The latest UK National Institute for Health and Clinical Excellence (NICE) guidelines on antihypertensives “should be welcomed” as “a pragmatic compromise”, writes The Lancet in an editorial.
The latest UK National Institute for Health and Clinical Excellence (NICE) guidance recommends that antihypertensives be offered to people younger than 80 years with stage 1 hypertension and a 10% or greater risk of developing cardiovascular disease within the next 10 years.
Stage 1 hypertension is defined as 140/90 mm Hg and above. The guidance points out that the 10% or greater risk is a change from the 2011 guideline of a cardiovascular risk level of 20% or more.
The reduction, assessed using the QRISK2 score, should be welcomed since research has shown that a 10% threshold will result in the prevention of an additional 33% of cardiovascular events and would be almost as efficient as the previous threshold.
In 2015, approximately 13·5 million people in England were diagnosed with hypertension, which contributed to 75,000 deaths.
NICE estimates that the lowering of the cardiovascular risk will mean that an additional 450,000 men and 270,000 women would be eligible for treatment. However, research has shown that basing treatment on an arbitrary definition of hypertension is unhelpful because about 50% of the UK population aged 30-79 years have a systolic blood pressure (SBP) of 120-139 mm Hg (ideal SBP is 120 mm Hg or lower), yet none will be recommended for drug treatment by NICE, regardless of their cardiovascular disease risk.
For example, under the latest guidelines a patient with a SBP of 138 mm Hg and a 10-year risk of 20% will not be recommended for treatment, but a person with a SBP of 142 mm Hg and a 10-year risk of 10% will be: such a situation is illogical since the patient with a SBP of 138 mm Hg is likely to gain about twice the benefit from blood pressure lowering.
That NICE has stuck with a definition of hypertension at 140/90 mm Hg or greater but lowered the risk score to 10% is a pragmatic compromise. Updating the guidelines so that all patients with a SBP above the 120 mm Hg ideal and a cardiovascular risk score of 10% or higher would be offered treatment would have shown true grit.
Hypertension in adults: Diagnosis and management
NICE guideline [NG136]
This guideline covers identifying and treating primary hypertension (high blood pressure) in people aged 18 and over, including people with type 2 diabetes. It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively.