Talking about blood pressure

Mrs Khan 56 BP 158/99 BMI 32 Total cholesterol 5.4 (HDL 0.8) HbA1c 43 She has been promising to do more exercise and eat more healthily for the last 2 years but her weight has gone up. She gets side effects with most meds and isn t keen to take any tablets. She feels fine thank you

Measuring Blood Pressure Clinic (Doctor) manual vs automated Clinic (non-doctor) Home readings (1week) Ambulatory (24hrs) Lying/sitting/standing Size of cuff Position of arm Which arm?

Causes of Hypertension Unknown or essential Hyperaldosteronism 5-10% Renal disease Cushings syndrome Thyroid disease Phaechromocytoma 0.1-0.6%

The Lancet 2014 383, 1899-1911DOI: (10.1016/S0140-6736(14)60685-1) Copyright 2014 Rapsomaniki et al. Open Access article distributed under the terms of CC BY Terms and Conditions Figure 1 Is high blood pressure bad for you? HR per 20/10mm Hg

What systolic blood pressure is bad for you? It depends on how you look at it

What does weight loss achieve? Evidence is of poor quality 4kg weight loss overall produced 4.5/3.2 mm Hg reduction No data on mortality or morbidity

moderate reduction (3gram/day) may achieve up to 3-5/1.8-2.5 mmhg reduction No data on morbidity/mortality Switch to low alcohol beer resulted in a 3/1.5 mm Hg reduction No data on morbidity/mortality

Dietary Approaches to Stop Hypertension 1997 NEJM 459 adults av. Age 44 BP 132/85 Food prepared in lab kitchen Control Fruit and Vegetables Diet Combination Diet

4.5yrs

What about exercise?

16 MAs, 305 RCTs with 339274 participants

Perspectives on Drugs to lower mild BP

Use of blood pressure lowering drugs in the prevention of cardiovascular disease: metaanalysis of 147 randomised trials in the context of expectations from prospective epidemiological studies M R Law, professor of epidemiology J K Morris, professor of medical statistics N J Wald, professor of environmental and preventive medicine BMJ 2009;338:b1665

Cochrane 2012

What about different medications?

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ALLHAT study overview Double-blind, randomized trial to determine whether the occurrence of fatal CHD or nonfatal MI is lower for high-risk hypertensive patients treated with newer agents (amlodipine, lisinopril, or doxazosin) compared with a diuretic (chlorthalidone) Cohort 42,418 patients ( 55 years old) from 623 sites in North America Stage 1 or 2 hypertension 1 additional risk factor for CHD Comparisons between chlorthalidone and amlodipine and chlorthalidone and lisinopril have been reported together, excluding the doxazosin arm (n=9,062), which was terminated early CHD=coronary heart disease; MI=myocardial infarction ALLHAT Research Group. JAMA. 2002;288:2981-2997. www.hypertensiononline. org

Doxazosin n=9,062 ALLHAT Study Design Discontinued early at 3.3 yrs Randomized n=42,418 YEAR 1 Chlorthalidone n=15,255 n=13,854 2,235 (16.1%) stopped drug Amlodipin e n=9,048 n=8,215 1,357 (16.5%) stopped drug Lisinopril n=9,054 n=8,158 1,842 (22.6%) stopped drug YEAR 5 n=6,210 1,873 (30.2%) stopped drug n=3,769 1,052 (27.9%) stopped drug n=3,605 1,399 (38.8%) stopped drug n=9,054 218 (2.4%) lost to followup 58 (0.6%) refused follow-up ntent-to- Treat Analysis n=15,255 339 (2.2%) lost to followup 80 (0.5%) refused follow-up n=9,048 200 (2.2%) lost to follow-up 58 (0.6%) refused follow-up ALLHAT Research Group. JAMA. 2002;288:2981-2997. www.hypertensiononline. org

ALLHAT Endpoints Primary endpoint Composite of fatal coronary heart disease (CHD) or nonfatal myocardial infarction (MI) Other predefined endpoints all-cause mortality stroke combined CHD nonfatal MI, CHD death, coronary revascularization, hospitalized angina combined cardiovascular disease combined CHD, stroke, lower extremity revascularization, treated angina, fatal/ hospitalized/treated congestive heart failure, hospitalized or outpatient peripheral arterial disease other renal ALLHAT Research Group. JAMA. 2002;288:2981-2997. www.hypertensiononline. org

