British Hypertension Guidelines Update 1999.

Author: Francisco Machado

Date: 4/11/99

This tutorial is based on a lunchtime presentation at Abersychan Surgery abd should be read in conjuction with the recent BHS guidelines published in the BMJ

To read this document on-line click on the link below.

British Hypertension Society guidelines for hypertension management 1999: summary BMJ 1999;319:630-635 ( 4 September )

Who wrote the guidelines?

Not a single PHCT professional amongst authors in BMJ article!!

How can these guidelines help us manage patients with hypertension?

Questions I asked when looking at the guidelines

1. How often should patients have their BP measured?
2. How should I measure BP?
3. When should I use ambulatory BP monitoring?
4. How should I assess a patient with hypertension:
   - history
   - examination
   - Investigations
5. What non-pharmacological measures are effective?
6. When should I treat?
7. Which drug should I use?
8. How should I use these drugs?
9. Are there any special groups?
10. When should I refer?
11. What about statins and aspirin?
12. How should patients be followed up?
13. What about a protocol?

• All adults up to 80 atleast 5 yearly if BP < 135/85
• Annually in those with high normal (135-139/85-89)
• Annually in those who have had high BP in the past but returned to normal and on no medication

Where do the errors occur?

BHS recommendations for BP measurement

• Use an appropriate cuff
• Ensure forearm is supported
• Inflate cuff to 30 mmHg above pulse occlusion
• Deflate at 2 mmHg per second
• Record systolic BP when first sound is heard
• Record diastolic BP when sounds disappear (Phase 5)
• Measure BP to nearest 2mmHg
• Atleast two measurements
• Sitting and standing in elderly

3. When should I use ambulatory BP monitoring?

• When clinic BP shows unusual variability
• Resistant hypertension
• When symptoms suggest hypotension
• To diagnose White Coat hypertension

Not mentioned in the guidelines but it is very important to elicit the patients

Ideas
Concerns
Expectations

With regard to hypertension and its management.

For initial blood pressure flow chart click here.

Targets for Blood Pressure.

Which drugs to use first?

8.How should I use these drugs?

• Mild ð Substitute
• Severe ð Combine
• Most will require a combination to achieve targets
• Synergistic effects
• Sub-maximal doses of two agents > maximum dose of single agent and less side effects e.g. amlodipine

A = ACEI, B = beta-blocker, C = Calcium antagonist, D = Diuretic

Dickerson JEC, Hingorani AD, Ashley MJ et al. Optimisation of antihypertensive treatment by crossover rotation of four major classes. Lancet 1999; 353: 2008-13

Elderly
>50% of all people > 60 ð >160/90

More to gain from treatment

Evidence to 80years of age

10.When should I refer?

• Urgent treatment indicated: malignant hypertension, impending complications
• To investigate potential underlying causes of hypertension when initial evaluation suggests this possibility
• To evaluate therapeutic problems or failures
• Special circumstances e.g. children, pregnancy, white coat hypertension

Primary prevention 75mg aspirin is recommended for hypertensive patients aged > 50 who have satisfactory control of BP and either target organ damage, diabetes or a 10 year coronary risk > 15

For primary prevention, statin therapy is indicated up to the age of 70 when serum total CE > 5.0 mmol/l and the 10 year coronary heart disease risk is > 30

For secondary prevention of coronary heart disease statin therapy is indicated up to 75 years if total CE is > 5.0mmol/l and aspirin is indicated (75mg)

Routine

3/12

• BP
• Weight
• General health
• Side effects
• Proteinuria
• Non Pharmacological measures

• Practice
• LHG