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New UK Consultation Document Unites National Hypertension Treatment Guidelines

A provisional hypertension guidelines update has been issued by the National Institute for Clinical Excellence (NICE), an independent organization within the UK National Health Service (NHS) that provides guidance on treatments in England and Wales. The update, called a "draft for consultation," was made available online in February for comment through March and contained substantial changes to the treatment recommendations made in the previous NICE guidelines, published in 2004.^[12] Calcium channel blockers (CCBs) and ACE inhibitors are now the drugs of first choice over thiazide-type diuretics and beta-blockers in older and younger patients, respectively.

NICE has updated its guidelines after reviewing new data from 20 clinical trials published since 2004, including the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT-BPLA).^[13] The update represents a major change not only to NICE treatment guidelines but also to those of the BHS, also issued in 2004.^[9] The BHS, which last year recommended that there should be a review of the existing NICE guideline recommendations dealing with pharmacologic treatment of hypertension, is working in collaboration with NICE to review this section of the guidelines; the final joint document is scheduled to be published by June 2006. UK physicians will then have a unified set of guidelines instead of 2, which many had regarded as too much to read.

The new update's first choice for drug therapy in people aged 55 years and older, or in black patients of any age, is a dihydropyridine CCB, with a thiazide-type diuretic as an alternative. In patients younger than 55 years, the guidelines recommend an ACE inhibitor or an ARB if an ACE inhibitor is not tolerated. After a dihydropyridine CCB or a thiazide-type diuretic, an ACE inhibitor is the second choice, and after an ACE inhibitor a dihydropyridine CCB or a thiazide-type diuretic.

The 2004 BHS treatment recommendations were based on classification of hypertensionas "high renin" or "low renin" and followed the "ABCD" algorithm, combining 2 categoriesof antihypertensive drug: those that inhibit the renin-angiotensinsystem, ie, ACE inhibitors or ARBs (A) or beta-blockers (B), and those that do not, ie, CCBs (C) or diuretics (D). According to Prof. Morris J. Brown, MD (University of Cambridge, Cambridge, United Kingdom), President of BHS and a member of the NICE/BHS guidance group, the new treatment algorithm will look more like "AbCd."

In the new NICE guidelines, beta-blockers are no longer preferred as routine initial therapy, but may be considered in younger women and patients with hypertension and evidence of increased sympathetic drive or intolerance to ACE inhibitors or ARBs. Beta-blockers should not be replaced in patients whose BP is already controlled with these drugs or who have compelling indications for beta-blockade, such as asymptomatic angina or myocardial infarction.