2011英国高血压指南(2)

Forpeopleagedover55yearsandblackpeopleofAfricanorCaribbeanfamilyoriginofanyage,offeracalciumchannelblocker.Ifthisisnotsuitable—forexample,becauseofoedemaorintolerance—orifthereisevidenceofheartfailureorahighriskofheartfailure,offera

thiazide-likediuretic.(Updatedrecommendation)[Basedonamoderatetohighqualityrandomisedcontrolledtrialandcosteffectivenessevidence]

Ifdiuretictreatmentistobestartedorchanged,offerathiazide-likediuretic,suchaschlortalidone(12.5-25.0mgoncedaily)orindapamide(1.5mgmodifiedreleaseoncedailyor2.5mgoncedaily),inpreferencetoaconventionalthiazidediureticsuchasbendroflumethiazideor

hydrochlorothiazide.(Updatedrecommendation)[Basedonmoderatetoverylowqualityevidencefromrandomisedcontrolledtrials]

Forpeoplewhoarealreadytakingbendroflumethiazideorhydrochlorothiazideandwhosebloodpressureisstable

英国高血压指南

andwellcontrolled,continuetreatmentwiththe

bendroflumethiazideorhydrochlorothiazide.(Updatedrecommendation)[BasedonmoderatetoverylowqualityevidencefromrandomisedcontrolledtrialsandontheexperienceandopinionoftheGDG]

onsystematicreviewsofverylowtomoderatequalityrandomisedcontrolledtrials,andcosteffectivenessevidence]

Forpeopleidentifiedashavinga“whitecoateffect”—thatis,adiscrepancyofmorethan20/10mmHgbetweenclinicandaveragedaytimeambulatorybloodpressureoraveragehomebloodpressuremeasurementsatthetimeofdiagnosis—considerambulatoryorhomebloodpressuremonitoringasanadjuncttoclinicbloodpressuremeasurementstomonitortheresponsetoantihypertensivetreatmentwithlifestylemodificationordrugs.(Updatedrecommendation)[Basedonsystematicreviewsandmeta-analysesofverylowtomoderatequalityrandomisedcontrolledtrials]

Step2

OfferacalciumchannelblockerincombinationwitheitheranACEinhibitororanARB.(Updatedrecommendation)[Basedonevidencefromamoderatequalityrandomisedcontrolledtrial]

Ifacalciumchannelblockerisnotsuitableforstep2treatment—forexample,becauseofoedemaor

intolerance—orifthereisevidenceofheartfailureorahighriskofheartfailure,offerathiazide-likediuretic.(Updatedrecommendation)[Basedonamoderatequalityrandomisedcontrolledtrial]

Bloodpressuretargets

Aimforatargetclinicbloodpressurebelow140/90mmHginpeopleagedunder80yearswithtreatedhypertension.(Updatedrecommendation)[Basedonsystematicreviewsofverylowtomoderatequalityrandomisedcontrolledtrials,andobservationalstudies]

Aimforatargetclinicbloodpressurebelow150/90mmHginpeopleaged80yearsandoverwithtreated

hypertension.(Updatedrecommendation)[Basedonasystematicreviewandmeta-analysisthatincluded

moderateandhighqualityrandomisedcontrolledtrials]

Step3

Iftreatmentwiththreedrugsisneeded,offeranACEinhibitororARB,combinedwithacalciumchannelblockerandathiazide-likediuretic.(Updatedrecommendation)[BasedonmoderatetoverylowqualityevidencefromrandomisedcontrolledtrialsandontheexperienceandopinionoftheGDG]

Step4(Resistanthypertension)

Overcomingbarriers

Therecommendationthatambulatorybloodpressureratherthanclinicbloodpressuremeasurementsshouldbeusedtoconfirmthediagnosisofhypertensionwillhaveaprofoundimpactonpatientcarebyreducingthenumberwhoareincorrectlylabelledashypertensiveandthusinappropriatelyprescribed

antihypertensivetreatment.Currently,onlysomeprimarycarepracticeshaveaccesstoambulatorybloodpressuremonitoringdevices,withtheresthavingtoaccessthemthroughreferraltosecondarycare.Sufficientnumbersofvalidatedambulatorydevices(/blood_pressure_list.stmforalistofclinicallyvalidatedmonitors)willneedtobeprocuredandadequatelymaintained.Staffwillneedtobetrainedintheiruseandhowtointerpretdatageneratedinthereports.Theimplementationofambulatorybloodpressuremonitoringshouldbedeterminedlocally,reflectwhatisbestandmostconvenientforpatients,andnotnecessarilybebasedoncurrentmodelsofserviceconfiguration.TheGuidelineDevelopmentGroupanticipatesthatpracticesandconsortiumswilldevisevariousstrategiesthatdonotinvolvespecialistreferraltoexpandprovision,andthatprocurementcostswillfallasdemandincreases.

ThemembersoftheGuidelineDevelopmentGroupwereBryanWilliams(chair),HelenWilliams,JaneNorthedge,JohnCrimmins,MarkCaulfield,MichaelaWatts,NaomiStetson,RichardMcManus,ShelleyMason,TerryMcCormack,BernardHiggins,KateLovibond,PaulMiller,RachelO’Mahony,andTarynKrause.

TKwrotethefirstdraft,andallauthorswereinvolvedinwritingfurtherdraftsandreviewedandapprovedthefinalversionforpublication.BWistheguarantor.

Funding:TheNationalClinicalGuidelineCentrewascommissionedandfundedbytheNationalInstituteforHealthandClinicalExcellencetowritethissummary.

Competinginterests:/coi_disclosure.pdf(availableonrequestfromthecorrespondingauthor)anddeclare:TKandKLwere

Ifclinicbloodpressureremainshigherthan140/90mmHgaftertreatmentwiththeoptimalorbesttolerateddosesofthedrugcombinationmentionedinstep3(anACEinhibitororanARBcombinedwithacalciumchannelblockerandadiuretic),regardthisasresistanthypertension,andconsideraddingafourthantihypertensivedrugand/orseekingexpertadvice.(Updatedrecommendation)[Basedonlowqualityobservationalevidence]

Fortreatmentofresistanthypertension:

-Considerfurtherdiuretictreatmentwithlowdose

spironolactone(25mgoncedaily)ifthebloodpotassiumconcentrationis4.5mmol/eparticularcautioninpeoplewithareducedestimatedglomerularfiltrationratebecausetheyhaveanincreasedriskofhyperkalaemia

-Considerhigherdosethiazide-likediuretictreatmentifthebloodpotassiumconcentrationishigherthan4.5mmol/L.

(Updatedrecommendation)[Basedonlowqualityobservationalevidence]

Iffurtherdiuretictreatmentforresistanthypertensionatstep4isnottoleratedoriscontraindicatedorineffective,consideranαblockerorβblocker.(Updated

recommendation)[Basedonlowqualityobservationalstudies]Ifbloodpressureremainsuncontrolledwiththeoptimalormaximumtolerateddosesoffourdrugs,seekexpertadviceifnotyetobtained.(Updatedrecommendation)[BasedontheexperienceandopinionoftheGDG]

Monitoringbloodpressuretreatment

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