BHS Guidelines for the management of hypertension

BHS IV, 2004 and Update of the NICE Hypertension Guideline, 2006

Guidelines for management of hypertension: report of the fourth Working Party of the British Hypertension Society, 2004 BHS IVB Williams et al: J Hum Hyp (2004); 18: 139-185.

www.nice.org.uk/CG034NICEguideline

www.bhsoc.org

•Measurement

Hypertension management issues

•Investigation

•Non-pharmacological treatment

•Thresholds for drug treatment

•Targets for drug treatment

•Drug choices – trial update

•Other treatments

•Follow-up

BHS classification of blood pressure levels

Category Systolic blood

pressure (mmHg)

Diastolic blood

pressure

(mmHg) Optimal blood pressure <120 <80

Normal blood pressure <130 <85

High-normal blood pressure 130-139 85-89

Grade 1 Hypertension (mild) 140-159 90-99

Grade 2 Hypertension (moderate) 160-179 100-109

Grade 3 Hypertension (severe) >180 >110

Isolated Systolic Hypertension (Grade 1) 140-159 <90

Isolated Systolic Hypertension (Grade 2) >160 <90

Potential indications for the use of ambulatory blood pressure monitoring 

•Unusual variability

•Possible white coat hypertension

•Informing equivocal treatment decisions

•Evaluation of nocturnal hypertension

•Evaluation of drug-resistant hypertension

•Determining the efficacy of drug treatment over 24 hours

•Diagnoses and treatment of hypertension in pregnancy

•Evaluation of symptomatic hypotension

Routine investigations

• Urine strip test for protein and blood

• Serum creatinine and electrolytes

• Blood glucose - ideally fasted

• Blood lipid profile (at least total and high density lipoprotein (HDL) cholesterol) – ideally fasted for consideration of triglycerides

• Electrocardiogram

Lifestyle measures

•Maintain normal weight for adults (body mass index 20-25 kg/m2)

•Reduce salt intake to <100 mmol/day (<6g NaCl or <2.4 g Na+/day)

•Limit alcohol consumption to 3 units/day for men and 2 units/day for women

•Engage in regular aerobic physical exercise (brisk walking rather than weight lifting) for 30 minutes per day, ideally on most of days of the week but at least on three days of the week

•Consume at least five portions/day of fresh fruit and vegetables

•Reduce the intake of total and saturated fat

  

Target organ damageor

cardiovascular complicationsor

diabetesor

10 year CVD risk† 20%

>180/110 160 179100 109

140 15990 99

130 13985 89

<130/85

160/100 140 15990 99

<140/90

No target organ damageand

no cardiovascular complicationsand

no diabetesand

10 year CVD risk† <20%

* ** ***

Treat Treat Treat Observe, reassessCVD risk yearly

Reassessyearly

Reassessin 5 years

* Unless malignant phase of hypertensive emergency confirm over 1 2 weeks then treat** If cardiovascular complications, target organ damage or diabetes is present, confirm over 3 4 weeks then treat; if absent re-measure

weekly and treat if blood pressure persists at these levels over 4 12*** If cardiovascular complications, target organ damage, or diabetes is present, confirm over 12 weeks then treat: if absent re-measure

monthly and treat if these levels are maintained and if estimated 10 year CVD risk is 20%† Assessed with CVD risk chart

THRESHOLDS FOR INTERVENTIONInitial blood pressure (mmHg)

Suggested target blood pressures during antihypertensive treatment. Systolic and diastolic blood pressures should both be attained, e.g. <140/85 mmHg means less than 140 mmHg for systolic blood pressure and less than 85 mmHg for diastolic blood pressure

  Clinic BP (mmHg)

No diabetes Diabetes

Optimal treated BP pressure <140/85 <130/80

Audit Standard <150/90 <140/80

 Audit standard reflects the minimum recommended levels of blood pressure control.

Despite best practice, the Audit Standard will not be achievable in all treated hypertensives.

For ambulatory (mean daytime) or home blood pressure monitoring - reducing these targets by ~10/5 is recommended.

Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs Class of drug

Compelling indications

Possible indications

Caution

Compelling contra-indications

Alpha-blockers

Benign prostatic hypertrophy

Postural hypotension, heart failure

Urinary incontinence

ACE-inhibitors

Heart failure, LV dysfunction, post MI or established CVD, Type I diabetic nephropathy, 2o stroke prevention

Chronic renal disease, Type II diabetic nephropathy, proteinuric renal disease

Renal impairment

PVD Pregnancy, renovascular disease

ARBs ACE inhibitor-intolerance, Type II diabetic nephropathy, hypertension with LVH, heart failure in ACE-intolerant patients, post MI

LV dysfunction post MI, intol-erance of other antihypertensive drugs, proteinuric renal disease, chronic renal disease,

heart failure

Renal impairment PVD

Pregnancy, renovascular disease

Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs Class of drug

Compelling indications

Possible indications

Caution

Compelling contraindications

Beta-blockers MI, Angina

Heart failure Heart failure, PVD,

Diabetes (except with CHD)

Asthma/COPD, Heart block

CCBs (dihydropyridine)

Elderly, ISH Angina - -

CCBs (rate limiting)

Angina Elderly Combination with beta-blockade

Heart block Heart failure

Thiazide/thiazide-like diuretics

Elderly ISH Heart failure 2 o stroke prevention

Gout

Other medications for hypertensive patients

Primary prevention

(1) Aspirin: use 75mg daily if patient is aged 50 years with blood pressure controlled to <150/90 mm Hg and either; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart)

(2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years, with a 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart) and with total cholesterol concentration 3.5mmol/l

(3) Vitamins—no benefit shown, do not prescribe

Secondary prevention (including patients with type 2 diabetes)

(1) Aspirin: use for all patients unless contraindicated

(2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years with a total cholesterol concentration 3.5 mmol/l

(3) Vitamins— no benefit shown, do not prescribe

Other medications for hypertensive patients

Targets for lipid lowering

Ideal - TC<4.0mmol/lor LDL <2.0mmol/lor 25% in TCor 30% in LDL-Cwhichever is the greater

‘Audit’ - TC <5.0mmol/lor LDL <3.0mmol/lor 25% in TCor 30% in LDL-Cwhichever is the greater

Lipid targets