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doi:10.1136/bmj.328.7440.

634
2004;328;634-640 BMJ
McInnes, John F Potter, Peter S Sever and Simon McG Thom
Bryan Williams, Neil R Poulter, Morris J Brown, Mark Davis, Gordon T

summary
hypertension management 2004 (BHS-IV):
British Hypertension Society guidelines for
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Education and debate


British Hypertension Society guidelines for
hypertension
management 2004 (BHS-IV): summary
Bryan Williams, Neil R Poulter, Morris J Brown, Mark Davis, Gordon T McInnes, John F Potter,
Peter S Sever, Simon McG Thom; the BHS guidelines working party, for the
British Hypertension Society

Introduction

Much new evidence has emerged on the importance of


blood pressure as a risk factor for cardiovascular
disease; the importance of lifestyle measures for the
prevention and treatment of hypertension; the efficacy
and safety of different drug classes; management of
hypertension in groups at higher risk, including people
with diabetes; the importance of assessing the total risk
of cardiovascular disease; and additional benefits associated
with the use of statins.
Concern remains that national surveys continue to
show substantial underdiagnosis, undertreatment, and
poor rates of blood pressure control in the United
Kingdom.1 A key reason for this is the predominant use
of monotherapy by most doctors.1 To improve this suboptimal
treatment, the British Hypertension Society
recommends a treatment algorithm based on the
AB/CD rule.2
Treatment of blood pressure alone will leave many
hypertensive patients at unacceptably high risk of
cardiovascular complications and death. This guideline
reinforces the view that doctors should not focus solely
on blood pressure but must also formally assess total
risk of cardiovascular disease and use multifactorial
interventions, including statins and aspirin, to reduce it.
Most management of blood pressure and risk of
cardiovascular disease will take place in primary care,
and these guidelines are intended for general
practitioners, practice nurses, and generalists in hospital
practice. Detailed advice on implementation and
the implications of the national service frameworks
and the general medical services contract are
contained in the full document (www.bhsoc.org). 3
These guidelines have been prepared by the guidelines
working party of the British Hypertension Society
on behalf of the society. The working party reviewed
new data that have become available since the previous
guidelines were published4 and amended the recommendations
accordingly. Drafts of the full document
were improved by consultation with national stakeholder
organisations (appendix 1). The evidence
supporting the recommendations contained in
BHS-IV is graded by using the criteria of the North of
England group (see box on bmj.com).5

Objectives of the guidelines


The objectives highlighted and prioritised in the
previous guidelines4 remain relevant and are reiterated.
x To promote the primary prevention of hypertension
and cardiovascular disease by changes in the
diet and lifestyle of the whole population
x To increase the detection and treatment of
undiagnosed hypertension by routine screening and
increase awareness of hypertension among the public
x To ensure that patients taking antihypertensive
drugs are controlled to optimal blood pressure levels
x To reduce the risk of cardiovascular disease of
treated hypertensive patients by non-pharmacological
measures, and by appropriate use of statin and aspirin
treatment
x To increase the identification and treatment of
patients with mild hypertension who are at high risk of
cardiovascular diseasefor example, elderly patients,
patients with ischaemic heart disease, people with
diabetes, people with target organ damage, or people
with multiple risk factors
Table 1 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
This classification equates with those of the European Society of Hypertension 6
and the World Health Organization-International Society of Hypertension 7 and is
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.

Categories of strength used in statements are on bmj.com


Department of
Cardiovascular
Sciences, University
of Leicester, Clinical
Sciences Building,
Leicester Royal
Infirmary, Leicester
Bryan Williams
professor of medicine
International
Centre for
Circulatory Health,
Imperial College
London and St
Marys Hospital,
London
Neil R Poulter
professor of preventive
cardiovascular
medicine
Peter S Sever
professor of clinical
pharmacology
Simon McG Thom
reader in medicine
Clinical
Pharmacology Unit,
Addenbrookes
Hospital, University
of Cambridge,
Cambridge
Morris J Brown
professor of clinical
pharmacology
Moorfield House
Surgery, Garforth,
Leeds
Mark Davis
general practitioner
Section of Clinical
Pharmacology and
Stroke Medicine,
Division of
Cardiovascular and
Medical Sciences,
Gardiner Institute,
Western Infirmary,
University of
Glasgow, Glasgow
Gordon T McInnes
professor of clinical
pharmacology
continued over
BMJ 2004;328:63440

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x To promote continued adherence to drug treatment,
by optimising the choice and use of drugs, minimising
side effects, and increasing information and

choice for patients.


Blood pressure measurement
The British Hypertension Societys classifications of
blood pressure levels have changed in line with recent
European guidelines (table 1).6
All adults should have blood pressure measured
routinely at least every five years until the age of 80
years. People with high normal systolic blood
pressure (130-139 mm Hg) or diastolic blood pressure
(85-89 mm Hg) and people who have had high blood
pressure readings at any time previously should have
their blood pressure measured annually. The European
recommendations for measuring blood pressure
should be followed (box 1).8 Seated blood pressure
recordings are generally sufficient, but standing blood
pressure should be measured in elderly or diabetic
patients to exclude notable orthostatic hypotension.
The average of two readings at each of a number of
visits (depending on severity) should be used to guide
the decision to treat. Automated or semiautomated
devices are increasingly used for home or ambulatory
blood pressure measurement. Box 2 shows possible
indications for the use of ambulatory blood pressure
measurement, and detailed guidance on blood
pressure measurement and validated monitors is available
at www.bhsoc.org.

Absolute risk of cardiovascular disease


estimation
The treatment of hypertension and the primary
prevention of cardiovascular disease should be
informed by assessment of total risk of cardiovascular
disease. In collaboration with the Joint British Societies
initiative for preventing cardiovascular disease, a new
cardiovascular disease chart and risk calculator
program have been produced (www.bhsoc.org). 3 The
chart and the program assess 10 year risk of cardiovascular
disease rather than risk of coronary heart disease,
reflecting the treatment objective of reducing all
cardiovascular events, including stroke. The new chart
has been simplified since 1999 by including only three
age strata, to improve the balance of emphasis between
relative risk and short term absolute risk. No chart is
provided for patients with type 2 diabetes because for
the vast majority (people aged > 50 years or whose
condition has been diagnosed for 10 years) their risk
of cardiovascular disease is equivalent to people who
have had a myocardial infarction and therefore should
be considered for secondary prevention.9 The use of
this chart or computer program is recommended to
aid decisions on treatment for people with grade 1
(mild) hypertension and to help guide the appropriate
use of statins and aspirin for primary prevention.

