2011英国高血压指南

英国高血压指南

BMJ2011;343:d4891doi:10.1136/bmj.d4891

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PRACTICE

GUIDELINES

Managementofhypertension:summaryofNICEguidance

TarynKrauseseniorprojectmanager,researchfellow1,KateLovibondseniorhealtheconomist1,MarkCaulfieldprofessorofclinicalpharmacology2,TerryMcCormackgeneralpractitioner3,BryanWilliamsprofessorofmedicine45,onbehalfoftheGuidelineDevelopmentGroup

1

National Clinical Guideline Centre Acute and Chronic Conditions, Royal College of Physicians, London NW1 4LE, UK;2William Harvey ResearchInstitute, Barts and the London School of Medicine, and NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, LondonEC1M 6BQ;3Whitby Group Practice, Spring Vale Medical Centre, Whitby YO21 1SD, UK;4Department of Cardiovascular Sciences, University ofLeicester, Leicester LE3 9QP, UK ;5Leicester NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester LE3 9QP

ThisisoneofaseriesofBMJsummariesofnewguidelinesbasedonthebestavailableevidence;theyhighlightimportantrecommendationsforclinicalpractice,especiallywhereuncertaintyorcontroversyexists.

HypertensionisoneofthemostimportantpreventablecausesofdeathworldwideandoneofthecommonestconditionstreatedinprimarycareintheUnitedKingdom,whereitaffectsmorethanaquarterofalladultsandoverhalfofthoseovertheageof65years.1Thisarticlesummarisesthemostrecent

recommendationsfromtheNationalInstituteforHealthandClinicalExcellence(NICE)onthemanagementofhypertension,2whichupdatesthe2004and2006clinicalguidelines.3-5

(Updatedrecommendation)[BasedontheexperienceandopinionoftheGuidelineDevelopmentGroup(GDG)]

Iftheclinicbloodpressureis140/90mmHgorhigher,useambulatorybloodpressuremonitoringtoconfirmthediagnosisofhypertension.Thisstrategywillimprovetheaccuracyofthediagnosiscomparedwithcurrentpractice6andwasalsoshowntobecosteffective—indeed,costsaving—fortheNHS.(Updatedrecommendation)[Basedonasystematicreviewofrandomisedcontrolledtrialsranginginqualityfrompoortogoodandoncosteffectivenessevidence] Whenusingambulatorybloodpressuremonitoringtoconfirmadiagnosisofhypertension,ensurethatatleasttwomeasurementsanhouraretakenduringtheperson’susualwakinghours(forexample,between0800and2200).Usetheaveragevalueofatleast14measurementstakenduringtheperson’susualwakinghourstoconfirma

diagnosisofhypertension.(Newrecommendation)[Basedonprognosticandreliabilityorreproducibilitystudiesdeterminedtobeatlowriskofbias]

Ifapersoncannottolerateambulatorybloodpressuremonitoring,homebloodpressuremonitoringisasuitablealternativetoconfirmthediagnosis.(New

recommendation)[Basedonasystematicreviewof

randomisedcontrolledtrialsranginginqualityfrompoortogoodandoncosteffectivenessevidence]

Whenusinghomebloodpressuremonitoringtoconfirmadiagnosisofhypertension:

-Foreachbloodpressurerecording,taketwoconsecutivemeasurements,atleastoneminuteapartandwiththepersonseated,and

Recommendations

NICErecommendationsarebasedonsystematicreviewsofbestavailableevidenceandexplicitconsiderationofcosteffectiveness.Whenminimalevidenceisavailable,

recommendationsarebasedontheGuidelineDevelopmentGroup’sexperienceandopinionofwhatconstitutesgood

practice.Evidencelevelsfortherecommendationsaregiveninitalicinsquarebrackets.

Diagnosinghypertension

Ifbloodpressuremeasuredintheclinicis140/90mmHgorhigher:

-Takeasecondmeasurementduringtheconsultation-Ifthesecondmeasurementissubstantiallydifferentfromthefirst,takeathirdmeasurement

-Recordthelowerofthelasttwomeasurementsastheclinicbloodpressure.