ALLHAT Baseline Characteristics Chlorthalidon e n=15,255 systoli c diastoli c Amlodipine n=9,048 systolic diastoli c Lisinopril n=9,054 systoli c diastoli c Mean BP (mmhg) 146 84 146 84 146 84 Treated (90%) 145 83 145 83 145 84 Untreated (10%) 156 89 157 90 156 89 Mean age (yrs) 67 67 67 Black (%) 35 36 36 Women (%) 47 47 46 Current smoking (%) 22 22 22 History of CHD (%) 26 24 25 BP=blood pressure CHD=coronary heart disease Type 2 diabetes (%) 36 37 36 ALLHAT Research Group. JAMA. 2002;288:2981-2997. www.hypertensiononline. org

Systolic BP (mmhg) Diastolic BP (mmhg) ALLHAT Mean Systolic and Diastolic Blood Pressure During Follow-up Chlorthalidone Chlorthalidone 150 Amlodipine Lisinopril 90 Amlodipine Lisinopril 145 140 Compared to chlorthalidone: SBP significantly higher in amlodipine (~1 mmhg) and lisinopril (~2 mmhg) groups. 85 80 Compared to chlorthalidone: DBP significantly lower in amlodipine group (~1 mmhg). 135 75 130 70 0 1 2 3 4 5 6 0 1 2 3 4 5 6 Follow-up, yrs SBP=systolic blood pressure ALLHAT Research Group. JAMA. 2002;288:2981-2997. pressure Copyright 2002, American Medical Association. DBP=diastolic blood www.hypertensiononline. org

% Patients with BP <140/90 mmhg ALLHAT BP Controlled to <140/90 mmhg 70 60 50 Chlorthalidone * * Amlodipine Lisinopril 40 30 20 10 0 Baseline Year 1 Year 2 Year 3 Year 4 Year 5 *P<0.001 for amlodipine vs chlorthalidone P<0.001 for lisinopril vs chlorthalidone ALLHAT Research Group. JAMA. 2002;288:2981-2997. www.hypertensiononline. org

Patients (%) ALLHAT Treatment and Blood Pressure Control 100 1 Drug 2 Drugs 3 Drugs 1.7 2.0 2 80 60 40 20 1.3 1.4 1.6 1.2 0.8 0.4 Average # of drugs 0 6 mos 1 yr 3 yr 5 yr Blood pressure controlled <140/90 mmhg 49.8% 55.2% 62.3% 65.6% Cushman WC, et al. J Clin Hypertens. 2002;4:393-405. www.hypertensiononline. org 0

Cumulative Fatal CHD and Nonfatal MI event rate (%) ALLHAT Primary Outcome by Treatment Group 20 16 12 Chlorthalidone Amlodipine Lisinopril 8 4 No. at Risk Chlorthalidone Amlodipine Lisinopril 0 0 1 2 3 4 5 6 Time to event, 13102 yrs 11362 15255 9048 9054 14477 8576 8535 13820 8218 8123 7843 7711 6824 6662 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association. 6340 3870 3832 2956 1878 1770 7 209 215 195 www.hypertensiononline. org

ALLHAT CHD Death and Nonfatal MI TOTAL Age <65 Age 65 Men Women Black Nonblack Diabetic Nondiabeti c Relative Risk Favors Favors Relative Risk Favors Favors (95% CI) amlodipine chlorthalidone (95% CI) lisinopril chlorthalidone 0.98 (0.90-1.07) 0.99 (0.85-1.16) 0.97 (0.88-1.08) 0.98 (0.87-1.09) 0.99 (0.85-1.15) 1.01 (0.86-1.18) 0.97 (0.87-1.08) 0.99 (0.87-1.13) 0.97 (0.86-1.09) 0.99 (0.91-1.08) 0.95 (0.81-1.12) 1.01 (0.91-1.12) 0.94 (0.85-1.05) 1.06 (0.92-1.23) 1.10 (0.94-1.28) 0.94 (0.85-1.05) 1.00 (0.87-1.14) 0.99 (0.88-1.11) 0.5 1 2 0.5 1 2 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association. www.hypertensiononline. org

