Could we simplify NICE guidance on choosing anti-hypertensive drugs?

Stratification by age Current NICE recommendations represent an evolution of the view that blood pressure is best lowered with β blockers or ACE inhibitors in patients under 55 years (in whom an activated H igh blood pressure is the most common modifiable cause of cardiovascular morbidity and mortality worldwide, and blood pressure lowering drugs from four major classes (angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers, β blockers, calcium channel blockers, and diuretics) are prescribed in large volumes. Among these, treatment would be dictated by cost or tolerability if all drugs were of similar efficacy and safety and had an additive effect when used in combination. However, guidance from the National Institute for Health and Clinical Excellence (NICE) and the British Hypertension Society emphasises differences between drug classes and combinations in blood pressure response and clinical outcomes. NICE’s recommendations are based on the view that younger patients (≤55 years) are more responsive to drugs targeting the reninangiotensin system than older patients; that β blockers are less effective than the other drug classes for the prevention of stroke; and that β blockers and diuretics lead to a clinically important increase in the risk of type 2 diabetes. Consequently, its 2006 guidelines gave primacy to angiotensin modifying drugs and calcium channel blockers, with a substantial influence on prescribing behaviour in EngDate No o f p re sc rip tio ns