NICE (National institute for health and clinical excellence, in the UK, which sends out recommendations for many clinical issues — well-researched and probably less influenced by pharmaceutical money, etc –. These are very thoughtful guidelines with some major changes over JNC here (though rumor has it that a revised JNC is on the near horizon). A few very notable changes:–hctz should not be first line, and that in general, ccb’s be used first line in people over 55yo and in african-caribbean patients, while ace/arb’s be used in under 55yo non-african descent (use with care for women who might become pregnant, though there was an article suggesting that ACE-I not so bad in early pregnancy — ). There was a very interesting review, which argues that there are no efficacy data on low dose hctz and that high dose is dangerous (studies found inc in sudden cardiac deaths). Also much less decrease in ambulat bp monitoring on hctz low dose than on other meds — e.g. office BPs are ok with hctz (short-acting effect), but bp increases later so that 24-hour monitoring finds higher blood pressure on hctz. The advice to not use hctz applies as a single agent, not in combo with ace-i or betablocker, where hctz augments the effect of these synergistically. Chlorthalidone seems much better than hctz, as suggested in the messerli meta-analysis and supported by NICE, if one wants to use diuretic as first agent.
–should relax target BP in older (>80yo) to 150/90, on an individualized basis (I have many older patients who need target even higher than this, or they become dizzy and risk falling — either because of autonomic dysfunction leading to orthostatic hypotension, or orthostasis when they decrease their fluids some days or sweat more….)
–strong support for using ambulatory blood pressure monitoring for diagnosis of htn. Dovetails with review article , suggesting that pretty much anyone with office bp>140/90 should get one. (if severe htn, such as in the 180/110 or higher range, then treat). Bottom line: strong literature that 30% of patients with office htn have normal ambulatory bp, several articles reinforce that cardiac endpoints correlate with ambulatory bp and not office bp. both of these last articles find no relationship between office blood pressure and cardiac events. the refractory htn article (defining pts as higher than goal of 140/90 on 3 meds at full dose,including a diuretic) found that 40% of patients labeled as refractory are actually well-controlled as assessed by ambulat bp. Both NICE and the meta-analysis note that ambulatory bp monitoring may be difficult or unacceptible for some patients, and that home-based monitoring (and perhaps checking in the local pharmacies) may be adequate — but limited data.)
Geoff
Ed. note: (apologies that this note does not include specific article references; it was a prior post from another dissemination system)