Walking
4/2mmHg reduction with 150 minutes of moderate intensity walking a week.
more
Aerobic exercise
5/3mmHg reduction with 30-60 minutes aerobic exercise 3 x a week.
more
Weight loss
4/3mmHg reduction with weight loss of about 4 kilos.
more
Alcohol intake reduction
3/2mmHg reduction with lowering alcohol intake by two-thirds (from a baseline of 3-6 units per day).
more
Salt intake reduction
5/3mmHg reduction with lowering salt intake by 4.4g/day
more
Much of this evidence is described as LOW quality. Why?
more
References
more
Stage 1 hypertension means: clinic BP 140-159/90-99mmHg.
NICE recommends considering drug treatment for adults with Stage 1 hypertension and a baseline QRISK score of 10% or more.
The amount of cardiovascular risk reduction for an individual depends on their baseline risk.
Here, “combined cardiovascular events” means: fatal and non-fatal angina, MI, TIA and stroke.
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We have presented information on Stage 1 hypertension separately, as the evidence base is more uncertain than that for Stage 2+3. Here, we show a lower risk reduction (RRR 12%) from drug treatment for Stage 1 hypertension, in line with the most recent NICE review. However, newer research suggests that the benefits may in fact be similar to those for treating Stage 2+3 (a RRR of 28%). This is uncertain, see the ‘Uncertainties and controversies’ button below. |
Figures derived from the 2019 NICE Guideline1:
Data detail
NICE acknowledged a challenge with the evidence base for stage 1 hypertension in that no ideal direct evidence exists for the treatment of stage 1 hypertension in patients without co-morbidities.
For their cost-effectiveness analysis, they applied the results of this systematic review which showed a 12% relative risk reduction (RRR) for combined cardiovascular events in a population with many patients with diabetes and CKD. This RRR has been applied here to baseline QRISK scores to give a rough estimate of benefits of treatment.
References
1)National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management[Internet]. [London]: NICE; 2019 . (NICE guideline [NG136]). Available from: https://www.nice.org.uk/guidance/ng136
2)Brunström M, Carlberg B. Association of Blood Pressure Lowering With Mortality and Cardiovascular Disease Across Blood Pressure Levels: A Systematic Review and Meta-analysis. JAMA Intern Med 2018; 178(1): 28-36
| This research provides some indication of the treatment effect.
There is a high possibility that the true effect is smaller or greater. |
NICE rated this evidence as LOW – VERY LOW quality1.
Although the data was derived from:
there is uncertainty about the results because of:
Reference
1)National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management[Internet]. [London]: NICE; 2019 . (NICE guideline [NG136]). Available from: https://www.nice.org.uk/guidance/ng136
The population characteristics in this systematic review1 were:
Reference
1)Brunström M, Carlberg B. Association of Blood Pressure Lowering With Mortality and Cardiovascular Disease Across Blood Pressure Levels: A Systematic Review and Meta-analysis. JAMA Intern Med 2018; 178(1): 28-36
The benefits of treating stage 1 hypertension in people with no established cardiovascular disease or co-morbidities such as diabetes and CKD are uncertain due to a lack of direct evidence.
NICE made a pragmatic recommendation in their guideline. However, you may hear different opinions – this is a brief summary of key aspects of the debate:
2012 Cochrane review: not enough evidence of treatment benefit
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2015-2016 systematic reviews including patients with CVD and other co-morbidities: evidence of benefit?
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2019 NICE’s approach: use data from primary prevention populations including those with type 2 diabetes
More
A practical approach?
When considering hypertension treatment for a patient without diabetes or CKD based on this evidence, we assume that they would get the same relative benefit as those with these co-morbidities.
We can adjust our estimates of benefit for an individual by using a baseline QRISK score, which will take into account whether or not they have diabetes or CKD.
Evidence update since NICE guidleine
more
References
more
3 drug classes have the strongest evidence regarding cardiovascular outcomes:
First-line treatment
NICE recommends which of these to choose as first line for particular groups of people1:
more
However, the difference in outcomes between these three classes is not great. Some details here:
more
Second- and third-line treatments
The three drug classes can be combined in any order.
Other drug classes: see the “Resistant hypertension” button.
References
1)National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management[Internet]. [London]: NICE; 2019 . (NICE guideline [NG136]). Available from: https://www.nice.org.uk/guidance/ng136
2)Wright JM, Musini VM, Gill R. First‐line drugs for hypertension. Cochrane Database of Systematic Reviews 2018, Issue 4. Art. No.: CD001841
3)Helmer A, Slater N, Smithgall S. A Review of ACE Inhibitors and ARBs in Black Patients With Hypertension. Ann Pharmacother 2018; 52(11): 1143-1151
A target of below 140/90mmHg (clinic reading) is recommended for most people.