Evaluation of hypertensive patients


All hypertensive patients should have a thorough
history and physical examination but need only a
limited number of routine investigations (box 3). The
purpose of the evaluation is to assess the cause(s) of the
hypertension, associated cardiovascular risk factors,
evidence of target organ damage and comorbid
diseases, all of which may influence treatment decisions
(box 4). More complex investigations may require
specialist referralbox 5 shows indications for this.
Thresholds for intervention with drug treatment
Figure 1 shows recommended blood pressure thresholds

for intervention with drug treatment. Drug


treatment is recommended in patients with sustained
grade 2 hypertension ( 160/100mmHg). All patients
with grade I hypertension (systolic blood pressure 140159 or diastolic blood pressure 90-99 mm Hg, or both)
should be offered treatment with antihypertensive
drugs if there is any complication of hypertension or
target organ damage (defined in box 4), or diabetes, or
Box 1: Blood pressure measurement by
standard mercury sphygmomanometer or
semiautomated device
Use a properly maintained, calibrated, and validated
device
Measure sitting blood pressure routinely: standing
blood pressure should be recorded at least at the initial
estimation in elderly or diabetic patients
Remove tight clothing, support arm at heart level,
ensure arm relaxed and avoid talking during the
measurement procedure
Use cuff of appropriate size (see box 3 in the full
guidelines,3 www.bhsoc.org)
Lower mercury column slowly (2 mm per second)
Read blood pressure to the nearest 2 mm Hg
Measure diastolic blood pressure as disappearance
of sounds (phase V)
Take the mean of at least two readings, more
recordings are needed if marked differences between
initial measurements are found
Do not treat on the basis of an isolated reading
For full details of methods see www.bhsoc.org and
reference 8

Box 2: Potential indications for the use of


ambulatory blood pressure monitoring
Unusual variability of blood pressure
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
Diagnosis and treatment of hypertension in
pregnancy
Evaluation of symptomatic hypotension

Box 3: Routine investigations


Urine strip test for protein and blood
Serum creatinine and electrolytes
Blood glucoseideally fasted
Blood lipid profile (at least total and high density
lipoprotein (HDL) cholesterol)ideally fasted for
consideration of triglycerides
Electrocardiogram

Education and debate


Ageing and Stroke
Medicine Section,
Department of
Cardiovascular
Sciences, Glenfield
Hospital, University
of Leicester,
Leicester
John F Potter
professor of ageing
and stroke medicine
Correspondence to:
B Williams bw17@
le.ac.uk

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if there is an estimated 10 year risk of cardiovascular
disease of 20% despite lifestyle advice.

When it is decided not to treat grade I (mild)


hypertension with drugs, lifestyle measures should be
encouraged and blood pressure and risk of cardiovascular
disease should be reassessed annually. The
reason for this is that blood pressure will rise within
five years to levels requiring treatment in about
10-15% of patients, and risk of cardiovascular disease
will rise with age.
Treatment goals or targets
Definitive evidence on optimal targets for blood
pressure lowering is lacking. The hypertension optimal
treatment (HOT) trial was underpowered but to date,
still provides the best evidence on optimal targets. 10 It
reported, albeit on the basis of an on-treatment analysis,
that the optimal blood pressure for reduction of
major cardiovascular events was 139/83 mm Hg and
that reduction of blood pressure below this value
caused no harm. However, patients whose blood pressure
was between 139/83 mm Hg and 150/90 mm Hg
were also not disadvantaged. In light of these observations
we previously recommended a blood pressure
target of < 150/90 mm Hg as an audit standardthe
minimal target that all treated patients should attain. 4
This recommendation remains unchanged. Box 6
shows recommendations for optimal blood pressure
targets during treatment. Evidence from intervention
trials in hypertensive people with diabetes, people at
high risk of cardiovascular disease, and people who
have had a stroke supports a lower the better policy
for optimal blood pressure. 1012 Hence, lower targets are
recommended for these higher risk populations.

Treatment
Lifestyle measures
Recent trial evidence has reinforced recommendations
that certain lifestyle measures can lower blood
pressure.1315 Hence advice on lifestyle modifications
should be provided to all people with high blood pressure
and people with borderline or high normal blood
pressure. This approach can reduce the age associated
rise in blood pressure and therefore reduce the large
proportion of people with high normal blood pressure
who would otherwise eventually require drug therapy.
For those with grade 1 (mild) hypertension and no
complications of cardiovascular disease or damage to
the target organ, lifestyle measures should be evaluated
for up to six months. For people who need antihypertensive
therapy, lifestyle measures should still be
Box 4: Evaluation of hypertensive patients
Causes of hypertension
Drugs (non-steroidal anti-inflammatory drugs, oral
contraceptives, steroids, liquorice, sympathomimetics,
some cold cures)
Renal disease (present, past, or family history,
proteinuria or haematuria: palpable
kidney(s)polycystic, hydronephrosis, or neoplasm)
Renovascular disease (abdominal or loin bruit)
Phaeochromocytoma (paroxysmal symptoms)
Conns syndrome (tetany, muscle weakness, polyuria,
hypokalaemia)
Coarctation (radio-femoral delay or weak femoral
pulses).
Cushings (general appearance)
Contributory factors
Overweight
Excess alcohol ( > 3 units/day for men; > 2
units/day for women)

Excess salt intake


Lack of exercise
Environmental stress
Complications of hypertension or target organ
damage
Stroke, transient ischaemic attack, dementia, carotid
bruits
Left ventricular hypertrophy or left ventricular strain
on electrocardiogram
Heart failure
Myocardial infarct, angina, coronary artery bypass
graft, or angioplasty
Peripheral vascular disease
Fundal haemorrhages or exudates, papillodoema
Proteinuria
Renal impairment (raised serum creatinine)
Risk factors for cardiovascular disease
Smoking
Diabetes
Ratio of total cholesterol: HDL cholesterol
Family history
Age
Sex
Drug contraindications
See table 2.

