Guidelines
Guidelines
Before you begin, have you completed:
- Hypertension: part one
- Hypertension: part two
- Hypertension: part three
NICE and European Society of Cardiology (ESC) and European Society of Hypertension (ESH) guidelines differ in their approaches, and it is important for pharmacy technicians to be aware of this in order to support patients on their chosen treatment pathway.
ESC/ESH guidelines recommend initiating treatment with two antihypertensive agents, unless systolic blood pressure is less than 150mmHg or the person is frail.
A summary of NICE guidelines
- Lifestyle advice should be offered to all people with high blood pressure (BP)
- Age over 80, clinic BP >150/90 mmHg: consider starting drug treatment
- Age less than 80 with target organ damage, cardiovascular disease (CVD), renal disease, diabetes or 10-year CVD risk greater than 10 per cent: discuss starting drug treatment
- Age less than 60 with 10-year CVD risk less than 10 per cent: consider starting drug treatment
- Age less than 40: consider specialist referral to evaluate secondary causes and assess long-term benefits and risks of treatment.
- Offer lifestyle advice and drug treatment
- Age less than 40: consider specialist referral to evaluate secondary causes and assess long- term benefits and risks of treatment.
- Offer lifestyle advice and drug treatment.
In cases where more than one medicine is required, NICE advocates a stepwise approach, with at least four weeks between each step to monitor for potential adverse drug reactions and to re-check BP readings.
At each step, discussions should be had with the patient about which medicine should suit them, based on their comorbidities and preferences.
People with hypertension that is resistant to three antihypertensives should have a discussion about their medicine-taking behaviour and beliefs prior to adding a step 4 medicine, and their BP readings should be confirmed using ABPM/HBPM. Their potassium levels should also be checked and if found to be >4.5 mmol/L, alpha or beta-blockers may be more appropriate than spironolactone.
When using diuretic therapy at step 4, blood tests including renal function, sodium and potassium, should be monitored one month after starting therapy and repeated annually.
Specialist advice should be sought if BP remains uncontrolled despite optimised therapy using four antihypertensive medicines.