TOTAL Age <65 Age 65 Men Women Black Nonblack Diabetic Nondiabeti c ALLHAT All-Cause Mortality Relative Risk Favors Favors Relative Risk Favors Favors (95% CI) amlodipine chlorthalidone (95% CI) lisinopril chlorthalidone 0.96 (0.89-1.02) 0.96 (0.83-1.10) 0.96 (0.88-1.03) 0.95 (0.87-1.04) 0.96 (0.86-1.07) 0.97 (0.87-1.09) 0.94 (0.87-1.03) 0.96 (0.87-1.07) 0.95 (0.87-1.04) 1.00 (0.94-1.08) 0.93 (0.81-1.08) 1.03 (0.95-1.12) 0.99 (0.91-1.08) 1.02 (0.91-1.13) 1.06 (0.95-1.18) 0.97 (0.89-1.06) 1.02 (0.91-1.13) 1.00 (0.91-1.09) 0.5 1 2 0.5 1 2 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association. www.hypertensiononline. org

TOTAL Age <65 Age 65 Men Women Black Nonblack Diabetic Nondiabeti c ALLHAT Combined CV Disease Relative Risk Favors Favors Relative Risk Favors Favors (95% CI) amlodipine chlorthalidone (95% CI) lisinopril chlorthalidone 1.04 (0.99-1.09) 1.03 (0.94-1.12) 1.05 (0.99-1.12) 1.04 (0.98-1.11) 1.04 (0.96-1.13) 1.06 (0.96-1.16) 1.04 (0.97-1.10) 1.06 (0.98-1.15) 1.02 (0.96-1.09) 1.10 (1.05-1.16) 1.05 (0.97-1.15) 1.13 (1.06-1.20) 1.08 (1.02-1.15) 1.12 (1.03-1.21) 1.19 (1.09-1.30) 1.06 (1.00-1.13) 1.08 (1.00-1.17) 1.12 (1.05-1.19) 0.5 1 2 0.5 1 2 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association. www.hypertensiononline. org

Cumulative event rate (%) 10 8 6 ALLHAT Stroke by Treatment Group Chlorthalidone Amlodipine Lisinopril 4 2 No. at Risk Chlorthalidone Amlodipine Lisinopril 0 0 1 2 3 4 5 6 Time to event, yrs 11570 15255 9048 9054 14515 8617 8543 13934 8271 8172 13309 7949 7784 6937 6765 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association. 6385 3845 3891 3217 1813 1828 7 567 506 949 www.hypertensiononline. org

ALLHAT Stroke Relative Risk Favors Favors Relative Risk (95% CI) amlodipine chlorthalidone (95% CI) Favors Favors lisinopril chlorthalidone TOTAL Age <65 Age 65 Men Women Black Nonblack Diabetic Nondiabeti c 0.93 (0.82-1.06) 0.93 (0.73-1.19) 0.93 (0.81-1.08) 1.00 (0.85-1.18) 0.84 (0.69-1.03) 0.93 (0.76-1.14) 0.93 (0.79-1.10) 0.90 (0.75-1.08) 0.96 (0.81-1.14) 1.15 (1.02-1.30) 1.21 (0.97-1.52) 1.13 (0.98-1.30) 1.10 (0.94-1.29) 1.22 (1.01-1.46) 1.40 (1.17-1.68) 1.00 (0.85-1.17) 1.07 (0.90-1.28) 1.23 (1.05-1.44) 0.5 1 2 0.5 1 2 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association. www.hypertensiononline. org

Cumulative event rate (%) ALLHAT Heart Failure by Treatment Group 15 12 9 Chlorthalidone Amlodipine Lisinopril P<0.001 for chlorthalidone vs amlodipine and chlorthalidone vs lisinopril 6 3 No. at Risk Chlorthalidone Amlodipine Lisinopril 0 0 1 2 3 4 5 6 Time to event, yrs 11511 15255 9048 9054 14528 8535 8496 13898 8185 8096 13224 7801 7689 6785 6698 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association. 6369 3775 3789 3016 1780 1837 7 384 210 313 www.hypertensiononline. org

TOTAL Age <65 Age 65 Men Women Black Nonblack Diabetic Nondiabeti c ALLHAT Heart Failure Relative Risk Favors Favors Relative Risk Favors Favors (95% CI) amlodipine chlorthalidone (95% CI) lisinopril chlorthalidone 1.38 (1.25-1.52) 1.51 (1.25-1.82) 1.33 (1.18-1.49) 1.41 (1.24-1.61) 1.33 (1.14-1.55) 1.47 (1.24-1.74) 1.33 (1.18-1.51) 1.42 (1.23-1.64) 1.33 (1.16-1.52) 1.20 (1.09-1.34) 1.23 (1.01-1.50) 1.20 (1.06-1.35) 1.19 (1.03-1.36) 1.23 (1.05-1.43) 1.32 (1.11-1.58) 1.15 (1.01-1.30) 1.22 (1.05-1.42) 1.20 (1.04-1.38) 0.5 1 2 0.5 1 2 ALLHAT Research Group. JAMA. 2002;288:2981-2997. Copyright 2002, American Medical Association. www.hypertensiononline. org

