2.2 Notes & Guidance
Please see NICE Clinical Guidelines CG 127 (December 2016) before starting anti-hypertensive medication.
Key priorities for implementation relating to drug treatment of hypertension include:
Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following:
• target organ damage
• established cardiovascular disease
• renal disease
• a 10-year cardiovascular risk equivalent to 20% or greater.
Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.
For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people.
Choosing antihypertensive drug treatment
Offer people aged 80 years and over the same antihypertensive drug treatment as people aged 55–80 years, taking into account any comorbidities.
Step 1 treatment
Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged over 55 years and to black people of African or Caribbean family origin of any age. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic.
If a diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.
For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide.
Step 4 treatment
For treatment of resistant hypertension at step 4:
Consider further diuretic therapy with low-dose spironolactone (25 mg once daily) if the blood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia.
Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5 mmol/l.
Further detail of this guidance available here
The treatment of hypertension during pregnancy is outlined in: