Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV

Williams, B
Poulter, N R
Brown, M J
Davis, M
McInnes, G T
Potter, J F
Sever, P S
McG Thom, S

¹Department of Cardiovascular Sciences, Clinical Sciences Building, Leicester Royal Infirmary, University of Leicester, Leicester, UK; ²International Centre for Circulatory Health, Imperial College London & St Mary's Hospital, London, UK; ³Clinical Pharmacology Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK; ⁴Moorfield House Surgery, Garforth, Leeds, UK; ⁵Section of Clinical Pharmacology and Stroke Medicine, Division of Cardiovascular and Medical Sciences, Gardiner Institute, Western Infirmary, University of Glasgow, Glasgow, UK; ⁶Ageing and Stroke Medicine Section, Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, Leicester, UK

Journal of Human Hypertension (2004) 18, 139-185. doi:10.1038/sj.jhh.1001683

Correspondence: Professor B Williams, Department of Cardiovascular Sciences, Clinical Sciences Building, Leicester Royal Infirmary, PO Box 65, Leicester LE2 7LX, UK. E-mail: [email protected]

Guideline Working Party Chairman: Professor Bryan Williams, MD FRCP, University of Leicester. Guideline Working Party Members: Professor Neil R Poulter, MSc FRCP, Imperial College London. Professor Morris J Brown, MD FRCP FMedSci, University of Cambridge. Dr Mark Davis, MRCGP, General Practitioner, Leeds. Professor Gordon T McInnes, MD FRCP, University of Glasgow. Professor John F Potter, MD FRCP, University of Leicester. Professor Peter S Sever, PhD FRCP, Imperial College London. British Hypertension Society member: Dr Simon McG Thom, MD FRCP, Imperial College London.

Journal of Human Hypertension 18(3):p 139-185, March 2004.

Summary of recommendations

• Provide advice on life-style modifications for all people with high blood pressure (BP) and those with borderline or high-normal BP. Advice on effective nonpharmacological interventions is provided (A).

• Initiate antihypertensive drug therapy in people with sustained systolic BP (SBP) ≥ 160 mmHg or sustained diastolic BP (DBP) ≥ 100 mmHg (A).

• Make treatment decisions in people with sustained SBP between 140 and 159 mmHg and/or sustained DBP between 90 and 99 mmHg according to the presence or absence of cardiovascular disease, other target organ damage, or an estimated cardiovascular disease (CVD) risk of ≥ 20% over 10 years, according to the Joint British Societies CVD risk assessment programme/risk chart (A).

• CVD risk replaces CHD risk estimation to reflect the importance of stroke prevention as well as CHD prevention. The new CVD risk threshold of ≥ 20% is equivalent to a CHD risk of approximately ≥ 15% over 10 years.

• In people with diabetes mellitus, initiate antihypertensive drug therapy if SBP is sustained ≥ 140 mmHg and/or DBP is sustained ≥ 90 mmHg (B).

• In nondiabetic people with hypertension, the optimal BP treatment goals are: SBP < 140 mmHg and DBP < 85 mmHg. The minimum acceptable level of control (Audit Standard) recommended is < 150/< 90 mmHg. Despite the best practice, these levels will be difficult to achieve in some hypertensive people (B).

• In people with diabetes and high BP, optimal BP goals are: SBP < 130 mmHg and DBP < 80 mmHg. The minimum acceptable level of control (Audit Standard) recommended is < 140/< 80 mmHg. Despite the best practice, these levels will be difficult to achieve in some people with diabetes and hypertension (B).

• Meta-analyses of BP-lowering trials have confirmed that, in general, the main determinant of benefit from BP-lowering drugs is the achieved BP, rather than choice of therapy. In some circumstances, there are compelling indications and contraindications for specific classes of antihypertensive drugs, and these are specified (A).

• Most people with high BP will require at least two BP-lowering drugs to achieve the recommended BP goals. A treatment algorithm (AB/CD) is provided to advise on the sequencing of drugs and logical drug combinations (C). When there are no cost disadvantages, fixed drug combinations are recommended to reduce the number of medications, which may enhance adherence to treatment (C).

• Other drugs that reduce CVD risk must also be considered, notably, low-dose aspirin and statin therapy (A).

• Unless contraindicated, low-dose aspirin (75 mg/day) is recommended for all people needing secondary prevention of ischaemic CVD, and primary prevention in people with hypertension over the age of 50 years who have a 10-year CVD risk ≥ 20% and in whom BP is controlled to the audit standard (A).

• Statin therapy is recommended for all people with high BP complicated by CVD, irrespective of baseline total cholesterol or low-density lipoprotein (LDL)-cholesterol levels. Similarly, statin therapy is also recommended for primary prevention in people with high BP who have a 10-year CVD risk ≥ 20%, estimated from the Joint British Societies CVD risk-assessment programme/chart. Optimal cholesterol lowering should reduce the total cholesterol by 25% or LDL-cholesterol by 30% or achieve a total cholesterol of < 4.0 mmol/l or LDL-cholesterol of < 2.0 mmol/l, whichever is the greatest reduction (A).

• Glycaemic control should be optimised in people with diabetes, for example, HbA1c < 7% (A).

• Advice is provided on the clinical management of hypertension in specific patient groups, that is, the elderly, ethnic minorities, people with diabetes mellitus, chronic renal disease, and in women (pregnancy, oral contraceptive use and hormone-replacement therapy).

• Suggestions for the improved implementation and audit of these guidelines in primary care are provided.