NICE News- November 2023
7m | Dec 12, 2023This podcast makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this video I will go through new and updated guidelines published in November 2023 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my interpretation of the guidelines and you must use your clinical judgement.
There is a podcast version of this and other videos that you can access here:
Primary Care guidelines podcast:
· Redcircle: https://redcircle.com/shows/primary-care-guidelines
· Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK
· Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148
There is a YouTube version of this and other videos that you can access here:
The Practical GP YouTube Channel:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The Clinic BP targets flowchart can be downloaded here:
· https://1drv.ms/b/s!AiVFJ_Uoigq0mFp2iUfq8rimJSmo?e=BnJaCD
The Clinic BP targets tables can be downloaded here:
· https://1drv.ms/b/s!AiVFJ_Uoigq0mFtrsXeUGOB58DKE?e=J7filE
The Full NICE News bulletin for November 2023 can be found here:
The links to the update guidance covered can be found here:
Hypertension in adults: diagnosis and management:
· https://www.nice.org.uk/guidance/ng136
Transient loss of consciousness ('blackouts') in over 16s:
· https://www.nice.org.uk/guidance/cg109
Suspected acute respiratory infection in over 16s: assessment at first presentation and initial management:
· https://www.nice.org.uk/guidance/ng237
Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction:
· https://www.nice.org.uk/guidance/ta929
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Transcript
Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in November 2023, focusing on what is relevant in Primary Care only. We will be covering: postural hypotension, empagliflozin for HFpEF, and acute respiratory infections.
Make sure to stay for the entire episode because, at the end, I will go through the new tables published by NICE summarising blood pressure targets in the hypertension guideline as well as in the guidelines on type 1 diabetes and CKD. If you wish to download a version of this table, I will put a link in the episode description
The episode is fairly short so let’s jump into it.
The first clinical area is an update on the guidance on measuring and managing postural hypotension.
This update is the result of an issue raised with NICE. The previous outdated guideline recommended that for people with symptoms of postural hypotension such as falls or postural dizziness, we should take the initial measurement of blood pressure either in the seated or supine position, and then have the BP measured again with the person standing for at least 1 minute. This is to establish if there is a significant BP drop when the person is standing.
However, it was queried that measuring blood pressure in the sitting (rather than the supine position) followed by the standing position may miss a significant proportion of postural hypotension cases, particularly in older and frail people.
So, following the review, it was decided that, based on international consensus, supine to standing blood pressure measurement is the best practice and it is preferable to the sitting to standing measurements.
Therefore, the guideline was updated along these lines. However, the guidance still says that if it is inconvenient to take the blood pressure measurement in the supine position, a seated position may be considered.
This change affects not only the guideline on hypertension but also the guideline on transient loss of consciousness.
So, in summary the new recommendations state that when checking for postural hypotension, the lying down or supine position is preferred to a seated position, then we will recheck the standing BP after at least 1 minute of the patient standing and if the systolic blood pressure falls by 20 mmHg or more, or diastolic blood pressure falls by 10 mmHg or more when standing, then we will diagnose postural hypotension. In that case:
· We will consider the likely causes including a medication review
· We will manage the risk of falls appropriately
· And we will consider referral to specialist care if symptoms persist
However, if the BP drop is less than these thresholds despite a suggestive history:
· We will repeat the measurements with the person lying down if the first measurement was taken while seated and
· We will refer the person for specialist cardiovascular assessment if the symptoms persist and remain unexplained.
As a reminder, we should check for postural hypotension in people:
· With symptoms such as falls or postural dizziness as well as people
· With type 2 diabetes and those
· Aged 80 or over
And we must also remember that if there is a significant postural drop or three are symptoms of postural hypotension, we will treat to a blood pressure target based on standing blood pressure.
Finally, on a separate issue, NICE will no longer use in their guidelines the term “orthostatic hypotension” and they will only use the term “postural hypotension” instead.
The second clinical area refers to the use of empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction
You may be aware that empagliflozin is already recommended for chronic heart failure with reduced ejection fraction in adults and that dapagliflozin is recommended for both HFrEF and HFpEF.
And following this update, empagliflozin is now recommended as an option for chronic heart failure with preserved or mildly reduced ejection fraction in adults, although it should only be started on the advice of a heart failure specialist.
And let’s remind ourselves that chronic heart failure with preserved or mildly reduced ejection fraction is usually treated with standard care using loop diuretics, and treatment for other comorbidities that the patient may have and, following a recent NICE updates, patients may also have dapagliflozin.
Empagliflozin works in a similar way to dapagliflozin and evidence shows that empagliflozin also reduces cardiovascular mortality and hospitalisations for heart failure. There is no clinical trial evidence directly comparing empagliflozin with dapagliflozin but when adjustments for clinical trial differences are made, the comparison suggests that both drugs have similar clinical effect on quality of life.
Also, because empagliflozin has similar costs to dapagliflozin, empagliflozin can therefore be recommended too.
The third and final clinical area is on the initial management of suspected acute respiratory infection. And, to be honest, this update is hardly worth mentioning because it only spells out what we have always been doing, that is, that the threshold for treatment or referral may be lower for people who are more likely to have a poor outcome, for example, people with comorbidities or multimorbidity and people who are frail. So, we may be justified prescribing antibiotics early, or admitting those patients who we are most worried about because of their age, frailty or medical conditions.
And now, as promised, let’s have a look at the two tables that NICE has produced to clarify the blood pressure targets. But we must first remember that there are separate guidelines for hypertension in pregnancy.
And there are 2 tables, one for the under 80s and one for those aged 80 and over. And these tables cover people with hypertension with or without type 2 diabetes as well as people with CKD or type 1 diabetes.
So, in the under 80s we have two targets:
· Below 140/90 for those with:
o Hypertension, with or without type 2 diabetes
o Type 1 diabetes and ACR less than 70 or
o CKD and ACR less than 70
· Below 130/80 for those with
o Type 1 diabetes and ACR of 70 or more or
o CKD and ACR of 70 or more
And, in those aged 80 and over, we have three targets:
· Below 150/90 for those with:
o Hypertension, with or without type 2 diabetes or, and this may come as a surprise,
o Type 1 diabetes regardless of ACR levels. Then it is
· Below 140/90 for those with:
o CKD and ACR less than 70 and finally it is
· Below 130/80 for those with
o CKD and ACR of 70 or more
We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
