Lothian Hypertension Guidelines (2013)

A Guide to Practice in Lothian based on 2011 British Hypertension Society Guidelines

Download the PDF Guideline 2013

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
  • Glucose
  • Electrolytes and creatinine
  • Urine strip test - blood, protein, glucose
  • Cholesterol / HDL
  • ECG

Estimation of Cardiovascular Disease (CVD) Risk
Modern management is focused on assessing overall 10 year CVD risk, which can be calculated using the CVD Risk Charts and Calculator on this website.

Management - Lifestyle Measures

Life style measures aim to

  1. reduce blood pressure
  2. improve CVD risk factor profile

  • Weight - aim for BMI between 20-25kg/m2
  • Exercise - ideally 30+ minutes 3 times per week
  • Alcohol - safe weekly limits (Male <21 units, Female <14 units)
  • Smoking - cessation vital to decrease overall CVD risk
    • nicotine replacement therapy may help
  • Diet
    • reduce salt and saturated fat
    • increase fruit, vegetables and oily fish

Management - Drug Treatment Thresholds

Definite: >160/100, Borderline: 140-160/90-100, Normal: <140/90

'DEFINITE'

Treat

'BORDERLINE'

Make necesary lifestyle changes
Treat if

  • target organ damage/disease
  • diabetes
  • 10 year CVD risk > 20%

'NORMAL'

Reassess

  • >130/85 - Annually
  • <130/85 - 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 blood pressure with drugs that suit the patient and cause minimal side-effects. Two drugs or more will usually be required.

Management - 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:

  1. Bendroflumethiazide 2.5mg (lisinopril if < 50 years)
  2. Bendroflumethiazide and lisinopril
  3. Add nifedipine LA
  4. Add atenolol 50mg
  5. Doxazosin or spironolactone or moxonidine or referral for specialist advice

Brief notes on drug use

  • AII receptor antagonists (ARAs) are reserved for ACEI intolerant patients
  • Indications for particular drugs
    • ACE inhibitors (and ARAs) for impaired LV function, post-MI and diabetic nephropathy
    • β-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

Other drugs to consider

  • Aspirin 75mg if BP controlled and any of
    • vascular disease present
    • diabetes
    • high CVD risk (>20% over 10 year)
  • Statins (target total cholesterol <5.0mmol/L or 25% reduction) if any of
    • vascular disease present
    • diabetes or high CVD risk (>20% over 10 year)

Management - When 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