NICE have just released an update to their clinical guideline CG127 (published August 2011) which updates and replaces NICE clinical guideline 34 (published June 2006). The Press Release can be viewed here.

NICE now recommend that a diagnosis of hypertension should be made using 24-hour ambulatory blood pressure monitoring (ABPM) which should be offered to patients if the clinic blood pressure is 140/90 mmHg or higher.

The full guidelines can be viewed on NICEs website here as well as number of supporting documents including quick reference guides, clinical case studies, costing templates and implementation advice.

As a specialist supplier of cardiovascular instruments, including blood pressure monitors, P.M.S (Instruments) Ltd have supplied ABPM monitors in the UK since 1989. We are a registered NICE stakeholder for this Hypertension update and gave feedback during the initial consultation period.

We represent Meditech and A&D Medical and can offer informed advice on the best ABPM monitor to suit your needs as well as demonstration/loan equipment. We are also an approved service centre for these companies and can offer professional advice on purchasing and after sales backup, ensuring you get the best value from your ABPM investment.

 The guidelines provided a detailed, systematic, clinical and costed review of the advantages of ABPM monitoring and concluded that

" This analysis of cost-effectiveness found that, confirming a diagnosis of hypertension with ABPM instead of CBPM or HBPM was the most cost-effective option in all age/gender subgroups (40, 50, 60, 70 and 75 years). In fact, ABPM was cost saving compared to CBPM when long term costs were taken into account. The key driver of cost savings with ABPM compared to CBPM was hypertension treatment costs avoided due to more accurate diagnosis (increased specificity)."

Key recommendations of the guidelines relating to blood pressure measurement include the following:-

 When considering a diagnosis of hypertension, 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 pressure in the arm with the higher reading. [new 2011]

If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new 2011]

If a person is unable to tolerate ABPM, home blood pressure monitoring (HBPM) is a suitable alternative to confirm the diagnosis of hypertension. [new 2011]

If the person has severe hypertension, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM. [new 2011]

While waiting for confirmation of a diagnosis of hypertension, carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy) (see 21) and a formal assessment of cardiovascular risk using a cardiovascular risk assessment tool (see 20). [new 2011]

If hypertension is not diagnosed but 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. [new 2011]

If hypertension is not diagnosed, measure the person’s clinic blood pressure at least every 5 years subsequently, and consider measuring it more frequently if the person’s clinic blood pressure is close to 140/90 mmHg. [new 2011]

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. [new 2011]

When using 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. [new 2011]

Refer the person to specialist care the same day if they have:

• accelerated hypertension, that is, 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). [2004, amended 2011]

Consider the need for specialist investigations in people with signs and symptoms suggesting a secondary cause of hypertension. [2004, amended 2011]

Follow this link to find out more about our ABPM range.