypertension: the population average blood pressure in England has fallen by about 3 mmHg systolic and the proportion of adults with untreated high blood pressure has decreased. However, the Public Health England Blood Pressure Action Plan called for further action to reduce the population average blood pressure by 5 mmHg through improved prevention, detection and management (Public Health England's Tackling high blood pressure: from evidence into action, 2015 and Tackling high blood pressure: an update, 2018). Since the publication of the 2011 NICE guideline on hypertension, new studies have been published in key areas of management; in particular, the optimal method and threshold for diagnosis of hypertension, managing blood pressure in lower risk populations and reducing blood pressure to lower targets in people with hypertension (including those with type 2 diabetes). The updated guideline makes new recommendations in these areas, based on the evidence, that aim to improve care and reduce variation in current practice. Treating resistant hypertension (when more than 3 drugs are needed to treat hypertension) remains challenging. New data was also reviewed in this area and the recommendations updated. There is uncertainty in current practice about which people with symptomatic very high blood pressure (accelerated hypertension) to refer for immediate assessment. The available evidence was reviewed and new recommendations made to provide guidance for primary care on when to refer. Finding more information and committee details To find NICE guidance on related topics, including guidance in development, see the NICE webpage on hypertension. For full details of the evidence and the guideline committee's discussions, see the evidence reviews. You can also find information about how the guideline was developed, including details of the committee. NICE has produced tools and resources to help you put this guideline into practice. For general help and advice on putting our guidelines into practice, see resources to help you put NICE guidance into practice. Update information March 2022: We have reviewed the evidence on blood pressure targets for people with cardiovascular disease, and made a new recommendation. This is marked [2022]. We have also reassessed the evidence on antihypertensive drug treatment, and made a new recommendation for people with cardiovascular disease. This is marked [2022]. For recommendations ending [2019, amended 2022], we have not reviewed the evidence for people without cardiovascular disease. We have made minor changes to the wording of the recommendations without changing the intent. For an explanation of these changes, see the rationale and impact section on blood pressure targets for people with cardiovascular disease. August 2019: We have reviewed the evidence and made new recommendations on diagnosis, monitoring and drug treatment for hypertension, and identifying who to refer for same-day specialist review. These recommendations are marked [2019]. We have also made some changes without an evidence review: the information on cuff size for measuring blood pressure was moved to avoid repetition plasma glucose testing was replaced with glycated haemoglobin (HbA1C) to reflect current practice a note was added because of concerns about the risks of salt substitutes in some groups the information on when to refer to the hypertension in pregnancy guideline was made clearer. These recommendations are marked [2004, amended 2019] or [2011, amended 2019]. evidence review in that year. In some cases minor changes have been made to the wording to bring the language and style up to date, without changing the meaning. Recommendations 1.2.11 and 1.4.24 (marked [2009]) were originally published in section 1.4 of NICE's guideline on type 2 diabetes in adults, which was updated by this guideline. Minor changes since publication July 2022: In recommendation 1.5.1 we clarified the options for people with a blood pressure of 180/120 mmHg or more and no target organ damage. November 2021: We added a link to the blood pressure@home scheme in recommendation 1.4.17. December 2019: Recommendation 1.4.13 was amended to clarify that it applies to adults over 80 with stage 1 hypertension. We also made changes to introductory text to clarify that recommendations apply to all adults, including those with type 2 diabetes, unless links to other NICE guidelines indicate that treatment differs. Accreditation