A NICE patient decision aid on treatment choices for high blood pressure has been developed to support healthcare professionals and people with hypertension to discuss their treatment options and make informed decisions. How the recommendations might affect practice The recommendations are unlikely to alter current practice. The options for drug treatment remain the same and most step 2 or 3 treatment decisions are already based on an individualised approach. Return to recommendations Step 4 treatment Why the committee made the recommendations No evidence on step 4 treatment was identified that could be used to formulate new recommendations. However, the committee reviewed the 2011 recommendations and agreed that they should be retained and updated to reflect current best practice. The committee discussed the importance of confirming resistant hypertension before starting step 4 treatment. Based on their clinical experience and knowledge of best current practice, the committee members agreed that a recommendation to highlight this would help prevent overtreatment and ensure that people receive the right care. Despite the lack of evidence formally reviewed, the committee discussed the recommendation based on their clinical experience, taking the 2011 recommendations into account. The committee agreed that although the evidence for spironolactone did not meet the criteria for inclusion in the updated review for the guideline because the key study had a very short follow up and did not report any of the cardiovascular outcomes specified in this review protocol, the use of an aldosterone antagonist is now common clinical practice. Therefore, there was no reason to suggest that this recommendation should be changed. In the 2011 guideline, high-dose thiazide diuretics were recommended as a potential step 4 treatment in people with high blood potassium levels. 