The most recent guidelines for adult hypertension investigations and diagnosis in 2023 (part 3)

recent guidelines for adult hypertension

Keep in mind that pregnant women, nursing mothers, and women planning to become pregnant should not take ACE inhibitors or angiotensin II receptor antagonists unless absolutely necessary, at which point the potential benefits and risks should be discussed. 

For ACE inhibitors and angiotensin II receptor antagonists, adhere to the MHRA's safety recommendations: not for use during pregnancy, with breastfeeding-specific instructions and a clarification on breastfeeding.

Picking antihypertensive medication treatment (for individuals regardless of type 2 diabetes)

1) This recommendations are applicable to individuals with hypertension and type 2 diabetes. 

2) Consult the NICE guideline on chronic kidney disease for advice on the appropriate hypertensive agent for patients. Offer medication that only needs to be taken once a day if at all possible.

3) Provide the same treatment to people with isolated systolic hypertension (systolic blood pressure of 160 mmHg or higher) as to people with raised systolic and diastolic blood pressure 

4) Proposition antihypertensive medication treatment to ladies of childbearing potential with determined hypertension in line to have the suggestions in this rule. Manage hypertension in accordance with NICE's guideline on hypertension in pregnancy's recommendations for managing pregnancy with chronic hypertension and antihypertensive treatment while breastfeeding for pregnant or breastfeeding women.

5) While picking antihypertensive medication treatment for grown-ups of Dark African or African-Caribbean family beginning, think about an angiotensin II receptor blocker (ARB).  

For individuals with cardiovascular illness:

When prescribing an ACE inhibitor or an ARB for secondary prevention of myocardial infarction, for instance, follow the NICE guideline's recommendations for disease-specific indications. 

Applicable suggestions include:

- in the NICE guideline for acute coronary syndromes, drug therapy for secondary prevention; 

- in the NICE guideline for acute heart failure, treatment after stabilization;

 - in the NICE guideline for chronic heart failure, treatment for heart failure with reduced ejection fraction; 

- in the NICE guideline for stable angina, drugs for secondary prevention of cardiovascular disease;

 - in the NICE guideline for type 1 diabetes in adults, management of blood pressure.

• Provide antihypertensive medication treatment in accordance with the recommendations in this section if their blood pressure does not improve. 

Step 1 treatment 

 Give adults who are starting step 1 antihypertensive treatment an ACE inhibitor or an ARB:

• are of any age or come from a family with type 2 diabetes or are younger than 55 but do not come from a Black African or African–Caribbean family.

If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB to treat hypertension.

Try not to join an ACE inhibitor with an ARB to treat hypertension. 

 Provide adults beginning step 1 of antihypertensive treatment with a calcium-channel blocker (CCB) if they:

• are over the age of 55 and do not have type 2 diabetes;

• are of Black African or African–Caribbean descent and do not have type 2 diabetes (at any age). 

 Provide a thiazide-like diuretic to treat hypertension if a CCB is not tolerated, such as due to oedema.

 Provide a thiazide-like diuretic and adhere to NICE's chronic heart failure guideline if there is evidence of heart failure.

Provide a thiazide-like diuretic like indapamide rather than a conventional thiazide diuretic like hydrochlorothiazide or bendroflumethiazide when starting or changing diuretic treatment for hypertension.

 Maintain current treatment for adults with hypertension who have stable, well-controlled blood pressure and are receiving bendroflumethiazide or hydrochlorothiazide. 

Stage 2 treatment

 Prior to considering subsequent stage treatment for hypertension examine with the individual in the event that they are accepting their medication as recommended and support adherence in accordance with Pleasant's rule on drugs adherence.

 In the event that hypertension isn't controlled in grown-ups making stride 1 treatment of an ACA inhibitor or ARB, offer the decision of 1 of the accompanying medications not withstanding stage 1 treatment:

• a thiazide-like diuretic or a CCB

 Provide the option of one of the following medications in addition to step 1 treatment for adults whose hypertension is not under control:

• an ACE inhibitor, an ARB, or a diuretic similar to thiazide.

 In the event that hypertension isn't controlled in grown-ups of Dark African or African-Caribbean family beginning who don't have type 2 diabetes making stride 1 treatment, consider an ARB, in inclination to an ACE inhibitor, not withstanding stage 1 treatment. 

Step 3 treatment 

 Before looking into the next step of hypertension treatment:

•audit the individual's drugs to guarantee they are being taken at the ideal endured dosages and

•examine adherence 

 

 Provide a combination of the following for adults undergoing step 2 treatment whose hypertension is not under control:

•an ACE inhibitor or ARB  and

•a CCB and

•a thiazide-like diuretic.

Stage 4 treatment

 In the event that hypertension isn't controlled in grown-ups taking the ideal endured dosages of a Pro inhibitor or an ARB in addition to a CCB and a thiazide-like diuretic, see them as having safe hypertension. 

 Prior to thinking about additional treatment for an individual with safe hypertension:

•Affirm raised center circulatory strain estimations utilizing mobile or home pulse accounts.

•Survey for postural hypotension.

•Examine adherence.

For individuals with affirmed safe hypertension, consider adding a fourth antihypertensive medication as stage 4 treatment or looking for expert counsel.

 

 Adults with resistant hypertension starting step 4 treatment who have a blood potassium level of 4.5 mmol/l or less should think about continuing diuretic therapy with low-dose spironolactone. 

People with a lower estimated glomerular filtration rate should be treated with extra caution because they are more likely to develop hyperkalemia. 

Monitor renal function and blood sodium and potassium levels within one month of starting diuretic therapy for step 4 treatment of resistant hypertension, and repeat as necessary thereafter. 

 Adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4.5 mmol/l should think about taking an alpha- or beta-blocker.

 Assuming B.P stays uncontrolled in individuals with safe hypertension taking the ideal endured portions of 4 medications, look for expert guidance.