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Report of the Third Working Party of the British Hypertension Society Journal of Human Hypertension (1999) 13, 569–592 1999 Stockton Press. All rights reserved 0950-9240/99 $15.00 http://www.stockton-press.co.uk/jhh BHS GUIDELINES Guidelines for management of hypertension: report of the third working party of the British Hypertension Society LE Ramsay, B Williams, GD Johnston, GA MacGregor, L Poston, JF Potter, NR Poulter and G Russell for the British Hypertension Society ¼ Use non-pharmacological measures in all hyperten- as first-line therapy for the majority of hypertensive sive and borderline hypertensive people. people. In the absence of compelling indications for ¼ Initiate antihypertensive drug therapy in people with beta-blockade, diuretics or long acting dihydropyrid- sustained systolic blood pressures (BP) у160 mm Hg ine calcium antagonists are preferred to beta-blockers or sustained diastolic BP у100 mm Hg. in older subjects. Compelling indications and contra- ¼ Decide on treatment in people with sustained systolic indications for all antihypertensive drug classes are BP between 140 and 159 mm Hg or sustained diastolic specified. BP between 90 and 99 mm Hg according to the pres- ¼ For most hypertensives, a combination of antihyper- ence or absence of target organ damage, cardio- tensive drugs will be required to achieve the rec- vascular disease or a 10-year coronary heart disease ommended targets for blood pressure control. у (CHD) risk of 15% according to the Joint British ¼ Other drugs that reduce cardiovascular risk must also Societies CHD risk assessment programme/risk chart. be considered. These include aspirin for secondary ¼ In people with diabetes mellitus, initiate antihyperten- у prevention of cardiovascular disease, and primary sive drug therapy if systolic BP is sustained 140 prevention in treated hypertensive subjects over the mm Hg or diastolic BP is sustained у90 mm Hg. у ¼ age of 50 years who have a 10-year CHD risk 15% In non-diabetic hypertensive people, optimal BP treat- and in whom blood pressure is controlled to the audit ment targets are: systolic BP Ͻ140 mm Hg and dias- standard. In accordance with existing British rec- tolic BP Ͻ85 mm Hg. The minimum acceptable level of ommendations, statin therapy is recommended for control (Audit Standard) recommended is Ͻ150/Ͻ90 hypertensive people with a total cholesterol mm Hg. Despite best practice, these levels will be dif- у5 mmol/L and established vascular disease, or 10- ficult to achieve in some hypertensive people. у ¼ In diabetic hypertensive people, optimal BP targets year CHD risk 30% estimated from the Joint British are; systolic BP Ͻ140 mm Hg and diastolic BP Ͻ80 Societies CHD risk chart. Glycaemic control should mm Hg. The minimum acceptable level of control also be optimised in diabetic subjects. ¼ (Audit Standard) recommended is Ͻ140/Ͻ90 mm Hg. Specific advice is given on the management of hyper- Despite best practice, these levels will be difficult to tension in specific patient groups, ie, the elderly, achieve in some people with diabetes and hyperten- ethnic subgroups, diabetes mellitus, chronic renal sion. disease and in women (pregnancy, oral contraceptive ¼ In the absence of contraindications or compelling use and hormone replacement therapy). indications for other antihypertensive agents, low ¼ Suggestions for the implementation and audit of dose thiazide diuretics or beta-blockers are preferred these guidelines in primary care are provided. Keywords: BHS; management of hypertension Introduction patients3–7; treatment of isolated systolic hyperten- sion in the elderly8; comparison of the antihyperten- These guidelines update previous reports by work- sive efficacy and tolerability of different classes of ing parties of the British Hypertension Society in drug9–11; and the role of non-pharmacological meas- 1 2 1989 and 1993. Since the 1993 guidelines much ures in the prevention12–15 and treatment16 of hyper- new evidence has emerged, notably on optimal tension. There has been a vigorous debate about the blood pressure targets during antihypertensive treat- 17,18 3 safety of dihydropyridine calcium antagonists, ment ; management of hypertension in diabetic but also new evidence from randomised controlled trials for their efficacy and safety, particularly in iso- lated systolic hypertension in the elderly.8 These Correspondence: Professor Bryan Williams, Cardiovascular important additions to an already formidable body Research Institute, University of Leicester, Sir Robert Kilpatrick Building, PO Box 65, Leicester Royal Infirmary, Leicester LE2 of evidence are very welcome and provide the basis 7LX, UK for these new recommendations from the British Received and accepted 7 July 1999 Hypertension Society. Guidelines for management of hypertension British