ALLHAT Conclusions Better control of systolic BP was achieved with chlorthalidone than with amlodipine or lisinopril There were no differences in risk for CHD death/nonfatal MI between chlorthalidone and amlodipine or lisinopril In secondary endpoints, chlorthalidone was associated with lower risk for stroke, combined CVD, and HF compared with lisinopril HF compared with amlodipine MI=myocardial infarction CHD=coronary heart disease www.hypertensiononline. HF=heart failure ALLHAT Research Group. JAMA. 2002;288:2981-2997. org

A randomised controlled trial of the prevention of CHD and other vascular events by BP and cholesterol lowering in a factorial study design B.Dahlof (Co-chair), P.Sever (Co-chair), N. Poulter (Secretary) H. Wedel (Statistician), G. Beevers, M. Caulfield, R. Collins S. Kjeldsen, A. Kristinsson, J. Mehlsen, G. McInnes, M. Nieminen E. O Brien, J. Östergren, on behalf of the ASCOT Investigators

ASCOT- BPLA Primary Objective To compare the effect on non-fatal myocardial infarction (MI) and fatal CHD of the standard antihypertensive regimen ( -blocker ± diuretic) with a more contemporary regimen (CCB ± ACE inhibitor)

Study design 19,257 hypertensive patients ASCOT-BPLA atenolol ± bendroflumethiazide PROBE design amlodipine ± perindopril 10,305 patients TC 6.5 mmol/l (250 mg/dl) ASCOT-LLA atorvastatin 10 mg Double-blind placebo Investigator-led, multinational randomised controlled trial

Patient inclusion criteria Screening and baseline BP 160/100 mm Hg untreated 140/90 mm Hg following treatment with 1 or more drugs Age 40-79 years No previous MI or current clinical CHD 3 or more CV risk factors

Treatment algorithm to BP targets < 140/90 mm Hg or < 130/80 mm Hg in patients with diabetes amlodipine 5-10 mg add perindopril 4-8 mg atenolol 50-100 mg add bendroflumethiazide-k 1.25-2.5 mg add doxazosin GITS 4-8 mg add additional drugs, eg, moxonidine/spironolactone

Baseline characteristics amlodipine perindopril atenolol thiazide Demographics and clinical characteristics n = 9639 n = 9618 Woman 2258 (23.4%) 2257 (23.5%) White 9187 (95.3%) 9170 (95.3%) Current smoker 3168 (32.9%) 3110 (32.3%) Age (years) 63.0 (8.5) 63.0 (8.5) SBP (mm Hg) 164.1 (18.1) 163.9 (18.0) DBP (mm Hg) 94.8 (10.4) 94.5 (10.4) Heart rate (bpm) 71.9 (12.7) 71.8 (12.6) BMI (kg/m 2 ) 28.7 (4.6) 28.7 (4.5) Drug therapy Previous antihypertensive treatments 0 1841 (19.1%) 1825 (19.0%) 1 4280 (44.4%) 4283 (44.5%) 2 3518 (36.5%) 3510 (36.5%) Lipid-lowering therapy 1046 (10.9%) 1004 (10.4%) Aspirin 1851 (19.2%) 1837 (19.1%) Values are number of patients, (%) or mean (SD)

mm Hg Systolic and diastolic blood pressure 180 160 140 164.1 163.9 SBP Mean difference 2.7 atenolol thiazide amlodipine perindopril 137.7 120 136.1 100 80 60 94.8 94.5 DBP Mean difference 1.9 79.2 77.4 Baseline 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 Time (years) Last visit

