Bhs guidelines iv_and_nice_algorithm_slides

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Bhs guidelines iv_and_nice_algorithm_slides

  1. 1. BHS Guidelines for the management of hypertension BHS IV, 2004 and Update of the NICE Hypertension Guideline, 2006 Guidelines for management of hypertension: report of the fourth Working Party of the British Hypertension Society, 2004 BHS IV B Williams et al: J Hum Hyp (2004); 18: 139-185. www.nice.org.uk/CG034NICEguideline www.bhsoc.org
  2. 2. •Measurement Hypertension management issues •Investigation •Non-pharmacological treatment •Thresholds for drug treatment •Targets for drug treatment •Drug choices – trial update •Other treatments •Follow-up
  3. 3. BHS classification of blood pressure levels Category Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)Optimal blood pressure <120 <80 Normal blood pressure <130 <85 High-normal blood pressure 130-139 85-89 Grade 1 Hypertension (mild) 140-159 90-99 Grade 2 Hypertension (moderate) 160-179 100-109 Grade 3 Hypertension (severe) >180 >110 Isolated Systolic Hypertension (Grade 1) 140-159 <90 Isolated Systolic Hypertension (Grade 2) >160 <90
  4. 4. Potential indications for the use of ambulatory blood pressure monitoring •Unusual variability •Possible white coat hypertension •Informing equivocal treatment decisions •Evaluation of nocturnal hypertension •Evaluation of drug-resistant hypertension •Determining the efficacy of drug treatment over 24 hours •Diagnoses and treatment of hypertension in pregnancy •Evaluation of symptomatic hypotension
  5. 5. Routine investigations • Urine strip test for protein and blood • Serum creatinine and electrolytes • Blood glucose - ideally fasted • Blood lipid profile (at least total and high density lipoprotein (HDL) cholesterol) – ideally fasted for consideration of triglycerides • Electrocardiogram
  6. 6. Lifestyle measures •Maintain normal weight for adults (body mass index 20-25 kg/m2 ) •Reduce salt intake to <100 mmol/day (<6g NaCl or <2.4 g Na+ /day) •Limit alcohol consumption to ≤3 units/day for men and ≤2 units/day for women •Engage in regular aerobic physical exercise (brisk walking rather than weight lifting) for ≥30 minutes per day, ideally on most of days of the week but at least on three days of the week •Consume at least five portions/day of fresh fruit and vegetables •Reduce the intake of total and saturated fat
  7. 7. Target organ damage or cardiovascular complications or diabetes or 10 year CVD risk† ≥ 20% >180/110 160−179 100−109 140−159 90−99 130−139 85−89 <130/85 ≥160/100 140−159 90−99 <140/90 No target organ damage and no cardiovascular complications and no diabetes and 10 year CVD risk† <20% * ** *** Treat Treat Treat Observe, reassess CVD risk yearly Reassess yearly Reassess in 5 years * 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 re-measure weekly and treat if blood pressure persists at these levels over 4−12 *** If cardiovascular complications, target organ damage, or diabetes is present, confirm over 12 weeks then treat: if absent re-measure monthly and treat if these levels are maintained and if estimated 10 year CVD risk is ≥20% † Assessed with CVD risk chart THRESHOLDS FOR INTERVENTION Initial blood pressure (mmHg)
  8. 8. Suggested target blood pressures during antihypertensive treatment. Systolic and diastolic blood pressures should both be attained, e.g. <140/85 mmHg means less than 140 mmHg for systolic blood pressure and less than 85 mmHg for diastolic blood pressure   Clinic BP (mmHg) No diabetes Diabetes Optimal treated BP pressure <140/85 <130/80 Audit Standard <150/90 <140/80   Audit standard reflects the minimum recommended levels of blood pressure control.  Despite best practice, the Audit Standard will not be achievable in all treated hypertensives. For ambulatory (mean daytime) or home blood pressure monitoring - reducing these targets by ~10/5 is  recommended.
  9. 9. Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs Class of drug Compelling indications Possible indications Caution Compelling contra- indications Alpha- blockers  Benign prostatic  hypertrophy    Postural  hypotension,  heart failure  Urinary  incontinence  ACE- inhibitors  Heart failure,  LV dysfunction, post  MI or established CVD,  Type I diabetic  nephropathy, 2o  stroke  prevention  Chronic renal  disease,  Type II diabetic  nephropathy,  proteinuric renal  disease  Renal impairment  PVD  Pregnancy,  renovascular  disease  ARBs  ACE inhibitor- intolerance,   Type II diabetic  nephropathy,  hypertension with LVH,  heart failure in ACE- intolerant patients, post  MI  LV dysfunction  post MI, intol- erance of other  antihypertensive  drugs, proteinuric  renal disease,  chronic renal  disease,  heart  failure  Renal impairment  PVD    Pregnancy,  renovascular  disease   
  10. 10. Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs Class of drug Compelling indications Possible indications Caution Compelling contraindications Beta-blockers MI, Angina Heart failure Heart failure, PVD, Diabetes (except with CHD) Asthma/COPD, Heart block CCBs (dihydropyridine) Elderly, ISH Angina - - CCBs (rate limiting) Angina Elderly Combination with beta- blockade Heart block Heart failure Thiazide/thiazide- like diuretics Elderly ISH Heart failure 2 o stroke prevention Gout
  11. 11. Other medications for hypertensive patients Primary prevention (1) Aspirin: use 75mg daily if patient is aged ≥50 years with blood pressure controlled to <150/90 mm Hg and either; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of ≥20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart) (2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years, with a 10 year risk of cardiovascular disease of ≥20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart) and with total cholesterol concentration ≥3.5mmol/l (3) Vitamins—no benefit shown, do not prescribe
  12. 12. Secondary prevention (including patients with type 2 diabetes) (1) Aspirin: use for all patients unless contraindicated (2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years with a total cholesterol concentration ≥3.5 mmol/l (3) Vitamins— no benefit shown, do not prescribe Other medications for hypertensive patients
  13. 13. Targets for lipid lowering Ideal - TC<4.0mmol/l or LDL <2.0mmol/l or 25% ↓ in TC or 30% ↓ in LDL-C whichever is the greater ‘Audit’ - TC <5.0mmol/l or LDL <3.0mmol/l or 25% ↓ in TC or 30% ↓ in LDL-C whichever is the greater Lipid targets

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