For those aged 80 and over, NICE recommends 150/90mmHg, and to use clinical judgement for those with frailty and multimorbidity1.
Evidence reviews by NICE in 2019 and Cochrane in 2020 found no benefit from treatment to lower targets1,2.
more
What about the SPRINT study? Didn’t that show benefit from low BP targets?
more
References
1)National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management[Internet]. [London]: NICE; 2019. (NICE guideline [NG136]). Available from: https://www.nice.org.uk/guidance/ng136
2)Arguedas JA, Leiva V, Wright JM. Blood pressure targets in adults with hypertension. Cochrane Database of Systematic Reviews 2020, Issue 12. Art. No.: CD004349
3)The SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373: 2103-2116
Of the combined cardiovascular events, how many are MIs, how many are strokes and how many are deaths?
This varies depending on age and sex, the numbers below are intended to be a rough guide only:
These two examples use very approximate numbers to give you an idea:
Data detail
For their Lipid guideline in 2019, NICE conducted a health economic analysis which used figures for proportions of first CV events in people of varying ages. These numbers were used to estimate the proportion of CV events in someone at a 40% baseline risk. Then the relative risk reduction of blood pressure treatment1 on each event was calculated. A similar method was used to develop the NICE statin decision aid2.
References
1)Brunström M, Carlberg B. Association of Blood Pressure Lowering With Mortality and Cardiovascular Disease Across Blood Pressure Levels: A Systematic Review and Meta-analysis. JAMA Intern Med 2018; 178(1): 28-36
2)Patient decision aid: user guide for healthcare professionals. Implementing the NICE guideline on lipid modification(CG181). [Internet]. [London]: NICE; 2014 Accessed Mar 2021
Resistant hypertension means: hypertension which is uncontrolled despite treatment with 3 classes of drugs (ACEi or ARB+CCB+thiazide).
NICE suggests 3 additional drug classes to consider in addition1:
These have no or very limited evidence of benefit on cardiovascular outcomes, but do lower blood pressure.
BP lowering effect of these drugs in patients with resistant hypertension already on standard treatment:
| Spironolactone 25-50mg | Bisoprolol 5-10mg | Doxazosin 4-8mg | |
| Mean difference in SBP compared to placebo over 12 weeks | -8.7 mmHg | -4.2 mmHg | -4.6 mmHg |
Side effect rates of these drugs seen in this trial:
| Placebo | Spironolactone 25-50mg | Bisoprolol 5-10mg | Doxazosin 4-8mg | |
| Dizziness | 4.5% | 6.1% | 12.2% | 6% |
| Exertional dyspnoea | 0 | 1.3% | 3.1% | 0.3% |
| Peripheral oedema | 0.7% | 1.3% | 4.4% | 0 |
| Muscle spasms | 0 | 1% | 1.7% | 6.6% |
| Diarrhoea | 1% | 3.7% | 2.7% | 0.7% |
| All adverse events | 15% | 19% | 23% | 23% |
Differences between treatments are statistically significant
more
References
1)National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management[Internet]. [London]: NICE; 2019. (NICE guideline [NG136]). Available from: https://www.nice.org.uk/guidance/ng136
2)Williams B, MacDonald TM, Morant S et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet 2015; 386(10008): 2059-2068
Information on treatment harms comes from older RCTs and a more recent observational study.
Both have their limitations but are presented here as a guide.
RCTs: Likelihood of withdrawal from treatment due to side effects from BP-lowering treatment over a 5 year period:
| Placebo | Drug treatment | Absolute Risk Increase | Number Needed to Harm |
| 3% | 14.4% | 11.4% | 9 |
The treatments being used were propranolol, bendroflumethiazide and methyldopa.
From: Cochrane review of drug treatment for mild hypertension1
Evidence quality rated as MODERATE because:
Observational study: rates of specific side effects from BP-lowering treatment over a 6-year period (all drug classes combined) in people at low cardiovascular risk.
Evidence quality rates as LOW because of the nature of the study, but its findings are well worth considering as the design is so relevant to general practice.
| Outcome | Not prescribed treatment | Prescribed treatment | Absolute Risk Increase* | Number Needed to Harm over 10 years** |
| Hypotension | 0.8% | 1.4% | 0.6% | 41 |
| Syncope | 2.5% | 3.2% | 0.7% | 35 |
| Acute kidney injury | 0.8% | 1.0% | 0.2% | 91 |
| Electrolyte abnormality | 0.3% | 0.5% | 0.2% | 111 |
| Falls | No increased risk found | |||
*Absolute risk increases are after a median follow up of 5.8 years. ** Figures calculated by the researchers.
