Cardiology - First-line in hypertension

New clinical guidelines recommend considerable changes in first-line hypertension treatment

Guidelines for the management of hypertension in the UK were updated recently. The major change is that beta-blockers are no longer recommended as the first-line drug for hypertension in patients without compelling indications.

The new approach recommended by the British Hypertension Society is that first-line therapy in patients over 55 should be a calcium channel blocker or a thiazide-type diuretic. For patients who are younger than 55, ACE inhibitors are the first-line drug of choice.

These new guidelines are based on a review of recently published data, adverse events data and a detailed health economic analysis comparing the cost-effectiveness of the main drug classes. The cause, development and effects of hypertension and the mechanism of action of the different classes of blood pressure lowering drugs, allowing for age and ethnicity, were also taken into account.

The decision not to recommend beta-blockers for first-line therapy is based on evidence that suggests that they perform less well than other drugs, particularly in older people, and the increasing evidence that the most frequently used beta-blockers at usual doses carries an unacceptable risk of provoking type 2 diabetes. Therefore, beta-blockers have been omitted from the routine AB/CD treatment algorithm, with B now being excluded.

However, there are some compelling indications for use of beta-blockers in hypertension. The guidelines state they should be considered in:

The guidelines also make recommendations beyond a three drug combination, where, although the evidence is less certain, they took account of existing guidelines and constructed recommendations most compatible with current good practice. The updated recommendations in the guidelines include:

They recommend that drug therapy is offered to patients with:

Patients over 80 years should be offered the same treatment as those over 55 but taking account of comorbidity and other drugs they may be taking. Patients with isolated systolic hypertension (systolic BP > 160mmHg) should be given the same treatment as patients with both raised systolic and diastolic blood pressure.

In measuring hypertension, the aim is to identify patients who are persistently raised above 140/90. This should be measured on three separate occasions.

Lifestyle intervention is important so patients should be asked about their diet and exercise patterns and given advice. Discourage excessive use of alcohol, coffee and other caffeine-rich products. Salt should be reduced. Advice should be given on smoking cessation.

The guidelines were launched by the National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Chronic Conditions in conjunction with the BHS.

Full guidelines are at:

– Geraldine Meagan

 Cardiology - First-line in hypertension


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