Box 5: Suggested indications for specialist


referral
Urgent treatment needed
Accelerated hypertension (severe hypertension and
grade III-IV retinopathy)
Particularly severe hypertension ( > 220/120 mm Hg)
Impending complications (for example, transient
ischaemic attack, left ventricular failure)
Possible underlying cause
Any clue in history or examination of a secondary
cause, such as hypokalaemia with increased or high
normal plasma sodium (Conns syndrome)
Elevated serum creatinine
Proteinuria or haematuria
Sudden onset or worsening of hypertension
Resistant to multidrug regimen ( 3 drugs)
Young age (any hypertension < 20 years; needing
treatment < 30 years)
Therapeutic problems
Multiple drug intolerance
Multiple drug contraindications
Persistent non-adherence or non-compliance
Special situations
Unusual blood pressure variability
Possible white coat hypertension
Hypertension in pregnancy

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recommended as they may complement the blood
pressure lowering effects of drugs and thus reduce the
dose or number of drugs required to control blood
pressure. Box 7 shows lifestyle measures that lower
blood pressure and pre-empt the rise of blood
pressure with age.
Lifestyle measures that reduce risk of cardiovascular
disease include smoking cessation, reducing
intake of total and saturated fats, replacement of saturated
with monounsaturated fats (such as olive oil,
rapeseed oil), and increasing consumption of fish.
Effective implementation of these lifestyle measures
requires knowledge, enthusiasm, patience, considerable

time spent with patients and other family


members, and reinforcement. It is best undertaken by
well trained health professionals such as practice or
clinic nurses and should be supported by clear written
information (www.bpassoc.org.uk).
Choice of antihypertensive drug therapy
For each major class of antihypertensive drug
compelling indications exist for use in specific groups
of patients and also compelling contraindications.
There are also indications, contraindications, and
cautions that are less clear cut and that are given
different weight by different doctors (table 2). When
none of the special considerations apply, initial drug
selection should follow step 1 of the AB/CD
algorithm (fig 2).2
Meta-analyses of blood pressure lowering trials
Since 1999 4 many large scale morbidity and mortality
trials have compared different classes of antihypertensive
drugs. The Blood Pressure Lowering Trialists Collaboration
has conducted two major meta-analyses of
blood pressure lowering drugs.16 17 The first compared
the effectiveness of newer therapies, such as
treatments based on angiotensin converting enzyme
inhibitors or calcium channel blockers, with conventional
therapies (based on diuretics or _ blockers) and
Thresholds for intervention
Initial blood pressure (mm Hg)
Reassess
yearly
Observe, reassess risk of
cardiovascular disease yearly
Reassess
in 5 years
Target organ damage or
cardiovascular complications or
diabetes or 10 year risk of
cardiovascular disease 20%
No target organ damage and
no cardiovascular complications
and no diabetes and 10 year risk
of cardiovascular disease < 20%
>180/110
Treat
160-179
100-109 90-99 85-89
140-159 130-139 <130/85
*
Treat Treat

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 remeasure weekly and treat if blood pressure persists at these levels over 4-12
weeks
If cardiovascular complications, target organ damage, or diabetes is present, confirm over 12 weeks
then treat; If absent remeasure monthly and treat if these levels are maintained and if estimated 10
year cardiovascular disease risk is 20%
Assessed with risk chart for cardiovascular disease
<140/90 140-159
90-99
160/100

Fig 1 Blood pressure thresholds for intervention

Box 6: Thresholds and treatment targets for


antihypertensive drug treatment
Drug treatment should be started in all patients with
sustained systolic blood pressures 160 mm Hg or
sustained diastolic blood pressures 100 mmHg
despite non-pharmacological measures (A)
Drug treatment is also indicated in patients with
sustained systolic blood pressures 140-159 mm Hg or
diastolic blood pressures 90-99 mm Hg if target organ
damage is present, or there is evidence of established
cardiovascular disease or diabetes, or if there is a 10
year cardiovascular disease risk of 20% (B)

For most patients a target of 140 mm Hg systolic


blood pressure and 85 mm Hg diastolic blood
pressure is recommended (B). For patients with
diabetes, renal impairment or established cardiovascular
disease a lower target of 130/80 mm Hg is
recommended
When using ambulatory blood pressure readings,
mean daytime pressures are preferred and this value
would be expected to be approximately 10/5 mm Hg
lower than the office blood pressure equivalent for
both thresholds and targets. Similar adjustments are
recommended for averages of home blood pressure
readings

Box 7: 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
Younger (<55 years)
and non-black
Older (55 years)
or black
A (or B*) Step 1 C or D
A (or B*) + C or D
A (or B*) + C + D
Add either blocker
or spironolactone or other diuretic
A: ACE inhibitor or angiotensin receptor blocker
C: Calcium channel blocker
* Combination therapy involving B and D may induce more new onset diabetes compared with
other combination therapies

B: blocker
D: Diuretic (thiazide
and thiazide-like)
Step 2
Step 3
Step 4
Resistant hypertension

Fig 2 Recommendations for combining blood pressure lowering


drugs (AB/CD rule) (adapted from reference 2, Brown et al)

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concluded, while conceding that insufficient data
existed, that newer therapies were as effective as, but no
more effective than, conventional therapy at reducing
stroke, morbidity or mortality due to coronary heart
disease, or all cause mortality.16 The second metaanalysis
included 29 major trials published as of 2003,
with over 700 000 years of patient follow up.17 The
findings of this second meta-analysis are largely
consistent with the first: the main driver of benefit from
blood pressure lowering therapy is blood pressure lowering
per se, and little evidence exists of additional
benefits specific to a class of drug with regard to major
cardiovascular outcomes overall. The caveats to this
general conclusion are, firstly, that calcium channel
blockers may be less protective than other agents
against the development of heart failure. Secondly,
previous concerns regarding the safety and efficacy of
treatment with calcium channel blockers for prevention
of cardiovascular disease are unfounded. Thirdly,
therapy based on calcium channel blockers may have
small benefits and treatment with angiotensin receptor

blockers may have possibly larger benefits with regard


to stroke prevention. Fourthly, specific drug classes
may have compelling indications (table 2).
The AB/CD algorithm
Most people require more than one drug to control
blood pressure. Clinical trials have clearly shown that
treatment algorithms deliver better blood pressure
control than current clinical practice. 1 17 The British
Hypertension Society recommends the use of a
treatment algorithm based on the AB/CD rule to
inform the better use of logical combinations of drugs. 2
Each letter refers to a blood pressure lowering drug
class (fig 2).
The theory underpinning the AB/CD algorithm is
that hypertension can be broadly classified as high
renin or low renin and is therefore best treated initially
with one of two categories of antihypertensive
drugthose that inhibit the renin-angiotensin system
(angiotensin converting enzyme inhibitors or angiotensin
receptor blockers (A) or _ blockers (B)), and
those that do not (calcium channel blockers (C) or
diuretics (D)). People who are younger than 55 and
white tend to have higher renin concentrations than
people aged 55 or older or the black population (of
African descent). A or B drugs are therefore generally
more effective as initial blood pressure lowering treatment
in younger white patients than C or D drugs.
However, C or D drugs are more effective first line
agents for older white people or black people of any
age.18 19 When the first drug is well tolerated but the
response is small and insufficient, substitution of an
alternative drug is appropriate if hypertension is mild
and uncomplicated. In more severe or complicated
hypertension it is safer to add drugs stepwise until
blood pressure is controlled. Treatment can be
stepped down later if blood pressure falls substantially
below the optimal level.
If two drugs are required logical combinations are:
(A or B)(C or D). Thereafter, if blood pressure is still
insufficiently controlled, the combination of (A or
B)CD is recommended. When fixed dose combinations
replicate the desired treatment plan for a patient
and when there is no cost disadvantage to their use,
they represent a sensible way of reducing the number
of tablets required. When hypertension remains resistant,
ABCD or the addition of an _ blocker or low
dose spironolactone may be effective.
The AB/CD protocol is not restrictive and provides
a template that allows the use of all classes of
antihypertensive drugs. All things being equal and
when there are no compelling indications for
treatment with a specific class of drugs (table 2), the
least expensive drugs should be used.
Table 2 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
Left ventricular dysfunction post-myocardial
infarction or established coronary heart disease
Type 1 diabetic nephropathy
Secondary stroke prevention
Chronic renal disease
Type 2 diabetic nephropathy
Proteinuric renal disease
Renal impairment
Peripheral vascular disease