Correspondence to: B Williams, Department of Cardiovascular Sciences, University of Leicester and Leicester NIHR Cardiovascular BiomedicalResearch Unit, Glenfield Hospital, Leicester LE2 7LX bw17@le.ac.uk

英国高血压指南

-Recordbloodpressuretwicedaily,ideallyinthemorningandevening,and

-Continuerecordingbloodpressureforatleastfourdays,ideallyforsevendays,and

-Discardthemeasurementstakenonthefirstdayandusetheaveragevalueofalltheremainingmeasurementstoconfirmadiagnosisofhypertension.

(Newrecommendation)[Basedonprognosticand

reproducibilitystudiesdeterminedtobeatlowriskofbias] Whilewaitingforaconfirmeddiagnosisofhypertension,investigatetargetorgandamage(suchasleftventricularhypertrophy,chronickidneydisease,andhypertensiveretinopathy)andformallyassesscardiovascularrisk.(Newrecommendation)[BasedontheexperienceandopinionoftheGDG] Useriskequationstoassesscardiovascularrisk—forexample,theFraminghamriskcalculator7(asusedintheJointBritishSocieties’riskchartsavailableintheBritishNationalFormularyandavailablefromhttp://www.77cn.com.cn/bnf/bnf/61/204016.htm)andQRISK2(availablefromhttp://www.77cn.com.cn/).8[BasedontheNICEguidelineonlipidmodification9]

Forpeopleagedunder40yearswithstage1hypertensionandnoevidenceoftargetorgandamage,cardiovasculardisease,renaldiseaseordiabetes,considerseeking

specialistevaluationforsecondarycausesofhypertensionandamoredetailedassessmentofpotentialtargetorgandamage.Thisisbecause10yearcardiovascularriskassessmentscanunderestimatethelifetimeriskof

cardiovasculareventsintheseyoungerpeople.(Updatedrecommendation)[Basedonsystematicreviewsand

meta-analysesoflowqualityobservationalandlowtohighqualityrandomisedcontrolledtrials;prognosticstudiesdeterminedtobeatlowriskofbias;andabloodpressureequivalencestudyoflowquality]

Bloodpressuremedication

Thefigure outlinesanalgorithmshowingthefourstepsinthedrugtreatmentofhypertension.

Ifbloodpressureisnotcontrolledbythetreatmentofferedateachstep,reviewmedicationtoensurethatthetreatmentisatoptimalorbesttolerateddosesbeforemovingtothenextstep.(Updatedrecommendation)[BasedontheexperienceandopinionoftheGDG] Forpeopleaged80yearsandover,offerthesame

antihypertensivedrugtreatmentasforpeopleaged55-80years,takingintoaccountanycomorbidities.(Updatedrecommendation)[Basedonasystematicreviewandmeta-analysisincludingmoderatetohighquality

randomisedcontrolledtrials,andoncosteffectivenessevidence]

Thresholdsforintervention

Ifthepersonhasseverehypertension(clinicbloodpressure≥180/110mmHg),considerstartingantihypertensivedrugtreatmentimmediately,withoutwaitingfortheresultsofambulatoryorhomebloodpressuremonitoring.(Newrecommendation)[BasedontheexperienceandopinionoftheGDG]

Offerlifestyleadvicetopeoplewithhypertensionatinitialdiagnosisandthenperiodicallythereafter[BasedontheexperienceandopinionoftheGDG]

Offerantihypertensivedrugtreatmenttopeopleagedunder80yearswithstage1hypertension(thatis,anaverageambulatoryorhomebloodpressureof≥135/85mmHgand<150/95mmHg;aclinicbloodpressureof≥140/90mmHgand<160/100mmHg)andwhohaveoneormoreofthefollowing:

-Targetorgandamage

-Establishedcardiovasculardisease-Renaldisease-Diabetes

-A10yearcardiovascularriskequivalentto≥20%.(Updatedrecommendation)[Basedonsystematicreviewsandmeta-analysesoflowqualityobservationalandlowtohighqualityrandomisedcontrolledtrials;prognosticstudiesdeterminedtobeatlowriskofbias;andabloodpressureequivalencestudyoflowquality]

Offerantihypertensivedrugtreatmenttopeopleofanyagewithstage2hypertension(anaverageambulatoryorhomebloodpressureof≥150/95mmHg;aclinicbloodpressure≥160/100mmHg)irrespectiveofthepresenceoftargetorgandamage,cardiovasculardisease,renaldisease,orthe10yearriskofcardiovasculardisease.(Updatedrecommendation)[Basedonsystematicreviewsand

meta-analysesoflowqualityobservationalandlowtohighqualityrandomisedcontrolledtrials;prognosticstudiesdeterminedtobeatlowriskofbias;andalowqualityobservationalstudy]

