LOTHIAN HYPERTENSION GUIDELINES 2005

A Guide to Practice in Lothian based on 2004 British Hypertension Society Guidelines BLOOD PRESSURE MEASUREMENT All adults should be measured every five years up to the age of 80. If borderline this should be increased to annually. Final estimation should be based on at least 4 separate seated blood pressure recordings. ABPM may help if there is unusual BP variability, white coat hypertension is suspected, or in borderline cases. ASSESSMENT A full assessment is necessary in patients with borderline or definite hypertension. This will focus on potential causes, other vascular risk factors and evidence of end-organ damage.
History vascular disease, drugs, family, lifestyle Examination arrhythmias, heart failure, weight Urine strip test blood, protein, glucose Glucose Cholesterol / HDL Electrolytes and creatinine ECG

Estimation of Cardiovascular Disease (CVD) Risk Modern management is focused on assessing overall 10 year CVD risk. This can be calculated following assessment using the CVD Risk Chart overleaf. MANAGEMENT Lifestyle Measures may help (i) to reduce blood pressure, and (ii) to improve CVD risk factor profile. Weight - aim for BMI between 20-25kg/m2 Exercise - ideally 30+ minutes 3 times per week Smoking - cessation vital to overall CVD risk Alcohol - safe weekly limits (<21 units, <14 units) nicotine replacement therapy may help Diet - salt, saturated fat, fruit, vegetables, oily fish Drug Treatment Thresholds
mmHg

180 170 160 150 140 130 120

Diastolic Systolic

Decision to treat based on 4 separate seated blood pressures. Necessary lifestyle changes should have been made in borderline cases.

Drug Choice Most patients will require more than one drug. Reduction of BP is the key determinant of benefit not the specific drugs used to achieve it. The following algorithm provides a logical guide to escalate treatment but will be modified according to circumstance:
Step 1 bendroflumethiazide 2.5mg (lisinopril if < 50 years) Step 2 bendroflumethiazide and lisinopril Step 3 add nifedipine LA Step 4 add atenolol 50mg Step 5 doxazosin or spironolactone or moxonidine or referral for specialist advice

DEFINITE
Treat

BORDERLINE
Treat if
target organ damage/disease diabetes 10 year CVD risk > 20%

Brief notes
AII receptor antagonists (ARAs) are reserved for ACEI intolerant patients. Indications for particular drugs include: ACE inhibitors (and ARAs) for impaired LV function, post-MI and diabetic nephropathy. -blockers for known coronary disease. Calcium antagonists and thiazide diuretics for elderly patients with isolated systolic hypertension. Systolic blood pressure is a better prognostic indicator than diastolic blood pressure. Older patients with hypertension accrue the greatest absolute benefit from treatment.
or diabetes or high CVD risk (>20% over 10 year) with BP controlled Statins - if vascular disease present or diabetes or high CVD risk (>20% over 10 year) target TC<5.0 or 25%
Further Information British Hypertension Society Guidelines Summary. Br Med J 2004;328:634-640. NICE Guidelines for Hypertension www.nice.org.uk British Hypertension Society www.bhsoc.org High Blood Pressure Foundation www.hbpf.org.uk

110 100 90 80 70 60

NORMAL
>130/85 Reassess annually <130/85 Reassess in 5 years Target Blood Pressure should be < 140/85 or < 130/80 in diabetes or renal disease. This reflects optimal responses that cannot be achieved in all cases. Major objective of treatment is to control b lood pressure with drugs that suit the patient and cause minimal side-effects. Two drugs or more will usually be required.

Other Drugs to Consider Aspirin 75mg - if vascular disease present

Reasons to Consider Specialist Referral

Secondary hypertension possible (young patient, failure to achieve target on 4 drugs, hypokalaemia, abnormal renal function) Severe hypertension Pregnancy Multiple drug side-effects Complicated risk assessment Established vascular disease
Further local advice on the diagnosis and management of blood pressure is available from: WGH - Cardiovascular Risk Clinic 537 1630 (Wednesday AM) or 537 1718 (Secretaries) or 537 1630 (Nurse) RIE - Hypertension Clinic 536 2213 (Monday PM & Wednesday AM)