4 Research recommendations
The Guideline Development Group has made the following recommendations for research,
based on its review of evidence, to improve NICE guidance and patient care in the future.
4.1 Out-of-office monitoring
In adults with primary hypertension, does the use of out-of-office monitoring (HBPM or ABPM)
improve response to treatment?
Why this is important
There is likely to be increasing use of HBPM and for the diagnosis of hypertension as a
consequence of this guideline update. There are, however, very few data regarding the utility of
HBPM or ABPM as means of monitoring blood pressure control or as indicators of clinical
outcome in treated hypertension, compared with clinic blood pressure monitoring. Studies should
incorporate HBPM and/or ABPM to monitor blood pressure responses to treatment and their
usefulness as indicators of clinical outcomes.
4.2 Intervention thresholds for people aged under 40 with
hypertension
In people aged under 40 years with hypertension, what are the appropriate thresholds for
intervention?
Why this is important
There is uncertainty about how to assess the impact of blood pressure treatment in people aged
under 40 years with stage 1 hypertension and no overt target organ damage or cardiovascular
disease (CVD). In particular, it is not known whether those with untreated hypertension are more
likely to develop target organ damage and, if so, whether such damage is reversible. Target
organ damage and CVD as surrogate or intermediate disease markers are the only indicators
that are likely to be feasible in younger people because traditional clinical outcomes are unlikely
to occur in sufficient numbers over the timescale of a typical clinical trial. The data will be
Hypertension NICE clinical guideline 127
© NICE 2011. All rights reserved. Last modified August 2011 Page 23 of 38
important to inform treatment decisions for younger people with stage 1 hypertension who do not
have overt target organ damage.
4.3 Methods of assessing lifetime cardiovascular risk in
people aged under 40 years with hypertension
In people aged under 40 years with hypertension, what is the most accurate method of
assessing the lifetime risk of cardiovascular events and the impact of therapeutic intervention on
this risk?
Why this is important
Current short-term (10-year) risk estimates are likely to substantially underestimate the lifetime
cardiovascular risk of younger people (aged under 40 years) with hypertension, because shortterm
risk assessment is powerfully influenced by age. Nevertheless, the lifetime risk associated
with untreated stage 1 hypertension in this age group could be substantial. Lifetime risk
assessments may be a better way to inform treatment decisions and evaluate the cost
effectiveness of earlier intervention with pharmacological therapy.
4.4 Optimal systolic blood pressure
In people with treated hypertension, what is the optimal systolic blood pressure?
Why this is important
Data on optimal blood pressure treatment targets, particularly for systolic blood pressure, are
inadequate. Current guidance is largely based on the blood pressure targets adopted in clinical
trials but there have been no large trials that have randomised people with hypertension to
different systolic blood pressure targets and that have had sufficient power to examine clinical
outcomes.
4.5 Step 4 antihypertensive treatment
In adults with hypertension, which drug treatment (diuretic therapy versus other step 4
treatments) is the most clinically and cost effective for step 4 antihypertensive treatment?
Hypertension NICE clinical guideline 127
© NICE 2011. All rights reserved. Last modified August 2011 Page 24 of 38
Why this is important
Although this guideline provides recommendations on the use of further diuretic therapy for
treatment at step 4 (resistant hypertension), they are largely based on post-hoc observational
data from clinical trials. More data are needed to compare further diuretic therapies, for example
a potassium-sparing diuretic with a higher-dose thiazide-like diuretic, and to compare diuretic
therapy with alternative treatment options at step 4 to define whether further diuretic therapy is
the best option.
4.6 Automated blood pressure monitoring in people with
atrial fibrillation
Which automated blood pressure monitors are suitable for people with hypertension and atrial
fibrillation?
Why this is important
Atrial fibrillation may prevent accurate blood pressure measurement with automated devices. It
would be valuable to know if this can be overcome.
Hypertension NICE clinical guideline 127
©