Pregnancy
Renovascular disease
Angiotensin II receptor
blockers
Angiotensin converting enzyme inhibitor
intolerance
Type 2 diabetic nephropathy
Hypertension with left ventricular hypertrophy
Heart failure in angiotensin converting enzyme
intolerant patients, after myocardial infarction
Left ventricular dysfunction after
myocardial infarction
Intolerance of other antihypertensive
drugs
Proteinuric renal disease, chronic renal
disease
Heart failure
Renal impairment
Peripheral vascular disease
Pregnancy
Renovascular disease
_ blockers Myocardial infarction, angina Heart failure** Heart failure**
Peripheral vascular disease,
Diabetes (except with coronary heart
disease)
Asthma or chronic obstructive
pulmonary disease,
Heart block
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.

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The AB/CD algorithm includes B in brackets. This
is to emphasise the fact that recent outcome trials have
reported an increased incidence of diabetes in patients
treated with B or D drugs compared with A or C drugs,
especially when B and D are combined. 20 We advise
caution when using BD in patients at especially high
risk of developing diabetesfor example, patients with
a strong family history of type 2 diabetes, obesity,
impaired glucose tolerance, features of the metabolic
syndrome, or of South Asian and African-Caribbean
descent.
Drug dosage
The drug or formulation used should ideally be effective
for 24 hours when taken as a single daily dose. An
interval of at least four weeks should be allowed to
observe the full response, unless it is necessary to lower
blood pressure more urgently. The drug dose (except
for thiazides or thiazide-like diuretics, the ideal dose of
which is uncertain) should be titrated up according to
manufacturers instructions.
Recommendations for use of aspirin and statins
AspirinNo new evidence to guide practice regarding
the use of aspirin for patients with hypertension
has been produced since the 1999 guidelines of the
British Hypertension Society. 4 Hence recommendations
remain unchanged (box 8).

StatinsRecommendations relating to the use of


statins for patients with hypertension have been
updated in light of recent trial data 21 22 and are in keeping
with recent European guidance.6 Box 8 shows indications
for using statins in the context of primary and
secondary prevention. Patients with type 2 diabetes are
considered as for secondary prevention in this context.
Target lipid concentrations are the same for primary
and secondary prevention and have been made more
stringent in light of the most recent trial evidence. New
ideal targets are to lower total cholesterol by 25% or
LDL cholesterol by 30% or to reach < 4.0 mmol/l or
< 2.0 mmol/l respectively, whichever is the greater.
However a total cholesterol concentration < 5.0 mmol/l
or LDL cholesterol < 3.0 mmol/l or reductions of 25%
or 30%, respectively (whichever is the greater), provides
a minimal acceptable audit standard.
Box 8: 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
(3) Vitaminsno benefit shown, do not prescribe
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) Vitaminsno benefit shown, do not prescribe

Summary points
All people with high blood pressure, borderline
or high normal blood pressure should be advised
on lifestyle modifications
Initiate antihypertensive drug therapy if sustained
systolic blood pressure 160 mm Hg or
sustained diastolic blood pressure 100 mm Hg
If sustained systolic blood pressure is 140-159
mm Hg or sustained diastolic blood pressure
90-99 mm Hg, consider initiating treatment if
cardiovascular disease or other target organ
damage present, or if estimated 10 year risk of
cardiovascular disease is 20%
Non-diabetic people: optimal goals for blood
pressure treatment are: systolic blood pressure
< 140 mm Hg and diastolic blood pressure
< 85 mm Hg. The minimum acceptable level of
control (audit standard) recommended is
<150/ < 90mmHg
In people with diabetes mellitus, initiate
antihypertensive drug treatment if systolic blood
pressure is sustained 140 mm Hg or diastolic
blood pressure is sustained 90 mm Hg
In hypertensive people with diabetes, chronic
renal disease, or established cardiovascular
disease optimal blood pressure goals are systolic

blood pressure < 130 mm Hg and diastolic blood


pressure < 80 mm Hg. Audit standard
<140/ < 80mmHg
Most people with high blood pressure will require
at least two blood pressure lowering drugs to
achieve the recommended goals. When no
disadvantages of cost exist, fixed drug
combinations are recommended
Low dose aspirin (75 mg/day) is recommended
for secondary prevention of ischaemic
cardiovascular disease and for primary
prevention, in people over the age of 50 who have
a 10 year risk of cardiovascular disease of 20%
and in whom blood pressure is controlled to the
audit standard
Statins are recommended for all people with high
blood pressure complicated by cardiovascular
disease, irrespective of baseline concentrations
total cholesterol or low density lipoprotein (LDL)
cholesterol. Statins are also recommended for
primary prevention in people with high blood
pressure who have a 10 year risk of cardiovascular
disease of 20%

Education and debate


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Follow up

The frequency of follow up for treated patients with


adequate blood pressure control depends on factors
including severity and variability of blood pressure,
complexity of the treatment regimen, and compliance.
Six monthly review is probably sufficient when
treatment and blood pressure are stable. The routine
for follow up visits, at which trained nurse practitioners
have an important role, should be simple: measure
blood pressure and weight, inquire about general
health and side effects, reinforce lifestyle advice and
adherence to drug therapy, and test for proteinuria
annually.