Hypertension Society 570 On the whole, physicians report that they adhered to previous recommendations by the British Hyper- BOX 1. Categories of Strength Used in Statements 19 (based on North of England evidence based guidelines, tension Society, but with some important excep- BMJ 1998)53 tions. They are less aware of, or less inclined to implement, recommendations to treat mild hyper- Strength of evidence tension and isolated systolic hypertension in the la-Evidence from meta-analysis of randomised controlled 19,20 trials elderly. National and international surveys con- Ib-Evidence from at least one randomised controlled trial tinue to reveal that there is under-diagnosis of IIa-Evidence from at least one controlled study without hypertension, that those diagnosed as hypertensive randomisation often do not continue on treatment, and that those IIb-Evidence from at least one other type of quasi- treated are often not controlled satisfactorily.21–23 experimental study III-Evidence from descriptive studies, such as The situation has improved in recent years but in comparative studies, correlation studies, and case- general the management of hypertension in the controlled studies United Kingdom remains suboptimal.23 IV-Evidence from expert committee reports or opinions Also disturbing is further evidence that conven- or clinical experience of respected authorities, or both tional management of hypertension leaves patients Strength of recommendation at an unacceptably high risk of cardiovascular com- A-Directly based on category I evidence plications and death, particularly from coronary B-Directly based on category II evidence or extrapolated heart disease (CHD) but also from stroke.24–29 In part recommendation from category I evidence this is a consequence of suboptimal blood pressure C-Directly based on category III evidence or extrapolated 30 recommendation from category I or II evidence control, but other factors are also important. In a D-Directly based on category IV evidence or extrapolated recent study, the persistent excess of CHD events in recommendation from category I, II or III evidence treated hypertensive subjects was predicted by three factors; (i) evidence of target organ damage before treatment, (ii) a history of cigarette smoking before treatment, and (iii) the serum cholesterol values Societies ‘Cardiac Risk Assessor’ computer pro- before and during treatment.29 These observations gramme. Consequently, whilst acknowledging that support the concept that effective management of CVD prevention is the proper focus of hypertension hypertension requires the identification of those at management, the levels of CHD risk quoted in these highest cardiovascular risk and the adoption of guidelines, appropriately precipitate intervention multifactorial intervention, targeting not only blood for those at higher CVD risk. pressure levels, but also associated cardiovascular These guidelines are intended for general prac- risk factors. These new guidelines embrace this con- titioners, practice nurses, and generalists in hospital cept and provide detailed guidance on the manage- practice, and aim to present as clearly as possible, ment of hypertension and associated cardiovascular the best currently available evidence on hyperten- risk factors. sion management. The evidence supporting the rec- The recent trials of statins31–34 and aspirin3,35 for ommendations contained in these new British the prevention of CHD are important steps forward Hypertension Society guidelines is graded using the for hypertension management since the previous North of England Group Criteria53 (Box 1). The guidelines. A significant proportion of hypertensive guidelines should be applied with due regard to patients will benefit from aspirin and statin treat- local circumstances and policies, and with appropri- ment, even if these treatments are only targeted at ate clinical judgement as regards the needs of indi- those with a high level of CHD risk.36,37 Formal esti- vidual patients (Box 2). mation of CHD risk has been proposed as an aid to 38–45 treatment decisions in hypertension, and Blood pressure measurement (Box 3) debated.46–49 This estimation ideally entails coun- ting and weighting major cardiovascular risk factors All adults should have blood pressure measured in addition to blood pressure itself.50 Mindful of the routinely at least every 5 years until the age of 80 strong relationship between blood pressure and the years. Those with high-normal values (135–139/85– risk of stroke, the Society acknowledges that tar- 89 mm Hg) and those who have had high readings geting cardiovascular disease risk (CVD) rather than at any time previously should have blood pressure CHD risk is preferable. However, in order to be con- re-measured annually. The British Hypertension sistent with
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