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

Systolic blood Diastolic blood

Category
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 140159 130139 <130/85

100109 9099 8589

* ** ***

160/100 140159 <140/90

9099

Target organ damage No target organ damage

or and
cardiovascular complications no cardiovascular complications
or and
diabetes no diabetes
or and
10 year CVD risk 20%
10 year CVD risk <20%

Treat Treat Treat Observe, reassess Reassess Reassess

CVD risk yearly yearly 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
Compelling
Class of Compelling Possible contra-
drug indications indications Caution indications

Alpha- Benign prostatic Postural Urinary

blockers hypertrophy hypotension, incontinence
heart failure
ACE- Heart failure, Chronic renal Renal impairment Pregnancy,
inhibitors LV dysfunction, post disease, PVD renovascular
MI or established CVD, Type II diabetic disease
Type I diabetic nephropathy,
nephropathy, 2o stroke proteinuric renal
prevention disease
ARBs ACE inhibitor- LV dysfunction Renal impairment Pregnancy,
intolerance, post MI, intol- PVD renovascular
Type II diabetic erance of other disease
nephropathy, antihypertensive
hypertension with LVH, drugs, proteinuric
heart failure in ACE- renal disease,
intolerant patients, post chronic renal
MI disease,
heart failure
Compelling and possible indications, contraindications, and
cautions for the major classes of antihypertensive drugs

Compelling Possible Compelling

Class of drug indications indications Caution contraindications

Beta-blockers MI, Heart failure Heart failure, Asthma/COPD,

Angina PVD, Heart block
Diabetes
(except with
CHD)
CCBs Elderly, ISH Angina - -
(dihydropyridine)
CCBs Angina Elderly Combination Heart block
(rate limiting) with beta- Heart failure
blockade
Thiazide/thiazide- Elderly Gout
like diuretics ISH
Heart failure
2 o stroke
prevention
 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) Vitaminsno 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