Summary of all end points Primary Non-fatal MI (incl silent) + fatal CHD Secondary Non-fatal MI (exc. Silent) +fatal CHD Total coronary end point Total CV event and procedures All-cause mortality Cardiovascular mortality Fatal and non-fatal stroke Fatal and non-fatal heart failure Tertiary Silent MI Unstable angina Chronic stable angina Peripheral arterial disease Life-threatening arrhythmias New-onset diabetes mellitus New-onset renal impairment 0.50 0.70 1.00 1.45 2.00 Amlodipine perindopril better Atenolol thiazide better Post hoc Primary end point + coronary revasc procs The area of the blue square is proportional to the amount of statistical information Unadjusted Hazard ratio (95% CI) 0.90 (0.79-1.02) 0.87 (0.76-1.00) 0.87 (0.79-0.96) 0.84 (0.78-0.90) 0.89 (0.81-0.99) 0.76 (0.65-0.90) 0.77 (0.66-0.89) 0.84 (0.66-1.05) 1.27 (0.80-2.00) 0.68 (0.51-0.92) 0.98 (0.81-1.19) 0.65 (0.52-0.81) 1.07 (0.62-1.85) 0.70 (0.63-.078) 0.85 (0.75-0.97) 0.86 (0.77-0.96)

Variables which differed significantly (baseline - final visit) between treatment regimens Mean differences (Amlodipine perindopril - Atenolol thiazide) Changes baseline to final visit p-value Systolic BP (mm Hg) -1.78 <0.0001 Diastolic BP (mm Hg) -2.05 <0.0001 Heart rate (bpm) 11.12 <0.0001 Weight (kg) -0.79 <0.0001 HDL-cholesterol (mmol/l) 0.11 <0.0001 Triglycerides (mmol/l) -0.23 <0.0001 Glucose (mmol/l) -0.20 <0.0001 Creatinine (µmol/l) -5.06 <0.0001 Potassium (mmol/l) 0.05 <0.0001

Impact on the treatment effect on coronary events after adjustment for BP and all variables that differed Hazard ratio 95% CI Unadjusted 0.86 0.77-0.96 SBP 0.88 0.79-0.98 SBP + covariates 0.93 0.81-1.07 SBP + DBP + covariates 0.92 0.80-1.06 MBP** + covariates 0.94 0.81-1.08 PP + covariates 0.91 0.79-1.04 Amlodipine perindopril better Atenolol thiazide better p-value 0.0058 0.0258 0.3276 0.2744 0.3519 0.1791 0.50 0.70 1.00 1.45 Hazard ratio ** MBP = (SBP+DBP)/2

Impact on the treatment effect on stroke events after adjustment for BP and all variables that differed Hazard Hazard ratio ratio 95% CI 95% CI Unadjusted 0.77 0.66-0.89 Mean BP 0.84 0.72-0.97 SBP + covariates 0.85 0.71-1.02 SBP + DBP + covariates 0.87 0.73-1.05 MBP** + covariates 0.87 0.73-1.05 PP + covariates 0.80 0.67-0.96 Amlodipine perindopril better Atenolol thiazide better p-value 0.0003 0.0170 0.0836 0.1386 0.1380 0.0164 0.50 0.70 1.00 1.45 Hazard ratio ** MBP = (SBP+DBP)/2

What about B-blockers?

What about the Elderly?

Systolic Hypertension in the Elderly JAMA 1991 Randomized, double-blind, placebo controlled 4736 people aged 60yrs+ BP 160-219/<90 Average BP 170/77, average age 72 Step 1 Chlorthalidone 12.5mg or placebo Step 2 Atenolol 25mg/placebo Atenolol 50mg/placebo

SHEP 1991 Follow up 4.5yrs Average BP 143/68 treatment group, 155/72 placebo 5.2% total stroke (treatment) vs 8.2% (placebo) 3% absolute risk reduction Coronary death and non fatal MI RR 0.73 All cause mortality RR 0.87

Indapamide 1.5mg MR then Perindopril 2mg/4mg

HYVET 2008

What about Diabetics?

Hypertension Optimal Treatment

HOT trial Non diabetics

HOT trial Diabetics

Randomised open label study 9361 average BP 140/78 at start Intensive 120/- or Standard 140/- Stopped early after 3.2yrs

Conclusions? How I see it anyway Good evidence for lowering BP in stage 2 BP reducing mortality and morbidity (SHEP) Some evidence for tighter targets for diabetic patients reducing cardiovascular mortality but not total mortality but from starting BP (HOT) Some emerging evidence for tighter BP targets in one recent study (SPRINT). Little difference between different drug groups (ASCOT, ALLHAT)

Conclusions 2 Medications for mild hypertension not demonstrated (apart from SPRINT) Tighter BP targets in CKD is based on observation of association not RCTs Some evidence that ACEI less good in black ethnic groups

Hypertension Implementing NICE guidance 2 nd Edition March 2013 NICE clinical guideline 127

High Blood Pressure: Background Major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension can cause vascular and renal damage leading to a treatment-resistant state. Each 2 mmhg rise in systolic blood pressure associated with increased risk of mortality: 7% from heart disease 10% from stroke.

