New UK guidelines on managing high blood pressure

High blood pressure is a major preventable and treatable risk factor for heart disease and stroke syndromes both in the developed and the developing world.

In an innovative partnership between a UK government agency - the National Institute for Health and Clinical Excellence (NICE) - and a professional organisation - the British Hypertension Society (BHS), NICE guidelines for managing hypertension in primary care were first issued in 2006. Key elements to those guidelines included a stepped care approach starting with different first line options for younger vs. older patients with a 55 year age boundary, and for patients of black African or Carribean origin compared to other ethnic groups. The 2006 guidelines also highlighted risks of new onset diabetes mellitus from beta-blocker treatment.

On 24th August, five years on, NICE, again supported by experts from the BHS, has released updated hypertension guidelines which include several key developments of interest to prescribers and patients. These include adding blood pressure measurements away from the clinical setting to confirm the diagnosis for patients with mild to moderate increases in clinic blood pressure readings. With even higher office readings, advice remains to treat based on those office readings. There is detailed advice both on blood pressure measurement using ambulatory devices as well as more systematic involvement of patients in their own management, supported by home blood pressure readings. It is of course important that any blood pressure monitoring device, whether for clinical or home use, should be validated. A helpful list of validated devices is is listed on the British Hypertension Society's website.

As an update on treatment options, the new 2011 guidelines now suggest systematic use of calcium channel blockers as first line treatment in older patients, with now specific, named diuretics as alternative options for specified indications. The 2011 guidelines for the first time also highlight the clinical and cost effectiveness of evidence-based treatment of hypertension in older patients, and in particular the over 80s.

For more information, see the summary documents and more detailed reports on the NICE website.

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Taboo tablets - beta-blockers and professional string players

The following blog arose from contributing to an article in The Strad by Catherine Nelson on drugs and occupational stress amongst professional musicians.

As clinical pharmacologist and amateur violinist gives me two perspectives on performance or audition anxiety: this is due to the triggering of an extra release of
 adrenaline – and other fight-or-flight response hormones – which in turn can cause
 string players to feel anxious and suffer a shaking bowing arm. Beta-blockers can stop 
unwanted reactions to these hormones, such as an increased heart 
rate, and thus lessen detrimental effects of stress on the musician’s performance.


I had heard of a violinist who was so anxious and stiff during an audition that the bow simply flew out of his hands. Many professional musicians are worried by the stress of performance, and beta-blockers may help some players control the debilitating physical symptoms of this stress.
It is of course extremely important that musicians, for whom medical treatment of occupational stress may be indicated, work
 with a medical practitioner to ensure, if a beta-blocker appears worth a trial, that they take the right dose, provided it has been checked that this would be medically safe to do so. I am particularly concerned about anecdotal evidence of players sharing medicines - which may not be the right medicine, or a possible cause of severe and rapid onset harmful effects. People are increasingly turning to the internet to
 obtain drugs. At best these pills may be out of date – at worse 
they may be contaminated. Taking them without getting advice from a
 doctor can be very dangerous.
Beta-blockers slow the heart, helping to make people feel calmer, but they also make your heartbeat less forceful than it should be,
 so that even fit people may feel tired and short of breath, and some people may be tipped into heart failure. Players with certain pre-existing medical conditions may suffer worse adverse reactions. These
 drugs also make the airways less open, so are dangerous in asthma.
 Other side effects include sleep disturbance, weight gain and stomach upset, including increased stool frequency and urgency. There 
are also reports of people suffering depression while taking
 beta-blockers, though it may be that people with heightened anxiety are 
more prone to suffering depression. It is therefore better to avoid medicines if possible.
The message for beta-blockers should be that if they are worth a trial on medical grounds, to try a low
 dose under the advice of a medical practitioner; the dose may then be carefully increased if needed. If medically indicated, it is also very important always to 
try beta-blockers first under rehearsal conditions, as being made too relaxed or having unwanted effects could be harmful when performance really matters.

The implications of the broader issue of anecdotal widespread use of beta-blockers raise important occupational health and ethical concerns which deserve to be discussed nationally and internationally, both by the music profession and relevant medical organisations.

See The Strad for more on the article.