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Proposal to lower threshold for hypertension treatment

NICE proposals could benefit thousands of patients

Adrian O'Dowd

Friday, 08 March 2019

The National Institute for Health and Care Excellence (NICE) is proposing to lower the threshold at which people can receive treatment for hypertension in a new draft updated guideline issued today.

However, a GP leader has urged caution over such a change as proposed in the draft guidance on diagnosis and treatment of hypertension out for public consultation, warning of possible overdiagnosis and limited benefits.


In 2015, it was reported that in England, high blood pressure affected more than a quarter of adults – around 13.5 million people – and contributed to 75,000 deaths. The clinical management of hypertension accounts for 12% of visits to primary care and as much as £2.1bn of healthcare expenditure.

Over the last decade progress has been made to improve the diagnosis and management of hypertension.

In the biggest change to the previous guidance published in 2011, the threshold for cardiovascular disease (CVD) risk at which treatment for high blood pressure should be considered has been reduced in the new guideline.

The draft guideline recommends that blood pressure lowering drugs should be offered to people aged under 80 with a diagnosis of stage 1 hypertension who have an estimated 10-year risk of CVD of 10% or more.

Stage 1 hypertension is defined as a clinic blood pressure reading of 140/90 mmHg or higher, or an ambulatory blood pressure daytime average or home blood pressure monitoring average of 135/85 mmHg or higher.

It is estimated that around 450,000 men and 270,000 women would fall into the category of having stage 1 hypertension and a CVD risk of between 10% and 20%.

However, it is difficult to predict what impact using the lower CVD risk threshold will have in practice because there is variability in how the 2011 recommendation with a threshold of 20% is being implemented in practice.

Anthony Wierzbicki, consultant in metabolic medicine and chemical pathology, and chair of the guideline committee, said: “Many people with high blood pressure don’t actually know they have it because it rarely causes any noticeable symptoms.

“However, it is by far the biggest preventable cause of death and disability in the UK through strokes, heart attacks and heart failure. A rigorous evaluation of new evidence has resulted in updated recommendations around when to treat raised blood pressure that have the potential to make a real difference to the lives of many thousands of people with the condition.

“The guideline effectively shifts the focus to earlier intervention with lifestyle or drug treatment because this may slow the age-related deterioration of blood pressure. This would keep people well for longer and reduce the long-term need for multiple medications.”

Professor Helen Stokes-Lampard, chair of the Royal College of GPs, said: “Taking steps to prevent cardiovascular disease in patients is vital to help safeguard their long-term health and wellbeing. But many GPs do also have concerns about overdiagnosis and the unintended harms of prescribing medication to groups of patients when the benefits may be limited.

“Lowering the threshold for making a diagnosis of hypertension – a condition that already affects a very large number of patients in the UK - is likely to affect thousands, if not millions of patients, so this decision must not be taken lightly and must be evidence-based.

“Clinical guidelines are regularly updated to take into account the most current research and make recommendations of how to implement it in the best interests of patients. Now that this draft guideline is open for consultation, we would encourage experts in the area to respond to express their views.”

The draft guideline is open for public consultation until 23 April and final guidance is expected to be published in August.

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