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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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Introduction
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.
634
635
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)
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
B: blocker
D: Diuretic (thiazide
and thiazide-like)
Step 2
Step 3
Step 4
Resistant hypertension
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.
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
Follow up
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
Comment
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.
Papers
926
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
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.
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
2. Which of the following should be should be monitored both prior to and during
treatment with these drugs?
Yes
No
Abstain
3. Which of the following statements are true in relation to the drug therapy?
True False Abstain
No
Abstain
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
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
7. Which of the following statements are true concerning the introduction of digoxin?
True False Abstain
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
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.
0 out of 5
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
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