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1. The British Approach to Antihypertensive Therapy: Guidelines from the National Institute of Health and Clinical Excellence Power Over Pressure www.poweroverpressure.com

2. Treatment guidelines provide a systematic approach to blood pressure (BP) management In 2011, the National Institute of Health and Clinical Excellence (NICE) in the UK published a simple step-wise treatment algorithm for the initiation and optimization of antihypertensive therapy National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. Power Over Pressure www.poweroverpressure.com

3. A simple step-wise algorithm to expedite BP control Patient ≥55 years old OR Any age black person of African or Caribbean origin No Initiate ACEI or ARB Step 1 Yes Initiate CCB BP still above goal? BP still above goal? CCB + ACEI or ARB Step 2 BP still above goal? CCB + ACEI or ARB + thiazide-like diuretic Step 3 BP still above goal? • Evaluate for treatment-resistant hypertension • Consider adding further diuretic or - or -blocker • Consider referral to a hypertension specialist Step 4 ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin-receptor blocker; CCB = calcium channel blocker. National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. Power Over Pressure www.poweroverpressure.com

4. Step 1: Initiating treatment • Initial treatment decisions should be based on patient’s age and race • Patients <55 years of age should start treatment with an ACEI oran ARB* • Patients 55 years of age and patients who are black of African or Caribbean origin, regardless of age, should initiate therapy with a CCB • In some cases, a CCB may not be suitable (eg, edema or intolerance) • If a CCB is not suitable or if there is evidence of heart failure or high risk of heart failure, a thiazide-like diuretic should be offered Patient ≥55 years old OR Any age black person of African or Caribbean origin No Initiate ACEI or ARB Step 1 Yes Initiate CCB BP still above goal? BP still above goal? CCB + ACEI or ARB Step 2 BP still above goal? CCB + ACEI or ARB + thiazide-like diuretic Step 3 BP still above goal? Practice Tip: Once drug therapy is initiated, patients should return for follow-up and adjustment of medications at least monthly until the BP goal is reached. • Evaluate for treatment-resistant hypertension • Consider adding further diuretic or - or -blocker • Consider referral to a hypertension specialist Step 4 *Do not combine an ACEI with an ARB. National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. Power Over Pressure www.poweroverpressure.com

5. Step 2: Advancing therapy • If single-drug therapy fails to control BP, patients should start combination therapy with a CCB in combination with either an ACEI or an ARB • If a CCB is not appropriate for step 2 treatment, offer a thiazide-like diuretic • For black people of African or Caribbean origin, consider an ARB rather than an ACEI in combination with a CCB Patient ≥55 years old OR Any age black person of African or Caribbean origin No Initiate ACEI or ARB Step 1 Yes Initiate CCB BP still above goal? BP still above goal? CCB + ACEI or ARB Step 2 BP still above goal? CCB + ACEI or ARB + thiazide-like diuretic Step 3 BP still above goal? Practice Tip: Thiazide-like diuretics such as chlortalidone or indapamide are preferred to conventional thiazide diuretics such as bendroflumethiazide or hydrochlorothiazide. • Evaluate for treatment-resistant hypertension • Consider adding further diuretic or - or -blocker • Consider referral to a hypertension specialist Step 4 National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. Power Over Pressure www.poweroverpressure.com

6. Step 3: Triple-combination therapy • If 2-drug combination therapy fails to control BP, the combination of an ACEI or an ARB + a CCB + a thiazide-like diuretic should be used Patient ≥55 years old OR Any age black person of African or Caribbean origin No Initiate ACEI or ARB Step 1 Yes Initiate CCB BP still above goal? BP still above goal? CCB + ACEI or ARB Step 2 BP still above goal? CCB + ACEI or ARB + thiazide-like diuretic Step 3 BP still above goal? Practice Tip: Treatment-resistant hypertension is frequently caused by suboptimal dosing. Before considering Step 3 treatment, review medication to ensure Step 2 treatment is at optimal or maximum tolerated doses. • Evaluate for treatment-resistant hypertension • Consider adding further diuretic or - or -blocker • Consider referral to a hypertension specialist Step 4 National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. Power Over Pressure www.poweroverpressure.com

7. Step 4: Treatment-resistant hypertension • BP >140/90 mm Hg after treatment with the optimal or maximum tolerated doses of an ACEI or an ARB + a CCB + a diuretic should be regarded as treatment-resistant hypertension • Consider adding a fourth antihypertensive drug and/or seeking expert advice • An α- or β-blocker may be useful • Further diuretic therapy with low-dose spironolactone should be considered, depending on the patient’s blood potassium level Patient ≥55 years old OR Any age black person of African or Caribbean origin No Initiate ACEI or ARB Step 1 Yes Initiate CCB BP still above goal? BP still above goal? CCB + ACEI or ARB Step 2 BP still above goal? CCB + ACEI or ARB + thiazide-like diuretic Step 3 BP still above goal? • Evaluate for treatment-resistant hypertension • Consider adding further diuretic or - or -blocker • Consider referral to a hypertension specialist Practice Tip: If BP remains uncontrolled with the optimal or maximum tolerated doses of 4 drugs, seek the advice of a hypertension expert. Step 4 National Institute for Health and Clinical Excellence. 2011. Hypertension: Clinical management of primary hypertension in adults. CG127. London, National Institute for Health and Clinical Excellence. Power Over Pressure www.poweroverpressure.com

8. Summary • The NICE guidelines provide a systematic, stepwise approach to the treatment of hypertension • Start with single-drug therapy, either an ACEI or ARB, or a CCB, depending on the patient’s age and race • If BP remains uncontrolled, initiate combination therapy with a CCB in combination with either an ACEI or an ARB • Ensure that the regimen is titrated to optimal or maximum tolerated doses • If 2-drug combination therapy fails to control BP, add a thiazide-like diuretic to the regimen • If BP remains uncontrolled on a 3-drug regimen, the patient should be considered treatment resistant • Consider adding a fourth antihypertensive agent, either an α- or β-blocker or low-dose spironolactone • Seek the advice of a hypertension specialist Power Over Pressure www.poweroverpressure.com