The NICE Hypertension Guidelines: A Monitoring Revolution
George Bakris, MD: Hello and thank you for joining us today. I'm Dr. George Bakris, Professor of Medicine and Director of the Hypertensive Diseases Unit at The University of Chicago Pritzker School of Medicine. I'm joined today by Dr. Rajiv Agarwal, Professor of Medicine, Division of Nephrology at Indiana University [in Indianapolis]. We'd like to talk to you today about some new and exciting guidelines that are certainly going to have an impact internationally as well as in the United States, and that is the National Institute for Health and Clinical Excellence (NICE) guidelines. These are the guidelines in the United Kingdom that are evidence based and were ahead of their time in terms of how they compiled the data to come up with these guidelines.
The most recent one is now available and has some relatively revolutionary comments. One of them is that all new patients with hypertension should have an ambulatory blood pressure monitor to make sure that they don't have masked hypertension, to know their dipping status, and to look for blood pressure variability -- which is now a very hot topic. This is especially true in people with chronic kidney disease. I thought that we would ask Dr. Agarwal this morning his opinion on this and his comments about what the guideline says. Rajiv?
Rajiv Agarwal, MD: Yes, George, I think that they are revolutionary. Ambulatory blood pressure monitoring has never been recommended by any guideline to confirm the diagnosis of hypertension, but we have known for a long time that white-coat hypertension and masked hypertension are real problems. This is the first guideline that takes this problem and addresses it by asking to do ambulatory blood pressure monitoring in all patients at the first visit.
The concern that I have with ambulatory blood pressure monitoring is that it might not be widely available to everybody, and it might not be applicable to everyone. I would say that home blood pressure monitoring would be an intermediate step, and some [who] also recognize the same guidelines [recommend] ambulatory or home blood pressure monitoring. In that respect, I like Tom Pickering's recommendations on this. He recommends that if you are newly diagnosed with hypertension that you perform home blood pressure monitoring. If home blood pressure monitoring is less than 125/75 mm Hg on average, then there is no need to worry -- just continue to monitor it. If it is more than 135/95 mm Hg, that diagnoses hypertension and you are eligible for treatment.
When you are in between 125 and 135 mm Hg and between 75 and 85 mm Hg, then you warrant ambulatory blood pressure monitoring. Using a stepped care approach might actually minimize costs and make it more broadly applicable. Home blood pressure monitoring also has a wonderful value in monitoring response to therapy. The NICE guidelines say that we really don't have much data on how to use home blood pressure monitoring for monitoring response to therapy, but if you are going to ask patients to do home blood pressure monitoring for diagnosis, I think we can use that for measuring response as well. Studies at least show that it improves adherence to therapy, and if physicians act upon the home blood pressure monitoring it might reduce therapeutic inertia and improve the control rates of hypertension.
Dr. Bakris: Very good. Now, there are a couple of things. When Tom Pickering made those recommendations, we did not appreciate the impact of blood pressure variability. Number two, if you do it that way you really don't catch whether or not patients have a nocturnal dip. We know that those have a significant impact on outcomes. What do you think about putting those things into the equation? Keep in mind that I'm a big fan of home blood pressure monitoring. I use it all the time. The data on the validity of it are coming out more and more. One of my countrymen, George Stergiou, has been a pioneer in this and published a huge study in 10,000 patients looking at this. So, I'm all for home blood pressure monitoring, but nobody's going to get up at 2:00 AM and check their blood pressure. Very few people, unless they really have obsessive-compulsive disorder, are going to be checking it 4 times a day to check for masked hypertension. How do you deal with that?
Dr. Agarwal: Clearly home blood pressure monitoring has limitations, and if the person did get up at 2:00 AM and measure their blood pressure, it's probably not their sleeping blood pressure. It's really not the time of the day but when they are asleep, and what their blood pressure is is what matters. Variability is an interesting issue. Perhaps if we measured home blood pressures for a long period of time -- and we are talking about months of measurements -- even a limited number of measurements may give you a fairly good idea about the variability of blood pressure. People have talked about morning surge and its risk for strokes, etc, and that is something that can be captured perhaps in a more accurate way with home blood pressure monitoring because you can take many mornings' worth of home blood pressure [readings], whereas you can only do one 24-hour ambulatory blood pressure monitoring. Clearly home blood pressure monitoring is limited in its ability to capture nocturnal dipping. Some home blood pressure monitors are being designed now that can actually take a limited number of home blood pressure recordings at night while patients are sleeping. So, the boundary between home blood pressure monitoring and ambulatory monitoring may become fuzzier as time goes on.
Dr. Bakris: Very good. Rajiv, thank you very much for giving us your insight into the new recommendations. I doubt very much whether this is going to be in the JNC 8 [Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure], which is going to be presented at the American Society of Hypertension (ASH) [meeting] next year, but nevertheless I think it's important to keep these perspectives in mind for clinicians. Thank you for your time and thank you for joining us today.
