Hypertension: BHS guidelines 2004

• Classification of blood pressure levels of the British Hypertension Society
• Threshold for intervention
• Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs
• Recommendations for combining blood pressure lowering drugs (AB/CD rule)
• Lifestyle measures
• Other medications for hypertensive patients
• References

Classification of blood pressure levels of the British Hypertension Society

Category Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) Blood pressure Optimal <120 <80 Normal <130 <85 High normal 130-139 85-89 Hypertension Grade 1 (mild) 140-159 90-99 Grade 2 (moderate) 160-179 100-109 Grade 3 (severe) 180 110 Isolated systolic hypertension Grade 1 140-159 <90 Grade 2 160 <90

• Based on clinic blood pressure and not values for ambulatory blood pressure measurement.
• Threshold blood pressure levels for the diagnosis of hypertension using self/home monitoring are greater than 135/85 mm Hg.
• For ambulatory monitoring 24 hour values are greater than 125/80 mm Hg.
• If systolic blood pressure and diastolic blood pressure fall into different categories the higher value should be taken for classification.

Threshold for intervention

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

Class of drug Compelling indications Possible indications Caution Compelling contraindications blockers Benign prostatic hypertrophy — Postural hypotension, heart failure* Urinary incontinence Angiotensin converting enzyme inhibitors Heart failure Chronic renal disease Renal impairment Pregnancy   Left ventricular dysfunction post-myocardial infarction or established coronary heart disease Type 2 diabetic nephropathy Peripheral vascular disease Renovascular disease   Type 1 diabetic nephropathy Proteinuric renal disease     Secondary stroke prevention¶ Angiotensin II receptor blockers Angiotensin converting enzyme inhibitor intolerance Left ventricular dysfunction after myocardial infarction Renal impairment Pregnancy   Type 2 diabetic nephropathy Intolerance of other antihypertensive drugs Peripheral vascular disease Renovascular disease   Hypertension with left ventricular hypertrophy Proteinuric renal disease, chronic renal disease     Heart failure in angiotensin converting enzyme intolerant patients, after myocardial infarction Heart failure blockers Myocardial infarction, angina Heart failure** Heart failure** Asthma or chronic obstructive pulmonary disease, Heart block Peripheral vascular disease, Diabetes (except with coronary heart disease) Calcium channel blockers (dihydropyridine) Elderly patient, isolated systolic hypertension Angina — — Calcium channel blockers (rate limiting) Angina Elderly patient Combination with blockade Heart block, heart failure Thiazides or thiazide-like diuretics Elderly patient, isolated systolic hypertension, heart failure, secondary stroke prevention — — Gout

^* In heart failure when used as monotherapy.

Angiotensin converting enzyme inhibitors or angiotensin II receptor blockers may be beneficial in chronic renal failure but should only be used with caution, close supervision, and specialist advice when there is established and significant renal impairment.

Caution with angiotensin converting enzyme inhibitors and angiotensin II receptor blockers in peripheral vascular disease because of association with renovascular disease.

Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers are sometimes used in patients with renovascular disease under specialist supervision.

^¶ In combination with a thiazide or thiazide-like diuretic.

^** blockers are used increasingly to treat stable heart failure but may worsen heart failure.

Thiazides or thiazide-like diuretics may sometimes be necessary to control blood pressure in people with a history of gout, ideally used in combination with allopurinol.

Recommendations for combining blood pressure lowering drugs (AB/CD rule)

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 weightlifting) 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

Other medications for hypertensive patients

Primary prevention

1. Aspirin: use 75 mg daily if patient is aged 50 years with blood pressure controlled to < 150/90 mm Hg and; 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

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

References

Derived from:

	British Hypertension Society guideline 2004 (BMJ summary)
	British Hypertension Society

• Brad Cheek: last updated Dec 2006
• Home
• Doctors
• Training
• IT
• Links
• Latest
• Search