Step1

Forpeopleagedunder55years,offeranangiotensinconvertingenzyme(ACE)inhibitororalowcost

angiotensinIIreceptorblocker(ARB).IfanACEinhibitorisprescribedandisnottolerated(forexample,becauseofcough),offeranARB.(Updatedrecommendation)[Basedonalowtohighqualityrandomisedcontrolledtrialandoncosteffectivenessevidence]

DonotcombineanACEinhibitorwithanARBtotreathypertension.Thisisnotthemostrationalcombinationtoreducebloodpressureandmayresultinmoreadverseeventswithoutanyadditionalclinicalbenefit.10(Updatedrecommendation)[Basedlowtohighqualityevidencefromarandomisedcontrolledtrial]

Forpeopleagedover55yearsandblackpeopleofAfricanorCaribbeanfamilyoriginofanyage,offeracalciumchannelblocker.Ifthisisnotsuitable—forexample,becauseofoedemaorintolerance—orifthereisevidenceofheartfailureorahighriskofheartfailure,offera

thiazide-likediuretic.(Updatedrecommendation)[Basedonamoderatetohighqualityrandomisedcontrolledtrialandcosteffectivenessevidence]

Ifdiuretictreatmentistobestartedorchanged,offerathiazide-likediuretic,suchaschlortalidone(12.5-25.0mgoncedaily)orindapamide(1.5mgmodifiedreleaseoncedailyor2.5mgoncedaily),inpreferencetoaconventionalthiazidediureticsuchasbendroflumethiazideor

hydrochlorothiazide.(Updatedrecommendation)[Basedonmoderatetoverylowqualityevidencefromrandomisedcontrolledtrials]

Forpeoplewhoarealreadytakingbendroflumethiazideorhydrochlorothiazideandwhosebloodpressureisstable

英国高血压指南

andwellcontrolled,continuetreatmentwiththe

bendroflumethiazideorhydrochlorothiazide.(Updatedrecommendation)[BasedonmoderatetoverylowqualityevidencefromrandomisedcontrolledtrialsandontheexperienceandopinionoftheGDG]

onsystematicreviewsofverylowtomoderatequalityrandomisedcontrolledtrials,andcosteffectivenessevidence]

Forpeopleidentifiedashavinga“whitecoateffect”—thatis,adiscrepancyofmorethan20/10mmHgbetweenclinicandaveragedaytimeambulatorybloodpressureoraveragehomebloodpressuremeasurementsatthetimeofdiagnosis—considerambulatoryorhomebloodpressuremonitoringasanadjuncttoclinicbloodpressuremeasurementstomonitortheresponsetoantihypertensivetreatmentwithlifestylemodificationordrugs.(Updatedrecommendation)[Basedonsystematicreviewsandmeta-analysesofverylowtomoderatequalityrandomisedcontrolledtrials]

Step2

OfferacalciumchannelblockerincombinationwitheitheranACEinhibitororanARB.(Updatedrecommendation)[Basedonevidencefromamoderatequalityrandomisedcontrolledtrial]

Ifacalciumchannelblockerisnotsuitableforstep2treatment—forexample,becauseofoedemaor

intolerance—orifthereisevidenceofheartfailureorahighriskofheartfailure,offerathiazide-likediuretic.(Updatedrecommendation)[Basedonamoderatequalityrandomisedcontrolledtrial]

Bloodpressuretargets

Aimforatargetclinicbloodpressurebelow140/90mmHginpeopleagedunder80yearswithtreatedhypertension.(Updatedrecommendation)[Basedonsystematicreviewsofverylowtomoderatequalityrandomisedcontrolledtrials,andobservationalstudies]

Aimforatargetclinicbloodpressurebelow150/90mmHginpeopleaged80yearsandoverwithtreated

hypertension.(Updatedrecommendation)[Basedonasystematicreviewandmeta-analysisthatincluded

moderateandhighqualityrandomisedcontrolledtrials]