Dr. Agarwal: Thank you, George.
George Bakris, MD: Hello and thank you for joining us today. I'm Dr. George Bakris, Professor of Medicine and Director of the Hypertensive Diseases Unit at The University of Chicago Pritzker School of Medicine. I'm joined today by Dr. Rajiv Agarwal, Professor of Medicine, Division of Nephrology at Indiana University [in Indianapolis]. We'd like to talk to you today about some new and exciting guidelines that are certainly going to have an impact internationally as well as in the United States, and that is the National Institute for Health and Clinical Excellence (NICE) guidelines. These are the guidelines in the United Kingdom that are evidence based and were ahead of their time in terms of how they compiled the data to come up with these guidelines.
The most recent one is now available and has some relatively revolutionary comments. One of them is that all new patients with hypertension should have an ambulatory blood pressure monitor to make sure that they don't have masked hypertension, to know their dipping status, and to look for blood pressure variability -- which is now a very hot topic. This is especially true in people with chronic kidney disease. I thought that we would ask Dr. Agarwal this morning his opinion on this and his comments about what the guideline says. Rajiv?
Rajiv Agarwal, MD: Yes, George, I think that they are revolutionary. Ambulatory blood pressure monitoring has never been recommended by any guideline to confirm the diagnosis of hypertension, but we have known for a long time that white-coat hypertension and masked hypertension are real problems. This is the first guideline that takes this problem and addresses it by asking to do ambulatory blood pressure monitoring in all patients at the first visit.
The concern that I have with ambulatory blood pressure monitoring is that it might not be widely available to everybody, and it might not be applicable to everyone. I would say that home blood pressure monitoring would be an intermediate step, and some [who] also recognize the same guidelines [recommend] ambulatory or home blood pressure monitoring. In that respect, I like Tom Pickering's recommendations on this. He recommends that if you are newly diagnosed with hypertension that you perform home blood pressure monitoring. If home blood pressure monitoring is less than 125/75 mm Hg on average, then there is no need to worry -- just continue to monitor it. If it is more than 135/95 mm Hg, that diagnoses hypertension and you are eligible for treatment.
When you are in between 125 and 135 mm Hg and between 75 and 85 mm Hg, then you warrant ambulatory blood pressure monitoring. Using a stepped care approach might actually minimize costs and make it more broadly applicable. Home blood pressure monitoring also has a wonderful value in monitoring response to therapy. The NICE guidelines say that we really don't have much data on how to use home blood pressure monitoring for monitoring response to therapy, but if you are going to ask patients to do home blood pressure monitoring for diagnosis, I think we can use that for measuring response as well. Studies at least show that it improves adherence to therapy, and if physicians act upon the home blood pressure monitoring it might reduce therapeutic inertia and improve the control rates of hypertension.
Dr. Bakris: Very good. Now, there are a couple of things. When Tom Pickering made those recommendations, we did not appreciate the impact of blood pressure variability. Number two, if you do it that way you really don't catch whether or not patients have a nocturnal dip. We know that those have a significant impact on outcomes. What do you think about putting those things into the equation? Keep in mind that I'm a big fan of home blood pressure monitoring. I use it all the time. The data on the validity of it are coming out more and more. One of my countrymen, George Stergiou, has been a pioneer in this and published a huge study in 10,000 patients looking at this. So, I'm all for home blood pressure monitoring, but nobody's going to get up at 2:00 AM and check their blood pressure. Very few people, unless they really have obsessive-compulsive disorder, are going to be checking it 4 times a day to check for masked hypertension. How do you deal with that?
Dr. Agarwal: Clearly home blood pressure monitoring has limitations, and if the person did get up at 2:00 AM and measure their blood pressure, it's probably not their sleeping blood pressure. It's really not the time of the day but when they are asleep, and what their blood pressure is is what matters. Variability is an interesting issue. Perhaps if we measured home blood pressures for a long period of time -- and we are talking about months of measurements -- even a limited number of measurements may give you a fairly good idea about the variability of blood pressure. People have talked about morning surge and its risk for strokes, etc, and that is something that can be captured perhaps in a more accurate way with home blood pressure monitoring because you can take many mornings' worth of home blood pressure [readings], whereas you can only do one 24-hour ambulatory blood pressure monitoring. Clearly home blood pressure monitoring is limited in its ability to capture nocturnal dipping. Some home blood pressure monitors are being designed now that can actually take a limited number of home blood pressure recordings at night while patients are sleeping. So, the boundary between home blood pressure monitoring and ambulatory monitoring may become fuzzier as time goes on.
Dr. Bakris: Very good. Rajiv, thank you very much for giving us your insight into the new recommendations. I doubt very much whether this is going to be in the JNC 8 [Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure], which is going to be presented at the American Society of Hypertension (ASH) [meeting] next year, but nevertheless I think it's important to keep these perspectives in mind for clinicians. Thank you for your time and thank you for joining us today.
Dr. Agarwal: Thank you, George.
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