2011英国高血压指南

英国高血压指南

BMJ2011;343:d4891doi:10.1136/bmj.d4891

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PRACTICE

GUIDELINES

Managementofhypertension:summaryofNICEguidance

TarynKrauseseniorprojectmanager,researchfellow1,KateLovibondseniorhealtheconomist1,MarkCaulfieldprofessorofclinicalpharmacology2,TerryMcCormackgeneralpractitioner3,BryanWilliamsprofessorofmedicine45,onbehalfoftheGuidelineDevelopmentGroup

1

National Clinical Guideline Centre Acute and Chronic Conditions, Royal College of Physicians, London NW1 4LE, UK;2William Harvey ResearchInstitute, Barts and the London School of Medicine, and NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, LondonEC1M 6BQ;3Whitby Group Practice, Spring Vale Medical Centre, Whitby YO21 1SD, UK;4Department of Cardiovascular Sciences, University ofLeicester, Leicester LE3 9QP, UK ;5Leicester NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester LE3 9QP

ThisisoneofaseriesofBMJsummariesofnewguidelinesbasedonthebestavailableevidence;theyhighlightimportantrecommendationsforclinicalpractice,especiallywhereuncertaintyorcontroversyexists.

HypertensionisoneofthemostimportantpreventablecausesofdeathworldwideandoneofthecommonestconditionstreatedinprimarycareintheUnitedKingdom,whereitaffectsmorethanaquarterofalladultsandoverhalfofthoseovertheageof65years.1Thisarticlesummarisesthemostrecent

recommendationsfromtheNationalInstituteforHealthandClinicalExcellence(NICE)onthemanagementofhypertension,2whichupdatesthe2004and2006clinicalguidelines.3-5

(Updatedrecommendation)[BasedontheexperienceandopinionoftheGuidelineDevelopmentGroup(GDG)]

Iftheclinicbloodpressureis140/90mmHgorhigher,useambulatorybloodpressuremonitoringtoconfirmthediagnosisofhypertension.Thisstrategywillimprovetheaccuracyofthediagnosiscomparedwithcurrentpractice6andwasalsoshowntobecosteffective—indeed,costsaving—fortheNHS.(Updatedrecommendation)[Basedonasystematicreviewofrandomisedcontrolledtrialsranginginqualityfrompoortogoodandoncosteffectivenessevidence] Whenusingambulatorybloodpressuremonitoringtoconfirmadiagnosisofhypertension,ensurethatatleasttwomeasurementsanhouraretakenduringtheperson’susualwakinghours(forexample,between0800and2200).Usetheaveragevalueofatleast14measurementstakenduringtheperson’susualwakinghourstoconfirma

diagnosisofhypertension.(Newrecommendation)[Basedonprognosticandreliabilityorreproducibilitystudiesdeterminedtobeatlowriskofbias]

Ifapersoncannottolerateambulatorybloodpressuremonitoring,homebloodpressuremonitoringisasuitablealternativetoconfirmthediagnosis.(New

recommendation)[Basedonasystematicreviewof

randomisedcontrolledtrialsranginginqualityfrompoortogoodandoncosteffectivenessevidence]

Whenusinghomebloodpressuremonitoringtoconfirmadiagnosisofhypertension:

-Foreachbloodpressurerecording,taketwoconsecutivemeasurements,atleastoneminuteapartandwiththepersonseated,and

Recommendations

NICErecommendationsarebasedonsystematicreviewsofbestavailableevidenceandexplicitconsiderationofcosteffectiveness.Whenminimalevidenceisavailable,

recommendationsarebasedontheGuidelineDevelopmentGroup’sexperienceandopinionofwhatconstitutesgood

practice.Evidencelevelsfortherecommendationsaregiveninitalicinsquarebrackets.

Diagnosinghypertension

Ifbloodpressuremeasuredintheclinicis140/90mmHgorhigher:

-Takeasecondmeasurementduringtheconsultation-Ifthesecondmeasurementissubstantiallydifferentfromthefirst,takeathirdmeasurement

-Recordthelowerofthelasttwomeasurementsastheclinicbloodpressure.

Correspondence to: B Williams, Department of Cardiovascular Sciences, University of Leicester and Leicester NIHR Cardiovascular BiomedicalResearch Unit, Glenfield Hospital, Leicester LE2 7LX bw17@le.ac.uk

英国高血压指南

-Recordbloodpressuretwicedaily,ideallyinthemorningandevening,and

-Continuerecordingbloodpressureforatleastfourdays,ideallyforsevendays,and

-Discardthemeasurementstakenonthefirstdayandusetheaveragevalueofalltheremainingmeasurementstoconfirmadiagnosisofhypertension.

(Newrecommendation)[Basedonprognosticand

reproducibilitystudiesdeterminedtobeatlowriskofbias] Whilewaitingforaconfirmeddiagnosisofhypertension,investigatetargetorgandamage(suchasleftventricularhypertrophy,chronickidneydisease,andhypertensiveretinopathy)andformallyassesscardiovascularrisk.(Newrecommendation)[BasedontheexperienceandopinionoftheGDG] Useriskequationstoassesscardiovascularrisk—forexample,theFraminghamriskcalculator7(asusedintheJointBritishSocieties’riskchartsavailableintheBritishNationalFormularyandavailablefrom/bnf/bnf/61/204016.htm)andQRISK2(availablefrom/).8[BasedontheNICEguidelineonlipidmodification9]

Forpeopleagedunder40yearswithstage1hypertensionandnoevidenceoftargetorgandamage,cardiovasculardisease,renaldiseaseordiabetes,considerseeking

specialistevaluationforsecondarycausesofhypertensionandamoredetailedassessmentofpotentialtargetorgandamage.Thisisbecause10yearcardiovascularriskassessmentscanunderestimatethelifetimeriskof

cardiovasculareventsintheseyoungerpeople.(Updatedrecommendation)[Basedonsystematicreviewsand

meta-analysesoflowqualityobservationalandlowtohighqualityrandomisedcontrolledtrials;prognosticstudiesdeterminedtobeatlowriskofbias;andabloodpressureequivalencestudyoflowquality]

Bloodpressuremedication

Thefigure outlinesanalgorithmshowingthefourstepsinthedrugtreatmentofhypertension.

Ifbloodpressureisnotcontrolledbythetreatmentofferedateachstep,reviewmedicationtoensurethatthetreatmentisatoptimalorbesttolerateddosesbeforemovingtothenextstep.(Updatedrecommendation)[BasedontheexperienceandopinionoftheGDG] Forpeopleaged80yearsandover,offerthesame

antihypertensivedrugtreatmentasforpeopleaged55-80years,takingintoaccountanycomorbidities.(Updatedrecommendation)[Basedonasystematicreviewandmeta-analysisincludingmoderatetohighquality

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