BHS Guidelines for the management of hypertension

1. 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 IV B Williams et al: J Hum Hyp (2004); 18: 139-185. www.nice.org.uk/CG034NICEguideline www.bhsoc.org

2. Hypertension management issues • Measurement • Investigation • Non-pharmacological treatment • Thresholds for drug treatment • Targets for drug treatment • Drug choices – trial update • Other treatments • Follow-up

3. BHS classification of blood pressure levels

4. 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

5. 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

6. 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

10. 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 diabetesDiabetes 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.

14. 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

15. Other medications for hypertensive patients • Secondary prevention • (including patients with type 2 diabetes) • 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

16. Lipid targets Targets for lipid lowering 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