2011NICE+成年人原发性高血压的临床管理(CG127)（摘要版）

Issue date: August 2011 Hypertension Clinical management of primary hypertension in adults This updates and replaces NICE clinical guideline 34 Quick reference guide NICE clinical guideline 127 Developed by the Newcastle Guideline Development and Research Unit and updated by the National Clinical Guideline Centre (formerly the National Collaborating Centre for Chronic Conditions) and the British Hypertension Society NICE clinical guideline 127 Quick reference guide2 Hypertension About this booklet This is a quick reference guide that summarises the recommendations NICE has made to the NHS in ‘Hypertension: clinical management of primary hypertension in adults’ (NICE clinical guideline 127). This guidance updates and replaces NICE clinical guideline 34 (published June 2006). Who wrote the guideline? The original guideline was developed by the Newcastle Guideline Development and Research Unit and published in 2004. The guideline was updated by the National Clinical Guideline Centre (NCGC) (formerly the National Collaborating Centre for Chronic Conditions) in collaboration with the British Hypertension Society (BHS) in 2006 and 2011. Recommendations from the original 2004 guideline are marked with footnotes. All other recommendations were developed by the NCGC in collaboration with the BHS for the 2006 and 2011 updated guidelines. Person-centred care Treatment and care should take into account people’s individual needs and preferences. Good communication is essential, supported by evidence-based information, to allow people to reach informed decisions about their care. Follow advice on seeking consent from the Department of Health or Welsh Government if needed. If the person agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales. This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Quick reference guideNICE clinical guideline 127 Hypertension Contents/Introduction/Definitions 3 Contents Introduction 3 Definitions used in this booklet 3 Key priorities for implementation 4 Care pathway for hypertension 6 Measuring blood pressure 7 Diagnosing hypertension 8 Assessing cardiovascular risk and 10 target organ damage 12 Lifestyle interventions 10 Antihypertensive drug treatment 11 Patient education and adherence to treatment 14 Further information 15 Introduction Hypertension is one of the most important preventable causes of premature morbidity and mortality in the UK, and its management is one of the most common interventions in primary care. This guideline contains new and updated recommendations on blood pressure measurement, the use of ambulatory and home blood pressure monitoring, blood pressure targets and antihypertensive drug treatment. Definitions used in this booklet Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher. Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher. Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher, or clinic diastolic blood pressure is 110 mmHg or higher. NICE clinical guideline 127 Quick reference guide4 Hypertension Key priorities for implementation Diagnosing hypertension ● If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. ● When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension. ● When using home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension, ensure that: − for each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated and − blood pressure is recorded twice daily, ideally in the morning and evening and − blood pressure recording continues for at least 4 days, ideally for 7 days. Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. Initiating and monitoring antihypertensive drug treatment, including blood pressure targets Initiating treatment ● Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following: − target organ damage − established cardiovascular disease − renal disease − diabetes − a 10-year cardiovascular risk equivalent to 20% or greater. ● Offer antihypertensive drug treatment to people of any age with stage 2 hypertension. ● For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people. Monitoring treatment and blood pressure targets ● For people identified as having a ‘white-coat effect’ 1 , consider ABPM or HBPM as an adjunct to clinic blood pressure measurements to monitor the response to antihypertensive treatment with lifestyle modification or drugs. Continued Key priorities for implementation 1 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. Quick reference guideNICE clinical guideline 127 Hypertension 5 Key priorities for implementation 2 At the time of publication (August 2011), spironolactone did not have a UK marketing authorisation for this indication. Informed consent should be obtained and documented. Choosing antihypertensive drug treatment ● Offer people aged 80 years and over the same antihypertensive drug treatment as people aged 55–80 years, taking into account any comorbidities. Step 1 treatment ● Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged over 55 years and to black people of African or Caribbean family origin of any age. