SudaMediCa, The Sudanese Medical Community

i found this note as one of the much useful and simple at the same time :-
NICE published updated guidelines for the management of hypertension in 2011. Some of the key changes include:
•classifying hypertension into stages
•recommending the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM)
•calcium channel blockers are now considered superior to thiazides
•bendroflumethiazide is no longer the thiazide of choice

Blood pressure classification

This becomes relevant later in some of the management decisions that NICE advocate.


Stage 1 hypertension

Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg


Stage 2 hypertension

Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg



Severe hypertension

Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg


Diagnosing hypertension

If a BP reading is >= 140 / 90 mmHg patients should be offered ABPM to confirm the diagnosis.

Patients with a BP reading of >= 180/110 mmHg should be considered for immediate treatment.

Ambulatory blood pressure monitoring (ABPM)
•at least 2 measurements per hour during the person’s usual waking hours (for example, between 08:00 and 22:00)
•use the average value of at least 14 measurements

If ABPM is not tolerated or declined HBPM should be offered.

Home blood pressure monitoring (HBPM)
•for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
•BP should be recorded twice daily, ideally in the morning and evening
•BP should be recorded for at least 4 days, ideally for 7 days
•discard the measurements taken on the first day and use the average value of all the remaining measurements

Managing hypertension

ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)
•treat if < 80 years of age and any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater

ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension)
•offer drug treatment regardless of age

For patients < 40 years consider specialist referral to exclude secondary causes.

Step 1 treatment
•patients < 55-years-old: ACE inhibitor (A)
•patients > 55-years-old or of Afro-Caribbean origin: calcium channel blocker

Step 2 treatment
•ACE inhibitor + calcium channel blocker (A + C)

Step 3 treatment
•add a thiazide diuretic (D, i.e. A + C + D)
•NICE now advocate using either chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide

NICE define a clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best tolerated doses as resistant hypertension. They suggest step 4 treatment or seeking expert advice

Step 4 treatment
•consider further diuretic treatment
•if potassium < 4.5 mmol/l add spironolactone 25mg od
•if potassium > 4.5 mmol/l add higher-dose thiazide-like diuretic treatment
•if further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker

If BP still not controlled seek specialist advice.

Blood pressure targets

Age < 80 years : 140/90 mmHg

Age > 80 years : 150/90 mmHg