2022 surveillance of hypertension (NG136) and transient loss of consciousness (CG109) guidelines for postural hypotension
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Methods
The surveillance process consisted of:
Considering and addressing comments from the enquiry.
Examining and comparing NICE guidance and quality standards related to postural or orthostatic hypotension.
Considering the evidence and committee rationales used to develop recommendations in the NICE guidelines on hypertension (NG136) and transient loss of consciousness (CG109).
Gathering feedback from topic experts to establish preferred terminology, standards of measurement and potential implementation challenges.
Assessing the topic expert feedback against current recommendations to determine whether to update the recommendations and terminology used.
Consulting on the proposal with stakeholders (this report).
Current NICE recommendations related to postural hypotension
We have reviewed our recommendations related to 'postural' or 'orthostatic' hypotension across all NICE guidelines. We identified the following inconsistencies:
Recommendations on measurement of blood pressure when postural or orthostatic hypotension is suspected are made in 2 guidelines [Hypertension (NG136) and Transient Loss of Consciousness, TLoC (CG109)], and the criteria used are inconsistent (see Table 1 for a summary).
'Orthostatic' or 'postural' hypotension is mentioned in 13 NICE guidelines. In two guidelines,[Type I Diabetes (NG17) and Rehabilitation after Traumatic injury (NG211)], both terms are used interchangeably. See Appendix A for the list of recommendations.
Information considered when developing the guideline
There was no evidence review for the orthostatic hypertension recommendations in the NICE guideline on hypertension (NG136), and there was only 1 study identified on orthostatic hypertension in diagnosing the cause of transient loss of consciousness (TLoC) in the NICE guideline on TLoC (CG109). See Appendix B for details.
Feedback from topic experts
We received feedback from five members of the CVD committee (1 GP lecturer, 1 cardiologist, 1 hypertension specialist, and 1 nephrologist) with an interest in hypertension. One respondent declared a potential conflict of interest in receiving (non-commercially) funded research in postural hypotension. Key points raised in the feedback were:
A consistent term for orthostatic or postural hypotension should be used in all recommendations
Standardised measurement criteria and terminology should be used across all NICE guidelines
Lying down to standing blood pressure measurement is the best practice based on international consensus and is preferable
There are implementation challenges of measuring blood pressure in the lying down position in general practice, and there should be an option to do this seated if lying down is not possible
Further details of topic expert feedback are available in Appendix C.
Addressing inconsistencies in NICE guidelines
It is proposed to align the recommendations in the Hypertension (NG136) (recommendation 1.1.5 and 1.1.6) and TLoC (CG109) (recommendation 1.2.1.1) guidelines (see Table 1 below for a comparison of the main measurement criteria used in the current recommendations versus proposed changes. It is proposed that the measurement method and criteria will only be stated in the Hypertension guideline (NG136), and a cross-reference to this will be made from the TLoC guideline (CG109). In addition, we propose to amend recommendation 1.4.16 in the hypertension guideline (NG136) to be consistent with recommendations 1.1.5 and 1.1.6 so that the emphasis is to measure the blood pressure in the lying down position. See Table 2 for comparison of existing versus proposed recommendations.
Table 1: Comparison of definitions and diagnosis methods for blood pressure measurement for postural hypotension
Hypertension (NG136) Recommendations 1.1.5 and 1.16 | TLoC (CG109) | Proposed amendments | |
Position | Seated or supine | Lying down | Lying down is preferred to a seated position |
Duration of standing before measurement | 1 minute | 3 minutes | Up to 3 minutes |
Threshold of difference between standing vs seated or supine | Systolic BP falls by 20mmHg or more when standing | No mention of the threshold | 20 mmHg |
Management |
| 'If orthostatic hypotension is confirmed, consider likely causes, including drug therapy, and manage appropriately (for example, see the NICE guideline on falls in older people: assessing risk and prevention).' | If postural hypotension falls by 20 mmHg or more when the person is standing.
If the blood pressure drop is less than 20mm Hg despite a suggestive history:
|
Table 2: Comparison of existing versus proposed recommendations
Guideline | Existing recommendation | Proposed recommendations |
Hypertension (NG136) | 1.1.5 In people with symptoms of postural hypotension (falls or postural dizziness):
| 1.1.5 In people with suspected postural hypotension (with symptoms such as falls or postural dizziness):
If it is inconvenient to take the blood pressure measurement lying down, a seated position may be considered. |
Hypertension (NG136) | 1.1.6 If the systolic blood pressure falls by 20 mmHg or more when the person is standing:
| 1.1.6 If the systolic blood pressure falls by 20 mmHg or more when the person is standing:
If the blood pressure drop is less than 20mm Hg despite a suggestive history:
|
Hypertension (NG136) Section 1.4 Treating and monitoring hypertension Monitoring treatment and blood pressure targets | 1.4.16 Measure standing as well as seated blood pressure (see recommendation 1.1.6) in people with hypertension and:
In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure. | 1.4.16 Measure standing as well as lying down blood pressure (see recommendation 1.1.6) in people with hypertension and:
In people with a significant postural drop or symptoms of postural hypotension, treat to a blood pressure target based on standing blood pressure. |
Transient loss of consciousness (CG109) Section 1.2 assessment and referral 1.2.1 Suspected orthostatic hypotension | 1.2.1.1 Suspect orthostatic hypotension on the basis of the initial assessment when:
If these criteria are met, measure lying and standing blood pressure (with repeated measurements while standing for 3 minutes). If clinical measurements do not confirm orthostatic hypotension despite a suggestive history, refer the person for further specialist cardiovascular assessment. If orthostatic hypotension is confirmed, consider likely causes, including drug therapy, and manage appropriately (for example, see NICE guideline on falls in older people: assessing risk and prevention). | 1.2.1.1 Suspect postural hypotension on the basis of the initial assessment when:
See Hypertension guideline NICE guideline on hypertension (recommendations 1.1.5 and recommendation 1.1.6) for details of diagnostic criteria. |
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