Step3

Iftreatmentwiththreedrugsisneeded,offeranACEinhibitororARB,combinedwithacalciumchannelblockerandathiazide-likediuretic.(Updatedrecommendation)[BasedonmoderatetoverylowqualityevidencefromrandomisedcontrolledtrialsandontheexperienceandopinionoftheGDG]

Step4(Resistanthypertension)

Overcomingbarriers

Therecommendationthatambulatorybloodpressureratherthanclinicbloodpressuremeasurementsshouldbeusedtoconfirmthediagnosisofhypertensionwillhaveaprofoundimpactonpatientcarebyreducingthenumberwhoareincorrectlylabelledashypertensiveandthusinappropriatelyprescribed

antihypertensivetreatment.Currently,onlysomeprimarycarepracticeshaveaccesstoambulatorybloodpressuremonitoringdevices,withtheresthavingtoaccessthemthroughreferraltosecondarycare.Sufficientnumbersofvalidatedambulatorydevices(http://www.77cn.com.cn/blood_pressure_list.stmforalistofclinicallyvalidatedmonitors)willneedtobeprocuredandadequatelymaintained.Staffwillneedtobetrainedintheiruseandhowtointerpretdatageneratedinthereports.Theimplementationofambulatorybloodpressuremonitoringshouldbedeterminedlocally,reflectwhatisbestandmostconvenientforpatients,andnotnecessarilybebasedoncurrentmodelsofserviceconfiguration.TheGuidelineDevelopmentGroupanticipatesthatpracticesandconsortiumswilldevisevariousstrategiesthatdonotinvolvespecialistreferraltoexpandprovision,andthatprocurementcostswillfallasdemandincreases.

ThemembersoftheGuidelineDevelopmentGroupwereBryanWilliams(chair),HelenWilliams,JaneNorthedge,JohnCrimmins,MarkCaulfield,MichaelaWatts,NaomiStetson,RichardMcManus,ShelleyMason,TerryMcCormack,BernardHiggins,KateLovibond,PaulMiller,RachelO’Mahony,andTarynKrause.

TKwrotethefirstdraft,andallauthorswereinvolvedinwritingfurtherdraftsandreviewedandapprovedthefinalversionforpublication.BWistheguarantor.

Funding:TheNationalClinicalGuidelineCentrewascommissionedandfundedbytheNationalInstituteforHealthandClinicalExcellencetowritethissummary.

Competinginterests:http://www.77cn.com.cn/coi_disclosure.pdf(availableonrequestfromthecorrespondingauthor)anddeclare:TKandKLwere

Ifclinicbloodpressureremainshigherthan140/90mmHgaftertreatmentwiththeoptimalorbesttolerateddosesofthedrugcombinationmentionedinstep3(anACEinhibitororanARBcombinedwithacalciumchannelblockerandadiuretic),regardthisasresistanthypertension,andconsideraddingafourthantihypertensivedrugand/orseekingexpertadvice.(Updatedrecommendation)[Basedonlowqualityobservationalevidence]

Fortreatmentofresistanthypertension:

-Considerfurtherdiuretictreatmentwithlowdose

spironolactone(25mgoncedaily)ifthebloodpotassiumconcentrationis4.5mmol/http://www.77cn.com.cneparticularcautioninpeoplewithareducedestimatedglomerularfiltrationratebecausetheyhaveanincreasedriskofhyperkalaemia

-Considerhigherdosethiazide-likediuretictreatmentifthebloodpotassiumconcentrationishigherthan4.5mmol/L.

(Updatedrecommendation)[Basedonlowqualityobservationalevidence]

Iffurtherdiuretictreatmentforresistanthypertensionatstep4isnottoleratedoriscontraindicatedorineffective,consideranαblockerorβblocker.(Updated

recommendation)[Basedonlowqualityobservationalstudies]Ifbloodpressureremainsuncontrolledwiththeoptimalormaximumtolerateddosesoffourdrugs,seekexpertadviceifnotyetobtained.(Updatedrecommendation)[BasedontheexperienceandopinionoftheGDG]

Monitoringbloodpressuretreatment

Useclinicbloodpressuremeasurementstomonitortheresponsetoantihypertensivetreatmentwithlifestyle

modificationsordrugs.(Updatedrecommendation)[Based

英国高血压指南

BMJ2011;343:d4891doi:10.1136/bmj.d4891Page4of6

Furtherinformationontheguidance

Thisupdatedguidelinecontainskeyrecommendationsthatrelatetothediagnosisofhypertension,thresholdsforstartingantihypertensivetreatment,bloodpressuretreatmenttargets,monitoringbloodpressuretreatment,andanupdatedalgorithmforantihypertensivetreatment.Recommendationsfromthepreviousguidelinesthathavenotbeenupdatedremain,includingthoseonlifestyleadvice,whichwerenotreviewedforthisupdate.What’snew

Ambulatorybloodpressuremonitoringismoreaccurateandcosteffectivethanclinicbloodpressuremeasurementforconfirmingthediagnosisofhypertension.

