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Download BHS Guidelines for the management of hypertension: Slide
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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 Hypertension management issues • Measurement • 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 Diastolic blood pressure (mmHg) pressure Optimal blood pressure <120 <80 (mmHg) 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 THRESHOLDS FOR INTERVENTION Initial blood pressure (mmHg) >180/110 * 160179 100109 140159 9099 ** *** 160/100 140159 9099 130139 8589 <130/85 <140/90 No target organ damage Target organ damage and or cardiovascular complications no cardiovascular complications and or no diabetes diabetes and or † 10 year CVD risk† <20% 10 year CVD risk 20% Treat * ** *** † Treat Treat Observe, reassess CVD risk yearly Reassess yearly Reassess in 5 years Unless malignant phase of hypertensive emergency confirm over 12 weeks then treat If cardiovascular complications, target organ damage or diabetes is present, confirm over 34 weeks then treat; if absent re-measure weekly and treat if blood pressure persists at these levels over 412 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 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 Alphablockers Benign prostatic hypertrophy ACEHeart failure, inhibitors LV dysfunction, post MI or established CVD, Type I diabetic nephropathy, 2o stroke prevention ARBs ACE inhibitorintolerance, Type II diabetic nephropathy, hypertension with LVH, heart failure in ACEintolerant patients, post MI Possible indications Chronic renal disease, Type II diabetic nephropathy, proteinuric renal disease LV dysfunction post MI, intolerance of other antihypertensive drugs, proteinuric renal disease, chronic renal disease, heart failure Caution Compelling contraindications Postural hypotension, heart failure Renal impairment PVD Urinary incontinence Renal impairment PVD Pregnancy, renovascular disease Pregnancy, renovascular disease Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs Compelling indications Possible indications Beta-blockers MI, Angina Heart failure CCBs (dihydropyridine) CCBs (rate limiting) Elderly, ISH Angina Angina Elderly Class of drug Thiazide/thiazide- Elderly like diuretics ISH Heart failure 2 o stroke prevention Caution Compelling contraindications Heart failure, PVD, Diabetes (except with CHD) - Asthma/COPD, Heart block Combination with betablockade Heart block Heart failure - 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 Other medications for hypertensive patients 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 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
