Transcript BHS Guidelines for the management of hypertension: Slide

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
*
160179
100109
140159
9099
**
***
160/100
140159
9099
130139
8589
<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 12 weeks then treat
If cardiovascular complications, target organ damage or diabetes is present, confirm over 34 weeks then treat; if absent re-measure
weekly and treat if blood pressure persists at these levels over 412
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