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. ● If a diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. ● For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide. Step 4 treatment ● For treatment of resistant hypertension at step 4: − Consider further diuretic therapy with low-dose spironolactone (25 mg once daily) 2 if the blood potassium level is 4.5 mmol/l or lower. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia. − Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5 mmol/l. Key priorities for implementation continued NICE clinical guideline 127 Quick reference guide6 Hypertension Care pathway for hypertension 3 Signs of papilloedema or retinal haemorrhage. 4 Labile or postural hypotension, headache, palpitations, pallor and diaphoresis. 5 Ambulatory blood pressure monitoring. 6 Home blood pressure monitoring. Care pathway for hypertension Refer same day for specialist care Offer to check blood pressure at least every 5 years (see page 9) Offer annual review of care (see page 14) Offer lifestyle interventions (see page 10) Offer patient education and interventions to support adherence to treatment (see page 14) Consider alternative causes for target organ damage (see page 9) Offer to assess cardiovascular risk and target organ damage (see page 8) If accelerated hypertension 3 or suspected phaeochromocytoma 4 If evidence of target organ damage If target organ damage present or 10-year cardiovascular risk > 20% If younger than 40 years Clinic blood pressure ≥ 180/110 mmHg (see page 8) Consider starting antihypertensive drug treatment immediately (see page 8) Clinic blood pressure ≥ 140/90 mmHg (see page 8) Offer ABPM 5 (or HBPM 6 if ABPM is declined or not tolerated) (see page 8) Consider specialist referral (see page 10) ABPM/HBPM < 135/85 mmHg Normotensive ABPM/HBPM ≥ 150/95 mmHg Stage 2 hypertension ABPM/HBPM ≥ 135/85 mmHg Stage 1 hypertension Offer antihypertensive drug treatment (see pages 11–14) Clinic blood pressure < 140/90 mmHg (see page 8) Normotensive Quick reference guideNICE clinical guideline 127 Hypertension Measuring blood pressure 7 ● Healthcare professionals taking blood pressure measurements need adequate initial training and should have their performance reviewed periodically 7 . ● Devices for measuring blood pressure must be properly validated, maintained and regularly recalibrated according to manufacturers’ instructions 7 . ● If using an automated blood pressure monitoring device, ensure that the device is validated 8 and an appropriate cuff size for the person’s arm is used. ● When measuring blood pressure in the clinic or in the home, standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. ● Palpate the radial or brachial pulse before measuring blood pressure, since automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation). If pulse irregularity is present, measure blood pressure manually, using direct auscultation over the brachial artery. Measuring blood pressure Postural hypotension ● In people with symptoms of postural hypotension (falls or postural dizziness): − measure blood pressure with the person either supine or seated − measure blood pressure again with the person standing for at least 1 minute prior to measurement. ● If the systolic blood pressure falls by 20 mmHg or more when the person is standing: − review medication − measure subsequent blood pressures with the person standing − consider referral to specialist care if symptoms of postural hypotension persist. 7 This recommendation was developed for the original 2004 guideline. 8 A list of validated blood pressure monitoring devices is available on the British Hypertension Society’s website (see www.bhsoc.org). The British Hypertension Society is an independent reviewer of published work. This does not imply any endorsement by NICE. NICE clinical guideline 127 Quick reference guide8 Hypertension Diagnosing hypertension Measuring the clinic blood pressure ● Measure blood pressure in both arms. − If the difference in readings between arms is more than 20 mmHg, repeat the measurements. − If the difference in readings between arms remains more than 20 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading. ● If blood pressure measured in the clinic is 140/90 mmHg or higher: − Take a second measurement during the consultation. − If the second measurement is substantially different from the first, take a third measurement. Record the lower of the last two measurements as the clinic blood pressure. Confirming the diagnosis ● If the clinic blood pressure is 140/90 mmHg or higher, offer ABPM to confirm the diagnosis of hypertension. ● If a person is unable to tolerate ABPM, HBPM is a suitable alternative to confirm the diagnosis of hypertension. ● While waiting to confirm the diagnosis, carry out investigations for target organ damage and a formal assessment of cardiovascular risk (see page 10). Diagnosing hypertension Severe hypertension ● Consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM, for people with severe hypertension. Specialist investigations ● Refer people to specialist care the same day if they have: − accelerated hypertension (blood pressure usually higher than 180/110 mmHg with signs of papilloedema and/or retinal