Implementation
These guidelines come at an opportune time. The
reduction of cardiovascular events in the population
has been given a high priority by the Department of
Health, which has introduced several key initiatives
through the national service frameworks. The new
contract for general medical services has given
substantial prominence to the management of
hypertension as a key performance target, and primary
care trusts across the country participate in redesigning
services. To implement this guideline effectively,
new systems of healthcare delivery will need to be
developed in primary care. Multidisciplinary teams will
need to work in a systematic and structured way to
advise, educate and support patients. A need exists for
an extended role for nurse practitioners, pharmacists,
and other healthcare professionals, to provide the
foundation for the more widespread and effective
detection, monitoring, and treatment of blood pressure
and risk of cardiovascular disease.
BW is chairman of the guideline working party; NRP, MJB, MD,
GTM, JFP, and PSS are members of the guideline working party;
SMcGT is a member of the British Hypertension Society. The
British Hypertension Society gratefully acknowledges the work
done by the representatives of the many stakeholder
organisations who reviewed the full guideline (appendix 1) and

whose comments greatly improved the final version. We also


acknowledge the outstanding administrative assistance provided
by Emma Fluck at the British Hypertension Societys
information service.
Competing interests: All authors have received honorariums
from a number of pharmaceutical companies for lectures and
consultancy, and research grant support for clinical trials from
the pharmaceutical industry.

Appendix 1: Stakeholders who reviewed the


guidelines
Blood Pressure Association
Nurses Hypertension Association
Diabetes UK
British Cardiac Association
Renal Association
Heart UK
Primary Care Cardiovascular Society
London Hypertension Society
British Heart Foundation
Royal College of General Practitioners
Friends of the British Hypertension Society
Department of Health

Appendix 2: Contact details


British Hypertension Society Information Service
Blood Pressure Unit, St Georges Hospital Medical School,
Cranmer Terrace, London SW17 0RE (tel 020 8725 3412;
fax 020 8725 2959; bhsis@sghms.ac.uk; www.bhsoc.org)
Blood Pressure Association
60 Cranmer Terrace, London SW17 0QS (tel 020 8772 4994;
fax 020 8772 4999; bpassoc.org.uk). To contact the
association by email, submit a query formthrough the website
1 Primatesta P, Brookes M, Poulter NR. Improved hypertension
management and control: results from the health survey for England
1998. Hypertension 2001;38:827-32.
2 Brown MJ, Cruickshank JK, Dominiczak AF, MacGregor GA, Poulter NR,
Russell GI, et al. Executive Committee, British Hypertension Society.
Better blood pressure control: how to combine drugs. J Hum Hypertens
2003;17:81-6.
3 Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al.
Guidelines for management of hypertension: report of the fourth working
party of the British Hypertension Society, 2004BHS IV. J Hum
Hypertens 2004;18:139-85.
4 Ramsay LE, Williams B, Johnston G, MacGregor G, Poston L, Potter J, et
al. Guidelines for management of hypertension: report of the third working
party of the British Hypertension Society. J Human Hypertens
1999;13:569-92.
5 Eccles M, Freemantle N, Mason J. North of England evidence based
guidelines development project: methods of developing guidelines for
efficient drug use in primary care. BMJ 1998;316:1232-5.
6 Guidelines Committee. 2003 European Society of HypertensionEuropean Society of Cardiology guidelines for the management of
arterial hypertension. J Hypertens 2003;21:1011-53.
7 Guidelines Subcommittee. 1999 World Health Organization-International
Society of Hypertension guidelines for the management of hypertension.
J Hypertens 1999;17:151-83.
8 OBrien E, Asmar R, Beilin L, Imai Y, Mallion JM, Mancia G, et al. European
Society of Hypertension Working Group on Blood Pressure Monitoring.
European Society of Hypertension recommendations for
conventional, ambulatory and home blood pressure measurement.
J Hypertens 2003;21:821-48.
9 Expert panel on detection, evaluation, and treatment of high blood cholesterol
in adults (Adult Treatment Panel III). Executive summary of the
third report of the National Cholesterol Education Program (NCEP)
JAMA 2001;285:24862497
10 Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, et
al. for the HOT Study Group. Effects of intensive blood pressure lowering
and low-dose aspirin in patients with hypertension: principal results of
the hypertension optimal treatment (HOT) randomised trial. Lancet
1998;351:1755-62.
11 The Heart Outcomes Prevention Evaluation Study Investigators. Effects
of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular
events in high-risk patients. New Eng J Med 2000;342:145-153
12 PROGRESS Collaborative Group. Randomised trial of a perindoprilbased
blood-pressure-lowering regimen among 6105 individuals with
previous stroke or transient ischaemic attack. Lancet 2001;358:1033-41.
13 Whelton PK, He J, Appel LJ, Cutler JA, Havas S, Kotchen TA, et al.
National High Blood Pressure Education Program Coordinating
Committee. Primary prevention of hypertension. Clinical and public
health advisory from the National High Blood Pressure Education
Program. JAMA 2002;288:1882-8.
14 Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, et al.
DASH-Sodium Collaborative Research Group. Effects on blood pressure
of reduced dietary sodium and the dietary approaches to stop
hypertension (DASH) diet. N Engl J Med 2001;344:3-10
15 He J, Whelton PK. Long-term effects of weight loss and dietary sodium

restriction on incidence of hypertension. Hypertension 2000;35:544-9.


16 Blood Pressure Lowering Treatment Trialists Collaboration. Effects of
ACE inhibitors, calcium antagonists, and other blood-pressure-lowering
drugs: results of prospectively designed overviews of randomised trials.
Lancet 2000;356:1955-64.
17 Blood Pressure Lowering Treatment Trialists Collaboration. Effects of
different blood-pressure-lowering regimens on major cardiovascular
events: results of prospectively-designed overviews of randomised trials.
Lancet 2003;362:1527-1545
18 Dickerson JE, Hingorani AD, Ashby MJ, Palmer CR, Brown MJ. Optimisation
of antihypertensive treatment by crossover rotation of four major
classes. Lancet 1999;353:2008-13.
19 Materson BJ, Reda DJ, Cushman WC. Department of veterans affairs
single-drug therapy of hypertension study. Revised figures and new data.
Department of Veterans Affairs Cooperative Study Group on Antihypertensive
Agents. Am J Hypertens 1995;8:189-92.
20 Dahlf B, Devereux RB, Kjeldsen SE, Julius S, Beevers G, de Faire U, et al.
LIFE Study Group. Cardiovascular morbidity and mortality in the Losartan
Intervention for Endpoint reduction in hypertension study (LIFE): A
randomised trial against atenolol. Lancet 2002;359:995-1003.
21 Heart Protection Study Group. MRC/BHF heart protection study of
cholesterol lowering with simvastatin in 20,536 high-risk individuals: a
randomised placebo-controlled trial. Lancet 2002;360:722.
22 Sever PS, Dahlof B, Poulter NR, Wedel H, Beevers G, Caulfield M;
ASCOT investigators. Prevention of coronary and stroke events with
atorvastatin in hypertensive patients who have average or lower-thenaverage
cholesterol concentrations, in the Anglo Scandinavian Cardiac
Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA): A multicentre
randomised controlled trial. Lancet 2003;361:1149-58.