These figures represent events recorded as clinical codes in GP or hospital records.
Click below for more details on the trial.
more
References
1)Diao D, Wright JM, Cundiff DK, Gueyffier F. Pharmacotherapy for mild hypertension. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD006742. DOI: 10.1002/14651858.CD006742.pub2
2)
3)Sheppard JP, Stevens S, Stevens R et al. Benefits and Harms of Antihypertensive Treatment in Low-Risk Patients With Mild Hypertension. JAMA Intern Med 2018; 178(12): 1626-1634
Stage 2-3 hypertension means: clinic BP 160/100 or higher.
NICE recommends offering drug treatment to adults with these levels of hypertension regardless of their baseline QRISK.
The extent to which drug treatment reduces an individual’s cardiovascular risk still depends on their baseline risk.
Here, “combined cardiovascular events” means: fatal and non-fatal MI and stroke (but not including angina or TIA), plus hospitalisation or death from heart failure.
Figures derived from a 2019 Cochrane review1:
Reference
1)Musini VM, Tejani AM, Bassett K et al. Pharmacotherapy for hypertension in adults 60 years or older. Cochrane Database of Systematic Reviews 2019, Issue 6. Art. No.: CD000028
| This research provides a good indication of the treatment effect.
There is a moderate possibility that the true effect is smaller or greater. |
Cochrane rated this evidence as MODERATE quality1.
Although the data was derived from:
there is some uncertainty about the results because of
Reference
1)Musini VM, Tejani AM, Bassett K et al. Pharmacotherapy for hypertension in adults 60 years or older. Cochrane Database of Systematic Reviews 2019, Issue 6. Art. No.: CD000028
The population characteristics in this systematic review of 16 trials 1 were:
* These two trials contributed less than 1% of participants to the overall analysis.
Reference
1)Musini VM, Tejani AM, Bassett K et al. Pharmacotherapy for hypertension in adults 60 years or older. Cochrane Database of Systematic Reviews 2019, Issue 6. Art. No.: CD000028
3 drug classes have the strongest evidence regarding cardiovascular outcomes:
First-line treatment
NICE recommends which of these to choose as first line for particular groups of people1:
more
However, the difference in outcomes between these three classes is not great. Some details here:
more
Second- and third-line treatments
The three drug classes can be combined in any order.
Other drug classes: see the “Resistant Hypertension” button.
References
1)National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management[Internet]. [London]: NICE; 2019 . (NICE guideline [NG136]). Available from: https://www.nice.org.uk/guidance/ng136
2)Wright JM, Musini VM, Gill R. First‐line drugs for hypertension. Cochrane Database of Systematic Reviews 2018, Issue 4. Art. No.: CD001841
3)Helmer A, Slater N, Smithgall S. A Review of ACE Inhibitors and ARBs in Black Patients With Hypertension. Ann Pharmacother 2018; 52(11): 1143-1151
A target of below 140/90mmHg (clinic reading) is recommended for most people.
For those aged 80 and over, NICE recommends 150/90mmHg, and to use clinical judgement for those with frailty and multimorbidity1.
Evidence reviews by NICE in 2019 and Cochrane in 2020 found no benefit from treatment to lower targets1,2.
more
What about the SPRINT study? Didn’t that show benefit from low BP targets?
more
References
1)National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management[Internet]. [London]: NICE; 2019 . (NICE guideline [NG136]). Available from: https://www.nice.org.uk/guidance/ng136
2)Arguedas JA, Leiva V, Wright JM. Blood pressure targets in adults with hypertension. Cochrane Database of Systematic Reviews 2020, Issue 12. Art. No.: CD004349
3)The SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373: 2103-2116
Of the combined cardiovascularevents, how many are MIs, how many are strokes and how many are deaths?
This varies depending on age and sex, the numbers below are intended to be a rough guide only:
These two examples use very approximate numbers to give you an idea:
Data detail
For their Lipid guideline in 2019, NICE conducted a health economic analysis which used figures for proportions of first CV events in people of varying ages. These numbers were used to estimate the proportion of CV events in someone at a 40% baseline risk. Then the relative risk reduction of blood pressure treatment1 on each event was calculated. A similar method was used to develop the NICE statin decision aid2.
References
1)Brunström M, Carlberg B. Association of Blood Pressure Lowering With Mortality and Cardiovascular Disease Across Blood Pressure Levels: A Systematic Review and Meta-analysis. JAMA Intern Med 2018; 178(1): 28–36
2)Patient decision aid: user guide for healthcare professionals. Implementing the NICE guideline on lipid modification(CG181). [Internet]. [London]: NICE; 2014 Accessed Mar 2021
Resistant hypertension means: hypertension which is uncontrolled despite treatment with 3 classes of drugs (ACEi or ARB+CCB+thiazide).