haemorrhage) or − suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor and diaphoresis). ● Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. Quick reference guideNICE clinical guideline 127 Hypertension Diagnosing hypertension 9 Using ambulatory or home blood pressure monitoring Ambulatory blood pressure monitoring ● Ensure that at least two measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00). ● Use the average value of at least 14 measurements taken during the person's usual waking hours to confirm the diagnosis. Home blood pressure monitoring ● Ensure that: − for each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated − blood pressure is recorded twice daily, ideally in the morning and evening − blood pressure recording continues for at least 4 days, ideally for 7 days. ● Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm the diagnosis. If hypertension is not diagnosed ● Offer to measure the person’s blood pressure at least every 5 years. ● Consider measuring it more often than every 5 years if the person’s clinic blood pressure is close to 140/90 mmHg. ● If there is evidence of target organ damage such as left ventricular hypertrophy, albuminuria or proteinuria, consider carrying out investigations for alternative causes of the target organ damage. NICE clinical guideline 127 Quick reference guide10 Hypertension Assessing cardiovascular risk and target organ damage/ Lifestyle interventions ● Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension, both for raised blood pressure and other modifiable risk factors 9,10 . ● Estimate cardiovascular risk in line with the recommendations on Identification and assessment of CVD risk in ‘Lipid modification’ 11 . ● Assess target organ damage 12 : − Test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip. − Take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate (eGFR), serum total cholesterol and HDL cholesterol. − Examine the fundi for the presence of hypertensive retinopathy. − Arrange for a 12-lead electrocardiograph to be performed. ● For people aged under 40 with stage 1 hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of target organ damage. This is because 10-year cardiovascular risk assessments can underestimate the lifetime risk of cardiovascular events in these people. 9 This recommendation was developed for the original 2004 guideline. 10 Clinic blood pressure measurements must be used in the calculation of cardiovascular risk. 11 NICE clinical guideline 67 (2008), available from www.nice.org.uk/guidance/CG67 12 For NICE guidance on the early identification and management of chronic kidney disease see ‘Chronic kidney disease’ (NICE clinical guideline 73, 2008), available from www.nice.org.uk/guidance/CG73 13 For NICE guidance on the prevention of obesity and cardiovascular disease see ‘Obesity’ (NICE clinical guideline 43, 2006), available from www.nice.org.uk/guidance/CG43, and ‘Prevention of cardiovascular disease at population level’ (NICE public health guidance 25, 2010), available from www.nice.org.uk/guidance/PH25 ● Lifestyle advice should be offered initially and then periodically to people undergoing assessment or treatment for hypertension 9,13 . ● Ask people about their diet and exercise patterns, and offer guidance and written or audiovisual materials to promote lifestyle changes 9 . ● Ask people about their alcohol consumption and encourage them to cut down if they drink excessively 9 . ● Discourage excessive consumption of coffee and other caffeine-rich products 9 . ● Encourage people to keep their salt intake low or substitute sodium salt 9 . ● Offer people who smoke advice and help to stop smoking 9 . ● Tell people about local initiatives (for example, run by healthcare teams or patient organisations) that provide support and promote lifestyle change 9 . ● Do not offer calcium, magnesium or potassium supplements as a method of reducing blood pressure 9 . ● Relaxation therapies can reduce blood pressure and people may wish to try them. However, it is not recommended that primary care teams provide them routinely 9 . Lifestyle interventions Assessing cardiovascular risk and target organ damage Quick reference guideNICE clinical guideline 127 Hypertension Antihypertensive drug treatment 11 General principles ● If possible, offer drugs taken only once a day 14 . ● Prescribe non-proprietary drugs if these are appropriate and minimise cost 14 . ● Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or higher) the same treatment as people with both raised systolic and diastolic blood pressure 14 . ● Offer people aged over 80 years the same antihypertensive drug treatment as people aged 55–80 years, taking into account any comorbidities. ● Do not combine an angiotensin-converting enzyme (ACE) inhibitor with an angiotensin II receptor blocker (ARB). ● Offer antihypertensive drug treatment to women of child-bearing potential in line with the recommendations on Management of pregnancy with chronic hypertension and Breastfeeding in ‘Hypertension in pregnancy’ 15 . Initiating and titrating antihypertensive drug treatment Also see the ‘Summary of antihypertensive drug treatment’ o