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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 IV
B Williams et al: J Hum Hyp (2004); 18: 139-185.
www.nice.org.uk/CG034NICEguideline
www.bhsoc.org
Hypertension management issues
Measurement
Investigation
Non-pharmacological treatment
Thresholds for drug treatment
Other treatments
Follow-up
BHS classification of blood pressure levels
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
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
THRESHOLDS FOR INTERVENTION
Initial blood pressure (mmHg)
* ** ***
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
Compelling
Class of Compelling Possible contra-
drug indications indications Caution indications
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) Vitaminsno benefit shown, do not prescribe
Other medications for hypertensive patients
Secondary prevention
(including patients with type 2 diabetes)
Ideal - TC<4.0mmol/l
or LDL <2.0mmol/l
or 25% in TC
or 30% in LDL-C
whichever is the greater
Audit - TC <5.0mmol/l
or LDL <3.0mmol/l
or 25% in TC
or 30% in LDL-C
whichever is the greater