Epidemiology Hypertension is common in the UK population. Prevalence influenced by age and lifestyle factors. 25% of the adult population in the UK have hypertension. 50% of those over 60 years have hypertension. With an ageing population, the prevalence of hypertension and requirement for treatment will continue to increase.

Definitions Stage 1 hypertension: Clinic blood pressure (BP) is 140/90 mmhg or higher and ABPM or HBPM average is 135/85 mmhg or higher. Stage 2 hypertension: Clinic BP 160/100 mmhg is or higher and ABPM or HBPM daytime average is 150/95 mmhg or higher. Severe hypertension: Clinic BP is 180 mmhg or higher or Clinic diastolic BP is 110 mmhg or higher.

Diagnosis (1) If the clinic blood pressure is 140/90 mmhg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.

Diagnosis (2) When using the following to confirm diagnosis, ensure: ABPM: at least two measurements per hour during the person s usual waking hours, average of at least 14 measurements to confirm diagnosis HBPM: two consecutive seated measurements, at least 1 minute apart blood pressure is recorded twice a day for at least 4 days and preferably for a week measurements on the first day are discarded average value of all remaining is used.

Initiating drug treatment Offer antihypertensive drug treatment to people: who have stage 1 hypertension, are aged under 80 and meet identified criteria who have stage 2 hypertension at any age. If aged under 40 with stage 1 hypertension and without evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider: specialist evaluation of secondary causes of hypertension further assessment of potential target organ damage.

Monitoring drug treatment (1) Use clinic blood pressure measurements to monitor response to treatment. Aim for target blood pressure below: 140/90 mmhg in people aged under 80 150/90 mmhg in people aged 80 and over

Type 2 Diabetes BP targets

Monitoring drug treatment (2) For people identified as having a white-coat effect consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor response to treatment. Aim for ABPM/HBPM target average of: below 135/85 mmhg in people aged under 80 below 145/85 mmhg in people aged 80 and over. White-coat effect: a discrepancy of more than 20/10 mmhg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis.

CBPM 140/90 mmhg & ABPM/HBPM 135/85 mmhg Stage 1 hypertension CBPM 160/100 mmhg & ABPM/HBPM 150/95 mmhg Stage 2 hypertension Care pathway If target organ damage present or 10-year cardiovascular risk > 20% Offer antihypertensive drug treatment If younger than 40 years Consider specialist referral Offer lifestyle interventions Offer patient education and interventions to support adherence to treatment Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

Aged under 55 years A Aged over 55 years or black person of African or Caribbean family origin of any age C 2 Step 1 Summary of antihypertensive drug treatment A + C 2 A + C + D Resistant hypertension A + C + D + consider further diuretic 3, 4 or alpha- or beta-blocker 5 Consider seeking expert advice Step 2 Step 3 Step 4 Key A ACE inhibitor or low-cost angiotensin II receptor blocker (ARB) 1 C Calcium-channel blocker (CCB) D Thiazide-like diuretic See slide notes for details of footnotes 1-5

Choosing antihypertensive drug treatment Offer people aged 80 and over the same antihypertensive drug treatment as people aged over 55, taking into account any comorbidities. Drug treatment

* See notes Measuring blood pressure: updated recommendations Standardise the environment and provide a relaxed, temperate setting with the person quiet and seated. When using an automated device: palpate the radial or brachial pulse before measuring blood pressure. If pulse if irregular measure blood pressure manually ensure that the device is validated* and an appropriate cuff size for the person s arm is used.

Assessing cardiovascular risk and target organ damage: updated recommendations Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension. For all people with hypertension offer to: test urine for presence of protein take blood to measure glucose, electrolytes, creatinine, estimated glomerular filtration rate and cholesterol examine fundi for hypertensive retinopathy arrange a 12-lead ECG.

Additional recommendations Lifestyle interventions Offer guidance and advice about: diet (including sodium and caffeine intake) and exercise alcohol consumption smoking. Patient education and adherence Provide: information about benefits of drugs and side effects details of patient organisations an annual review of care.