Education and debate


640

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69-81 months, P = 0.05; doctor diagnosed asthma, 91
months, P = 0.005), it should be noted that, because of
small numbers in some groups, the confidence intervals
were wide and the results did not support the
hypothesis. When we adjusted for potential confounding
factors we detected no significant associations
(P = 0.1-0.8).

Comment

These findings confirm and extend our previous observations


of the lack of an independent association
between pertussis vaccination in infancy with inactivated,
whole cell vaccine and the subsequent development
of asthma or atopy during later childhood.
Acknowledgments: We thank the mothers and children who
took part and the midwives for their cooperation and help in
recruitment. The whole ALSPAC study team comprises
interviewers, computer technicians, laboratory technicians,
clerical workers, research scientists, volunteers, and managers
who continue to make the study possible. The ALSPAC study is
part of the European Longitudinal Study of Parents and
Children initiated by the World Health Organization.
Contributors: MG had the original idea. AM, AS, JH did the
analysis. All authors contributed to the interpretation of the
data. AM wrote the paper. JH will act as guarantor.
Funding: Core funding for the long termfollow up of the cohort
came from the Medical Research Council, the Wellcome Trust,
the UK Department of Health, the Department of the Environment,
DfEE, the National Institutes of Health, and a variety of
medical research charities. No specific funding was obtained for
this analysis.
Competing interests: None declared.
Ethical approval: Avon Longitudinal Study of Parents and
Children Ethics and Law Committee.
1 Odent MR, Kimmel T. Pertussis vaccination and asthma: is there a link?
JAMA 1994;272:592-593.
2 Kemp T, Pearce N, Fitzharris P, Crane J, Fergusson D, St George I,
Wickens K, Beasley R. Is infant immunization a risk factor for childhood
asthma or allergy? Epidemiology 1997;8:678-680.
3 Nilsson L, Kjellman N-IM, Bjrksten B. A randomised controlled trial of
the effect of pertussis vaccines on atopic disease. Arch Pediatr Adolescent
Med 1998;152:734-738.
4 Henderson AJ, North K, Griffiths M, Harvey I, Golding J, ALSPAC Study
Team. Pertussis vaccination and wheezing illnesses in young children:
prospective cohort study. BMJ 1999;318:1173-1176.
5 Golding J, Pembrey M, Jones R., ALSPAC Study Team. ALSPACthe
Avon longitudinal study of parents and children I. Study methodology.
Paediatr Perinatal Epidemiol 2001;15:74-87.

(Accepted 8 December 2003)


doi 10.1136/bmj.38045.858889.EB

Corrections and clarifications


British Hypertension Society guidelines for hypertension
management 2004 (BHS-IV): summary
An error occurred in the order of the reference list
in this Education and Debate article by Bryan
Williams et al (13 March, pp 634-40). Reference 8
in the published version (Williams et al) should
have been reference 3; and the references
published as 3 (Ramsay et al) to 7 (OBrien et al) in
the reference list should then have been
renumbered and become references 4 to 8. The
two references cited in the footnote to table 1
should be renumbered as 6 (European Society of
Hypertension-European Society of Cardiology)
and 7 (WHO-International Society of
Hypertension); but the other references cited in the
text of the article are correct. The pdf (but not the
HTML) version on bmj.com has been amended.
Recent developments in secondary prevention and
cardiac rehabilitation after acute myocardial infarction
As a result of technology problems, some
amendments from the authors did not make it into
this clinical review by Hasnain Dalal and colleagues
(20 March, pp 693-7). In box 2, we should have
added the website address for SEARCH (the study
of additional reductions in cholesterol and
homocysteine): www.ctsu.ox.ac.uk/projects/
search.shtml. And the penultimate sentence of the
subsection Angiotensin converting enzyme
inhibitors should have said that rates of
revascularisation (not rates of readmission for heart
failure) were reduced in patients who took ramipril.
Obituary: Leonard (Johnnie) Walker
Our weekly quest to squeeze in as many obituaries
as possible led to the last minute deletion of an
important sentence from this obituary (BMJ
2003;327:1291).We omitted to say Christianity
was an abiding passion and his faith directed his
life.We have apologised to Dr Walkers wife.
Odds ratios with 95% confidence intervals for outcome variables according to pertussis
vaccination status
Outcome variable Non-vaccinated* Partially vaccinated Fully vaccinated P value
Asthma at age 69-81 months (1024/8240)
Prevalence in %
(No/total)
8.2 (12/146) 20.3 (14/69) 12.4 (998/8025)
Unadjusted 1.00 2.84 (1.24 to 6.53) 2.05 (0.8 to 5.23) 0.05
Adjusted 1.00 1.59 (0.88 to 2.97) 1.06 (0.58 to 1.95) >0.1
Periods of wheeze at age 69-81 months (798/8114)
Prevalence in %
(No/total)
9.0 (13/144) 16.2 (11/68) 9.8 (774/7902)
Unadjusted 1.00 1.95 (0.82 to 4.6) 1.09 (0.62 to 1.94) 0.2
Adjusted 1.00 1.55 (0.55 to 4.37) 0.94 (0.50 to 1.78) 0.2
Doctor diagnosed asthma at age 91 months (1597/7850)
Prevalence in %
(No/total)
15.8 (23/146) 36.2 (21/58) 20.3 (1553/7667)
Unadjusted 1.00 3.03 (1.51 to 6.09) 1.36 (0.87 to 2.13) 0.005
Adjusted 1.00 1.93 (0.86 to 4.33) 0.98 (0.61 to 1.58) 0.1
Atopy at age 7 years (1324/6463)
Prevalence in % (No) 17.7 (22/124) 15.4 (6/39) 20.6 (1296/6300)
Unadjusted 1.00 0.84 (0.32 to 2.26) 1.20 (0.75 to 1.91) 0.6
Adjusted 1.00 1.05 (0.35 to 3.21) 1.18 (0.69 to 2.03) 0.8
*No primary vaccinations, including pertussis.
Diphtheria and tetanus 3 doses and no pertussis.
Triple (diphtheria, tetanus, and pertussis) vaccine 3 doses.

Is Dad mad, doctor?

I had just put away the pleural aspiration kit and labelled the
samples, and had returned to the patient, whose family had now
arrived, to check that he was comfortable.
One of the adult children greeted me with the question, Do
you think Dads mad, doctor?
Mad? I was a little bemused as to where this had come from.
Yes. He said you are going to send off the fluid from his lungs
for psychology.
After a few puzzled moments, the penny dropped: No, not
psychology, cytology.

