MODULE 1: Historical Review of Evidence-Based Treatment of Hypertension

FIGURE 3

NICE algorithm for treatment of hypertension⁵⁰

ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; CCB, calcium channel blocker; NICE, National Institute for Health and Clinical Excellence.
^aChoose a low-cost ARB.
^bA CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has edema, evidence of heart failure, or a high risk of heart failure.
^cConsider a low dose of spironolactone^d or higher doses of thiazide-like diuretic
^dAt the time of publication (August 2011), spironolactone did not have a UK marketing authorization for this indication. Informed consent should be obtained and documented.
^eConsider an alpha- or beta-blocker if further diuretic therapy is not tolerated or is contraindicated or ineffective.
Source: National Institute for Health and Clinical Excellence (2011) CG 127 Hypertension: clinical management of primary hypertension in adults. London: NICE. Available from www.nice.org.uk/guidance/CG127. Reproduced with permission. The NICE guidance that this algorithm relates to was prepared for the National Health Service in England and Wales. NICE guidance does not apply to the United States and NICE has not been involved in the development or adaptation of any guidance for use in the United States.The ACCF/AHA and NICE guidelines also recommend that clinicians monitor electrolyte levels of patients on ACEIs/ARBs, with The frequency depending on each patient’s medical condition.^41,50

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Conclusion

With 7 major classes of antihypertensive drugs and several drugs within each class, there are numerous combinations available to clinicians to manage hypertension. Existing clinical trials cannot possibly evaluate all possible combinations. Yet, as noted in the ASH statement on combination therapy, the importance of achieving goal BP in individual patients cannot be overemphasized because small differences in on-treatment BP translate into major differences in the rates of CV events.⁴⁷ When considering appropriate and effective antihypertensive therapies, clinicians should assess the evidence presented in this article and from the various clinical guidelines cited. Each patient is unique and it is important for clinicians to identify the most-effective treatment regimen for each individual patient.