2018 ESC/ESH vs. 2019 NICE Hypertension Guideline

The findings of the SPRINT study in 2015 resulted in an update of international hypertension guidelines. This includes the American College of Cardiology and American Heart Association (ACC/AHA) guidelines which were updated in 2017, the European Society of Cardiology and European Society of Hypertension (ESC/ESH) guidelines which were updated in 2018, and the National Institute for Health and Care Excellence (NICE) guidelines which were updated in August 2019. While these three major guidelines agree on many points, there are some important differences in their recommendations. Here is a short overview of how the ESC/ESH guidelines differ from the NICE guidelines. 

The ESC/ESH guidelines continue to emphasise on the importance of reducing blood pressure below 140/90 mmHg for all patients. They also recommend that systolic blood pressure (SBP) for patients aged under 65 should be reduced to between 120 and 129 mmHg. Treatment threshold remains at an SBP of 140 mmHg. The ESC/ESH guidelines recommend a three-step approach with single pill dual therapy if SBP is ≥150 mmHg. In case the triple therapy is unsuccessful, the guidelines recommend low-dose spironolactone for resistant hypertension.  

The NICE guidelines recommend treating to a threshold and target blood pressure of 140/90 mmHg. There are no lower treatment targets in these guidelines. The updated guidelines have reduced the risk threshold for treatment in uncomplicated stage 1 hypertension to 10% 10-year cardiovascular risk from 20% previously. With respect to treatment, the NICE guidelines recommend monotherapy at Step 1, and patient-focused medication choice in Step 2 and Step 3. The NICE guidelines also recommend the use of spironolactone, other diuretics and alpha or beta-blockers for resistant hypertension. 

The two guidelines use different processes and different aims and methods. The NICE guidelines are intended for population treatment and are based on both clinical evidence and cost-effective analysis. The ESC/ESH guidelines, on the other hand, are broader in scope and are intended for the treatment of individuals in many European countries with different socio-economic backgrounds. The ESC/ESH guidelines encompass all aspects of blood pressure control, including pregnancy and peri-operative management while the NICE guidelines are broad-range and do not include recommendations for management of hypertension in pregnancy or for secondary prevention of cardiovascular disease or even in patients with chronic kidney disease. These patient groups are covered in separate guidelines. 

The process of developing guidelines is also different for these two. The ESC/ESH guidelines are based on a Task Force of 21 specialists who review five classes of graded evidence. The NICE guidelines, on the other hand, are developed by a smaller committee that includes a mix of people from primary and secondary care as well as patients, and are tailored to separate topics.  

This comparison is no way suggests that one guideline is better than the other. Both have similarities and differences, and both are designed to help guide clinicians to use the most effective treatments. While some discrepancies exist, they, in no way, make one guideline superior to the other.