Homebloodpressuremonitoringismoreaccuratethanclinicbloodpressuremeasurementbutlessaccuratethanambulatorybloodpressuremonitoringforconfirmingthediagnosisofhypertension.

Adiagnosisofstage1hypertensioninpatientsagedunder40yearsmightnotbebenign,andthesepeopleshouldnotautomaticallybeexcludedfromreceivingantihypertensivetreatment.

Evidencesupportstheprovisionofantihypertensivetreatmenttopeopleagedover80years.

ThereisanabsenceofevidenceforuseofbendroflumethiazideatthedosescommonlyprescribedincurrentUKpractice.Methods

TheGuidelineDevelopmentGroupfollowedthestandardNICEmethodsinthedevelopmentofthisguideline(http://www.77cn.com.cn.uk/aboutnice/howwework/developingniceclinicalguidelines/developing_nice_clinical_guidelines.jsp).Thisinvolvedsystematicsearching,criticallyappraising,andsummarisingtheclinicalandcosteffectivenessevidence.Newcost

effectivenessanalysiswasalsoundertaken,comparingdifferentmethodsfordiagnosinghypertension,andthepreviousdevelopedcosteffectivenessanalysisoffirstlinedrugtreatmentwasupdated.Thedraftguidelinewentthrougharigorousreviewingprocess,inwhichstakeholderorganisationswereinvitedtocomment;allcommentsweretakenintoconsiderationwhenproducingthefinalversionoftheguideline.

Theguidelinegroupcomprisedaconsultantincardiovascularmedicine(chair),twopatientrepresentatives,onepharmacist,threegeneralpractitioners,aclinicalpharmacologist,andtwonurses.

Evidencestatementsinthissummaryrelatetotheguidelineupdate.QualityratingswerebasedonGRADEmethodology(http://www.77cn.com.cn).Theserelatetothequalityoftheavailableevidenceforassessedoutcomesratherthanthequalityoftheclinicalstudy.Outcomesassessedincludedmortality,heartfailure,newonsetdiabetesmellitus,vascularprocedures,angina,healthrelatedqualityoflife,andbloodpressureresponsetotreatment.Costeffectivenessanalysisformethodofdiagnosis

Aneconomicmodelwasdevelopedtocomparethecosteffectivenessofthreedifferentoptionsforbloodpressuremeasurementfordiagnosinghypertension:clinic,home,andambulatorybloodpressuremonitoring.Ambulatorybloodpressuremonitoringwasthemostcosteffectivestrategyformenandwomenofallages.Itwascostsavingforallagesconsideredforbothmenandwomenandresultedinmorequalityadjustedlifeyears(QALYs)formaleandfemaleagegroupsover50.Thisresultwasrobusttoawiderangeofsensitivityanalysesaroundthebasecasebutwassensitiveifhomemonitoringwasconsideredtohaveequaltestperformancetoambulatorymonitoringoriftreatmentwasconsideredeffectiveinindividualswhowerenothypertensive.Costeffectivenessanalysisforfirstlinedrugtreatment

Theeconomicmodelassessingfirstlinedrugtreatmentdevelopedaspartoftheclinicalguideline344wasupdated.Thiscomparednointervention,ACEinhibitororARB,βblockers,calciumchannelblockers,andthiazide-typediureticsintermsoflifetimecostsandqualityadjustedlifeyears(QALYs)fromaUKhealthserviceperspective.DrugcostswerebasedongenericUKlistprices.Treatinghypertensionwashighlycosteffective,resultinginimprovedhealthoutcomes(moreQALYs)andcostsavingswithalldrugclassescomparedwithnotreatment.Calciumchannelblockerswereshowntobethemostcosteffectiveintervention,withanincrementalcosteffectivenessratioofunder£2000(

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