James S Dawson senior house officer, Queens Medical Centre,


Nottingham

Papers
926

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1. In the management of chronic heart failure


True False Confidence

the loop diuretic furosemide may lead to hyperkalaemia


beta blockers (such as bisoprolol) are contraindicated
angiotensin-converting enzyme (ACE) inhibitors (such
as enalapril) are proven to reduce mortality
the cardiac glycoside digoxin is usually used as first line
therapy
and concurrent atrial fibrillation the anticoagulant
warfarin should be considered
the dose of digoxin required is largely determined by
renal function
angiotensin AT1 receptor antagonists (such as losartan)
are reserved for patients who do not respond to
angiotensin converting enzyme (ACE) inhibitors (such
as enalapril)
(21 marks, negative marking)

Key:
Correct answer
Partially correct answer
Incorrect answer
Emboldened words shown in brackets represent the correct
response for each question (not the user's answer).

Print Results

1. In the management of chronic heart failure


Correct
Answer
False

False

True

Your
Answer
the loop diuretic furosemide may lead to
hyperkalaemia
It is associated with hypokalaemia.
beta blockers (such as bisoprolol) are
Unanswered
contraindicated
They have a major role in stable CHF. Therapy
should "start low" and "go slow".
angiotensin-converting enzyme (ACE) inhibitors
Unanswered
(such as enalapril) are proven to reduce mortality
Should be used in all patients unless contraUnanswered

False

True

True

False

2.

indicated (e.g. hypotension, renal atery stenosis)


the cardiac glycoside digoxin is usually used as
Unanswered
first line therapy
It is reserved for CHF with AF or used in CHF
when other therapies are insufficient
and concurrent atrial fibrillation the anticoagulant
Unanswered
warfarin should be considered
To reduce the risk of a TIA.
the dose of digoxin required is largely determined
Unanswered
by renal function
The dose is reduced in renal impairment to
prevent toxicity.
angiotensin AT1 receptor antagonists (such as
losartan) are reserved for patients who do not
Unanswered
respond to angiotensin converting enzyme (ACE)
inhibitors (such as enalapril)
They reserved for patients who are
INTOLERANT to ACEIs.

0 out of 21

1. Mr CHF (aged 65 years) noticed that he was becoming short of breath whilst taking
mild exercise and also reported breathlessness whilst lying down in bed and this
was relieved by propping himself up with pillows. On examination he was found to
have raised jugular venous pressure (JVP), marked ankle oedema, he was
normotensive and a chest X-ray revealed pulmonary oedema and cardiomegaly. A
diagnosis of chronic heart failure was confirmed by an echocardiogram, which
revealed a reduced ejection fraction. The General Practitioner (GP) prescribed:
Furosemide 40 mg (o.m.)
Lisinopril initially 2.5 mg (o.d.)
Your browser does not support iframes!
Which of the following are associated with causing or precipitating heart failure:
Yes

No

Abstain

Ischaemic heart disease


Use of non-steroidal anti-inflammatory
drugs
Use of diuretic drugs
Beta-blockers
Hypertension
(5 marks, negative marking)

2. Which of the following should be should be monitored both prior to and during
treatment with these drugs?
Yes

No

Abstain

Full blood count


Renal function (plasma creatinine)
Blood glucose
Blood pressure
Electrolytes
(5 marks, negative marking)

3. Which of the following statements are true in relation to the drug therapy?
True False Abstain

An angiotensin AT1 receptor antagonist (such as losartan)


could be used in place of lisinopril if it were not tolerated
Furosemide is prescribed to reduce pulmonary oedema
Lisinopril is associated with opposing cardiac neurohormonal
adaptation
Lisinopril should be prescribed with a potassium supplement
Lisinopril has been prescribed prematurely and should be
reserved for more serious cases
(5 marks, negative marking)

4. In terms of counselling which of the following points are appropriate:


Yes

No

Abstain

Furosemide is best taken in the morning


Lisinopril is associated with causing a dry cough
Whilst taking lisinopril the patient should monitor their pulse
and ensure that it does not drop below 60 beats per minute
Lisinopril is best initially taken whilst retiring to bed
Furosemide is often associated with causing severe diarrhoea
The patient should report any rash of swellings whilst taking
lisinopril
Over the counter ibuprofen make be taken with either drug
(7 marks, negative marking)

5. At his next appointment the patients symptoms have only partly resolved and his

prescription is changed
Which of the following are appropriate changes to his prescription?
Yes

No

Abstain

Increase lisinopril to 5 mg (o.d.)


Add bisoprolol 1.25 mg (o.d.)
Add propranolol 80 mg (b.d.)
Substitute furosemide with bendroflumethiazide (2.5
mg)
Add verapamil 120 mg (t.d.s.)
(5 marks, negative marking)

6. Over the following week the patient had several losses of consciousness. The
patient had an irregularly irregular pulse and an ECG indicated approximately 200 P
waves per minute and irregular QRS complexes and further additions were made to
the prescription:
Digoxin 250 micrograms (o.d.)
Warfarin 10 mg for 2 days and then determine the maintenance dose.

Which of the following statements are true concerning the changes to the patient?
True False Abstain

The patient is likely to have atrial fibrillation


The patient is at increased risk of suffering a pulmonary
embolism
The patient is at risk of transient ischaemic attacks (TIA)
The patient appears to have developed ventricular fibrillation
The patient is having an adverse reaction to the combination of
furosemide and lisinopril
(5 marks, negative marking)

7. Which of the following statements are true concerning the introduction of digoxin?
True False Abstain

The dose of digoxin is determined in relation to renal function


The digoxin and warfarin may lead to a serious drug interaction
Digoxin is used to control the rate of atrial contraction
Digoxin is often initiated as a loading dose
Digoxin toxicity may manifest as nausea and visual

disturbances
(5 marks, negative marking)

8. Which of the following statements are true concerning the introduction of warfarin?
True False Abstain

Low dose aspirin would have been more effective than warfarin
The effects of warfarin are monitored by the International
Normalised ratio (INR)
The effects of warfarin are manifest within the first few hours
Warfarin is prescribed to reduce the risk of transient ischaemic
attacks
If the patient suffers a chest infection then erythromycin is the
most appropriate antibacterial agent to use now
(5 marks, negative marking)

Key:
Correct answer
Partially correct answer
Incorrect answer
Emboldened words shown in brackets represent the correct
response for each question (not the user's answer).

