NICE and BHS guidelines on hypertension differ importantly
http://www.100md.com
《英国医生杂志》
EDITOR—The NICE guidelines on hypertension remind the public that hypertension is a major risk factor for cardiovascular diseases. Their added value to those who manage hypertension is, however, unclear, given the recent national and international guidelines from experts and primary care doctors with an interest in hypertension.1-3 The NICE guidance is largely consistent with these guidelines, but it differs from those of the British Hypertension Society in several important ways, thereby leading to confusion and potentially suboptimal management of hypertension. However, if both sets of guidelines improve the control of blood pressure the differences between guidelines will become less critical.
The NICE recommendation to treat hypertension initially with a thiazide-like diuretic irrespective of age, ethnic group, and whether isolated systolic hypertension is present or not is not supported by best evidence. Small crossover studies and large randomised trial data show differential effects on blood pressure with different antihypertensive agents by ethnic group and age.4 5 w1 In black patients these differences have been reflected in differential major cardiovascular outcomes by drug class.w1
Two large trials inform optimal practice in managing isolated systolic hypertension, so treating isolated systolic hypertension as if both systolic and diastolic blood pressures are raised seems unwise.w2 3
Dihydropyridine calcium channel blockers are incorrectly described by NICE as contraindicated in hypertensive patients with heart failure. Although the ALLHAT trial suggests other agents may be preferable for preventing heart failure,w1 calcium channel blockers are often needed as part of the cocktail of agents used to control blood pressure in heart failure.
The proposals to substitute lifestyle modification for drug treatment in patients with well-controlled hypertension are, on average, likely to worsen wellbeing.
Practitioners should continue to use the ABCD algorithm for drug sequencing because it is simple, easy to remember, flexible, and logical.3 It facilitates rapid and effective blood pressure lowering, is based on best currently available evidence, and advises how to change drugs without loss of blood pressure control in the 10% of patients yearly whom NICE recognises develop side effects with each drug.
Finally, the web based version of the NICE guidelines needs careful proofreading to correct some of the more obvious errors, such as coronary obstructive airways disease—presumably chronic obstructive airways disease is intended—and to ensure consistency in quoted blood pressure targets and thresholds.
Neil R Poulter, president, British Hypertension Society
Imperial College, London W2 1PG n.poulter@imperial.ac.uk
Additional references w1-w3 are on bmj.com
On behalf of the BHS Executive Committees, 2003-4: Philip Bath, Adrian Brady, Morris Brown, Mark Caulfield, Mark Davis, Alun Hughes, Thomas MacDonald, John Potter, and Nilesh Samani.
Competing interests: All authors have received honorariums from a number of pharmaceutical companies for lectures and consultancy, and research grant support for clinical trials from the pharmaceutical industry.
References
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289: 2560-72.
Guidelines Committee. 2003 European Society of Hypertension--European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens 2003;21: 1011-53.
Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ 2004;328: 634-40.
Dickerson JE, Hingorani AD, Ashby MJ, Palmer CR, Brown MJ. Optimisation of antihypertensive treatment by crossover rotation of four major classes. Lancet 1999;353: 2008-13.
Materson BJ, Reda DJ, Cushman WC. Department of Veterans Affairs single drug therapy of hypertension study. Revised figures and new data. Department of Veterans Affairs Co-operative Study Group on Antihypertensive Agents. Am J Hypertens 1995;8: 189-92.
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Two large trials inform optimal practice in managing isolated systolic hypertension, so treating isolated systolic hypertension as if both systolic and diastolic blood pressures are raised seems unwise.w2 3
Dihydropyridine calcium channel blockers are incorrectly described by NICE as contraindicated in hypertensive patients with heart failure. Although the ALLHAT trial suggests other agents may be preferable for preventing heart failure,w1 calcium channel blockers are often needed as part of the cocktail of agents used to control blood pressure in heart failure.
The proposals to substitute lifestyle modification for drug treatment in patients with well-controlled hypertension are, on average, likely to worsen wellbeing.
Practitioners should continue to use the ABCD algorithm for drug sequencing because it is simple, easy to remember, flexible, and logical.3 It facilitates rapid and effective blood pressure lowering, is based on best currently available evidence, and advises how to change drugs without loss of blood pressure control in the 10% of patients yearly whom NICE recognises develop side effects with each drug.
Finally, the web based version of the NICE guidelines needs careful proofreading to correct some of the more obvious errors, such as coronary obstructive airways disease—presumably chronic obstructive airways disease is intended—and to ensure consistency in quoted blood pressure targets and thresholds.
Neil R Poulter, president, British Hypertension Society
Imperial College, London W2 1PG n.poulter@imperial.ac.uk
Additional references w1-w3 are on bmj.com
On behalf of the BHS Executive Committees, 2003-4: Philip Bath, Adrian Brady, Morris Brown, Mark Caulfield, Mark Davis, Alun Hughes, Thomas MacDonald, John Potter, and Nilesh Samani.
Competing interests: All authors have received honorariums from a number of pharmaceutical companies for lectures and consultancy, and research grant support for clinical trials from the pharmaceutical industry.
References
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289: 2560-72.
Guidelines Committee. 2003 European Society of Hypertension--European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens 2003;21: 1011-53.
Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ 2004;328: 634-40.
Dickerson JE, Hingorani AD, Ashby MJ, Palmer CR, Brown MJ. Optimisation of antihypertensive treatment by crossover rotation of four major classes. Lancet 1999;353: 2008-13.
Materson BJ, Reda DJ, Cushman WC. Department of Veterans Affairs single drug therapy of hypertension study. Revised figures and new data. Department of Veterans Affairs Co-operative Study Group on Antihypertensive Agents. Am J Hypertens 1995;8: 189-92.