The British Approach to Antihypertensive Therapy:

Guidelines from the National Institute of Health and Clinical

Excellence

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In 2011, the National Institute of Health and Clinical Excellence (NICE) in the UK published a simple step-wise treatment algorithm for the initiation and optimization of antihypertensive therapy

Treatment guidelines provide a systematic approach to blood pressure (BP) management

National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

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A simple step-wise algorithm to expedite BP control

Patient ≥55 years oldOR

Any age black person of African or Caribbean origin

Initiate ACEI or ARBStep 1

Step 2

Step 3

Step 4

Initiate CCB

CCB + ACEI or ARB

CCB + ACEI or ARB + thiazide-like diuretic

• Evaluate for treatment-resistant hypertension• Consider adding further diuretic or - or -blocker • Consider referral to a hypertension specialist

Yes

BP still above goal?

No

BP still above goal?

BP still above goal?

BP still above goal?

National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

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ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin-receptor blocker; CCB = calcium channel blocker.

Step 1: Initiating treatment

• Initial treatment decisions should be based on patient’s age and race

– Patients <55 years of age should start treatment with an ACEI or an ARB*

– Patients 55 years of age and patients who are black of African or Caribbean origin, regardless of age, should initiate therapy with a CCB

• In some cases, a CCB may not be suitable (eg, edema or intolerance)

─ If a CCB is not suitable or if there is evidence of heart failure or high risk of heart failure, a thiazide-like diuretic should be offered

*Do not combine an ACEI with an ARB.National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

Practice Tip: Once drug therapy is initiated, patients should return for follow-up and adjustment of medications at least monthly until the BP goal is reached.

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Patient ≥55 years oldOR

Any age black person of African or Caribbean

origin

Initiate ACEI or ARBStep 1

Step 2

Step 3

Step 4

Initiate CCB

CCB + ACEI or ARB

CCB + ACEI or ARB + thiazide-like diuretic

• Evaluate for treatment-resistant hypertension• Consider adding further diuretic or - or -blocker • Consider referral to a hypertension specialist

Yes

BP still above goal?

No

BP still above goal?

BP still above goal?

BP still above goal?

Step 2: Advancing therapy

• If single-drug therapy fails to control BP, patients should start combination therapy with a CCB in combination with either an ACEI or an ARB

• If a CCB is not appropriate for step 2 treatment, offer a thiazide-like diuretic

• For black people of African or Caribbean origin, consider an ARB rather than an ACEI in combination with a CCB

National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

Practice Tip: Thiazide-like diuretics such as chlortalidone or indapamide are preferred to conventional thiazide diuretics such as bendroflumethiazide or hydrochlorothiazide.

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Patient ≥55 years oldOR

Any age black person of African or Caribbean

origin

Initiate ACEI or ARBStep 1

Step 2

Step 3

Step 4

Initiate CCB

CCB + ACEI or ARB

CCB + ACEI or ARB + thiazide-like diuretic

• Evaluate for treatment-resistant hypertension• Consider adding further diuretic or - or -blocker • Consider referral to a hypertension specialist

Yes

BP still above goal?

No

BP still above goal?

BP still above goal?

BP still above goal?

Step 3: Triple-combination therapy

• If 2-drug combination therapy fails to control BP, the combination of an ACEI or an ARB + a CCB + a thiazide-like diuretic should be used

National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

Practice Tip: Treatment-resistant hypertension is frequently caused by suboptimal dosing. Before considering Step 3 treatment, review medication to ensure Step 2 treatment is at optimal or maximum tolerated doses.

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Patient ≥55 years oldOR

Any age black person of African or Caribbean

origin

Initiate ACEI or ARBStep 1

Step 2

Step 3

Step 4

Initiate CCB

CCB + ACEI or ARB

CCB + ACEI or ARB + thiazide-like diuretic

• Evaluate for treatment-resistant hypertension• Consider adding further diuretic or - or -blocker • Consider referral to a hypertension specialist

Yes

BP still above goal?

No

BP still above goal?

BP still above goal?

BP still above goal?

Step 4: Treatment-resistant hypertension

• BP >140/90 mm Hg after treatment with the optimal or maximum tolerated doses of an ACEI or an ARB + a CCB + a diuretic should be regarded as treatment-resistant hypertension

• Consider adding a fourth antihypertensive drug and/or seeking expert advice– An α- or β-blocker may be useful– Further diuretic therapy with low-dose

spironolactone should be considered, depending on the patient’s blood potassium level

National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence.

Practice Tip: If BP remains uncontrolled with the optimal or maximum tolerated doses of 4 drugs, seek the advice of a hypertension expert.

Power Over Pressurewww.poweroverpressure.com

Patient ≥55 years oldOR

Any age black person of African or Caribbean

origin

Initiate ACEI or ARBStep 1

Step 2

Step 3

Step 4

Initiate CCB

CCB + ACEI or ARB

CCB + ACEI or ARB + thiazide-like diuretic

• Evaluate for treatment-resistant hypertension• Consider adding further diuretic or - or -blocker • Consider referral to a hypertension specialist

Yes

BP still above goal?

No

BP still above goal?

BP still above goal?

BP still above goal?

Summary• The NICE guidelines provide a systematic, stepwise approach to the

treatment of hypertension– Start with single-drug therapy, either an ACEI or ARB, or a CCB,

depending on the patient’s age and race• If BP remains uncontrolled, initiate combination therapy with a CCB in

combination with either an ACEI or an ARB– Ensure that the regimen is titrated to optimal or maximum tolerated

doses• If 2-drug combination therapy fails to control BP, add a thiazide-like diuretic to

the regimen• If BP remains uncontrolled on a 3-drug regimen, the patient should be

considered treatment resistant– Consider adding a fourth antihypertensive agent, either an α- or β-blocker

or low-dose spironolactone– Seek the advice of a hypertension specialist

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