Print Results

1. Mr CHF (aged 65 years) noticed that he was becoming short of breath whilst
taking mild exercise and also reported breathlessness whilst lying down in
bed and this was relieved by propping himself up with pillows. On
examination he was found to have raised jugular venous pressure (JVP),
marked ankle oedema, he was normotensive and a chest X-ray revealed
pulmonary oedema and cardiomegaly. A diagnosis of chronic heart failure
was confirmed by an echocardiogram, which revealed a reduced ejection
fraction. The General Practitioner (GP) prescribed:
o Furosemide 40 mg (o.m.)
o Lisinopril initially 2.5 mg (o.d.)
Which of the following are associated with causing or precipitating heart
failure:
Correct
Answer
Yes
Yes

Your
Answer
Unanswered Ischaemic heart disease
A major cause
Unanswered Use of non-steroidal anti-inflammatory drugs
These may cause fluid retention and worsen or
precipitate CHF

No
Yes

Yes

Unanswered Use of diuretic drugs


They are used to relieve the oedema
Unanswered Beta-blockers
Although used in stable CHF, they may
themselves uncover compensated heart failure,
hence they are used with caution
Unanswered Hypertension
A major cause

0 out of 5
2. Which of the following should be should be monitored both prior to and
during treatment with these drugs?
Correct
Your
Answer
Answer
No
Unanswered Full blood count
Not required
Yes
Unanswered Renal function (plasma creatinine)
Essential as ACEIs may cause a worsening of
renal function
No
Unanswered Blood glucose
Not routinely required for these drugs
Yes
Unanswered Blood pressure
Both agents are hypotensive
Yes
Unanswered Electrolytes
Furosemide is associated with hypokalaemia and
lisinopril is associated with hyperkalaemia
3. 0 out of 5
4. Which of the following statements are true in relation to the drug therapy?
Correct
Answer
True

True

True

Your
Answer
An angiotensin AT1 receptor antagonist (such as
Unanswered losartan) could be used in place of lisinopril if it
were not tolerated
This is the principal reason for using an AT1
receptor antagonist
Furosemide is prescribed to reduce pulmonary
Unanswered
oedema
For symptomatic relief in oedema
Lisinopril is associated with opposing cardiac
Unanswered
neurohormonal adaptation
Hence ACEIs have a major role

False

False

5.

Lisinopril should be prescribed with a potassium


supplement
This would might lead to a serious interaction
(hyperkalaemia)
Lisinopril has been prescribed prematurely and
Unanswered
should be reserved for more serious cases
ACEIs are used first line when there is a reduced
ejection fraction
Unanswered

0 out of 5

6. In terms of counselling which of the following points are appropriate:


Correct
Answer
Yes
Yes

No

Yes

No

Yes

No

7.

Your
Answer
Unanswered Furosemide is best taken in the morning
So that diuresis occurs during the day
Unanswered Lisinopril is associated with causing a dry cough
Important side effect
Whilst taking lisinopril the patient should monitor
Unanswered their pulse and ensure that it does not drop below
60 beats per minute
This applies to digoxin
Lisinopril is best initially taken whilst retiring to
Unanswered
bed
Because of first dose hypotension
Furosemide is often associated with causing
Unanswered
severe diarrhoea
This is not (if at all) a common side effect
The patient should report any rash of swellings
Unanswered
whilst taking lisinopril
Because of the risk of angioedema
Over the counter ibuprofen make be taken with
Unanswered
either drug
Ibufrofen is best avoided as it reduces the effets
of both of these drugs

0 out of 7

8. At his next appointment the patients symptoms have only partly resolved
and his prescription is changed
Which of the following are appropriate changes to his prescription?
Correct
Answer
Yes

Your
Answer
Unanswered Increase lisinopril to 5 mg (o.d.)

Yes
No

No

No

Upwards titration is appropriate


Unanswered Add bisoprolol 1.25 mg (o.d.)
This is a sensible addition at a low dose
Unanswered Add propranolol 80 mg (b.d.)
This is not licenced and the dose is too high
which may worsen CHF
Substitute furosemide with bendroflumethiazide
Unanswered
(2.5 mg)
Bendroflumethiazide is less effective than
furosemide and is not likely to improve the
situation
Unanswered Add verapamil 120 mg (t.d.s.)
Verapamil is contra-indicated in CHF as its
negative inotropic effects would worsen CHF

0 out of 5
9. Over the following week the patient had several losses of consciousness.
The patient had an irregularly irregular pulse and an ECG indicated
approximately 200 P waves per minute and irregular QRS complexes and
further additions were made to the prescription:
o Digoxin 250 micrograms (o.d.)
o Warfarin 10 mg for 2 days and then determine the maintenance
dose.
Which of the following statements are true concerning the changes to the
patient?
Correct
Answer
True

False

True

False

Your
Answer
Unanswered The patient is likely to have atrial fibrillation
As shown by the irregularly irrgeular pulse and
the dissociation between fast P waves and the
irregular QRS complexes
The patient is at increased risk of suffering a
Unanswered
pulmonary embolism
The cerebral circulation is the common site of
thromboembolism associated with AF
The patient is at risk of transient ischaemic
Unanswered
attacks (TIA)
The cerebral circulation is a common site of
thromboembolism associated with AF
The patient appears to have developed
Unanswered
ventricular fibrillation
Atrial fibrillation, untreated ventricular fibrillation

False

is rapidly fatal
The patient is having an adverse reaction to the
Unanswered
combination of furosemide and lisinopril
No, this is a standard combination and these
drugs do not interact in this way

0 out of 5
10. Which of the following statements are true concerning the introduction of
digoxin?
Correct
Your
Answer
Answer
The dose of digoxin is determined in relation to
True
Unanswered
renal function
Renal impairment requires a dose reduction as
digoxin is largely renally excreted
The digoxin and warfarin may lead to a serious
False
Unanswered
drug interaction
No significant interaction
Digoxin is used to control the rate of atrial
False
Unanswered
contraction
It causes a degree of heart block and controls
the ventricular rate
True
Unanswered Digoxin is often initiated as a loading dose
For rapid effects
Digoxin toxicity may manifest as nausea and
True
Unanswered
visual disturbances
An important counselling point and simple way of
monitoring treatment
11. 0 out of 5
12. Which of the following statements are true concerning the introduction of
warfarin?
Correct
Answer
False

True
False

Your
Answer
Low dose aspirin would have been more effective
than warfarin
Warfarin is more effective, and aspirin is used in
lower risk patients
The effects of warfarin are monitored by the
Unanswered
International Normalised ratio (INR)
The effects of warfarin are manifest within the
Unanswered
first few hours
It takes 2-3 days for its anticoagulant effects
Unanswered

True
False

13. 0 out of 5

Warfarin is prescribed to reduce the risk of


transient ischaemic attacks
If the patient suffers a chest infection then
Unanswered erythromycin is the most appropriate antibacterial
agent to use now
Erythromycin inhibits the metabolism of warfarin
and so is less suitable
Unanswered