NICE suggests 3 additional drug classes to consider in addition1:
These have no or very limited evidence of benefit on cardiovascular outcomes, but do lower blood pressure.
BP-lowering effect of these drugs in patients with resistant hypertension already on standard treatment:
| Spironolactone 25-50mg | Bisoprolol 5-10mg | Doxazosin 4-8mg | |
| Mean difference in SBP compared to placebo over 12 weeks | -8.7 mmHg | -4.2 mmHg | -4.6 mmHg |
Side effect rates of these drugs seen in this trial:
| Placebo | Spironolactone 25-50mg | Bisoprolol 5-10mg | Doxazosin 4-8mg | |
| Dizziness | 4.5% | 6.1% | 12.2% | 6% |
| Exertional dyspnoea | 0 | 1.3% | 3.1% | 0.3% |
| Peripheral oedema | 0.7% | 1.3% | 4.4% | 0 |
| Muscle spasms | 0 | 1% | 1.7% | 6.6% |
| Diarrhoea | 1% | 3.7% | 2.7% | 0.7% |
| All adverse events | 15% | 19% | 23% | 23% |
Differences between treatments are statistically significant
more
References
1)National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management[Internet]. [London]: NICE; 2019 . (NICE guideline [NG136]). Available from: https://www.nice.org.uk/guidance/ng136
2)Williams B, MacDonald TM, Morant S et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet 2015; 386(10008): 2059-2068
There is uncertainty about the rates of side effects from BP treatments.
RCTs vary in how they report harms, and tend to involve people who are at lower risk of harms to start with. These numbers should be viewed as a guide only.
Likelihood of withdrawal from treatment due to side effects from BP-lowering treatment over a 5 year period:
| Placebo | Drug treatment | Absolute Risk Increase | Number Needed to Harm |
| 5.4% | 15.7% | 10.3% | 10 |
From: Cochrane review (2109) of BP treatment in adults over 60 across all ranges of BP severity1
Evidence quality rated as LOW because
Rates of specific side effects from BP-lowering treatment over a 3 year period:
| Outcome | Placebo or less intense treatment | Treatment or more intense treatment | Absolute Risk Increase | Number Needed to Harm |
| All drug classes combined | ||||
| Hypotension | 3.3% | 6.1% | 2.7% | 36 |
| Syncope | 1.1% | 1.3% | 0.2% | 500 |
| Acute kidney injury | 1.5% | 2.1% | 0.6% | 171 |
| Falls | No increased risk found | |||
| ACE inhibitors and angiotensin receptor blockers (ARBs) | ||||
| Hyperkalaemia | 3.0% | 4.8% | 1.8% | 54 |
| Acute kidney injury | 1.1% | 1.5% | 0.4% | 250 |
| Thiazide diuretics | ||||
| Hypokalaemia | 0.8% | 8.2% | 7.4% | 13 |
| Gout* | 0.2% | 2.0% | 1.7% | 58 |
* The estimates for gout risks with thiazide diuretics were not quite statistically significant though probably represent a true effect
From: a systematic review of trials of drug treatment vs placebo AND intense treatment v less intense treatment across all ranges of BP severity2.
Evidence quality rated as VERY LOW because:
References
1)Musini VM, Tejani AM, Bassett K et al. Pharmacotherapy for hypertension in adults 60 years or older. Cochrane Database of Systematic Reviews 2019, Issue 6. Art. No.: CD000028
2) Association between antihypertensive treatment and adverse events: systematic review and meta-analysis
People who have an adverse event
People whose adverse event is prevented by treatment
People who were never going to have an adverse event anyway
Graphics and NNTs are rounded to the nearest integer
These three statistical terms offer three different ways of looking at the results of trial data.
Absolute Risk Reduction
This tells you how many people out of 100 who take a treatment have an adverse event prevented.
MoreNumber Needed to Treat
This tells you how many people need to take the treatment in order for one person to avoid an adverse event.
The lower the number, the more effective the treatment.
MoreRelative Risk Reduction
This tells you the proportion of adverse events that are avoided if the entire population at risk is treated.
MoreThis website is designed for use by General Practitioners and other healthcare professionals. The content is not exhaustive and assumes a standard level of GP professional knowledge. The information here is intended to support clinical judgement and shared decision making alongside clinical guidelines and standard practice.
If you are a patient/member of the public, do feel free to look around, but please don’t make any changes to your treatments based on information here. If you find something which seems relevant to you, you could show this website to your healthcare professional to help a discussion.