NICE and BHS guidelines on hypertension differ importantly

Editor—The NICE guidelines on hypertension remind the public that hypertension is a major risk factor for cardiovascular diseases. Their added value to those who manage hypertension is, however, unclear, given the recent national and international guidelines from experts and primary care doctors with an interest in hypertension.^1-3 The NICE guidance is largely consistent with these guidelines, but it differs from those of the British Hypertension Society in several important ways, thereby leading to confusion and potentially suboptimal management of hypertension. However, if both sets of guidelines improve the control of blood pressure the differences between guidelines will become less critical.

The NICE recommendation to treat hypertension initially with a thiazide-like diuretic irrespective of age, ethnic group, and whether isolated systolic hypertension is present or not is not supported by best evidence. Small crossover studies and large randomised trial data show differential effects on blood pressure with different antihypertensive agents by ethnic group and age.⁴,⁵ w1 In black patients these differences have been reflected in differential major cardiovascular outcomes by drug class.^w1

Two large trials inform optimal practice in managing isolated systolic hypertension, so treating isolated systolic hypertension as if both systolic and diastolic blood pressures are raised seems unwise.^{w2 3}

Dihydropyridine calcium channel blockers are incorrectly described by NICE as contraindicated in hypertensive patients with heart failure. Although the ALLHAT trial suggests other agents may be preferable for preventing heart failure,^w1 calcium channel blockers are often needed as part of the cocktail of agents used to control blood pressure in heart failure.

The proposals to substitute lifestyle modification for drug treatment in patients with well-controlled hypertension are, on average, likely to worsen wellbeing.

Practitioners should continue to use the ABCD algorithm for drug sequencing because it is simple, easy to remember, flexible, and logical.³ It facilitates rapid and effective blood pressure lowering, is based on best currently available evidence, and advises how to change drugs without loss of blood pressure control in the 10% of patients yearly whom NICE recognises develop side effects with each drug.

Finally, the web based version of the NICE guidelines needs careful proofreading to correct some of the more obvious errors, such as coronary obstructive airways disease—presumably chronic obstructive airways disease is intended—and to ensure consistency in quoted blood pressure targets and thresholds.