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BHS guidelines - summary recommendations (2004)

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  • use of non-pharmacological measures - these should be used in all hypertensive and borderline hypertensive people

  • antihypertensive drug therapy should be initiated if sustained systolic blood pressure 160 mm Hg or sustained diastolic blood pressure 100 mm Hg

  • if sustained systolic blood pressure is 140-159 mm Hg or sustained diastolic blood pressure 90-99 mm Hg
    • consider initiating treatment if cardiovascular disease or other target organ damage present, or if estimated 10 year risk of cardiovascular disease (CVD) * is 20%

  • in non-diabetic people:
    • optimal goals for blood pressure treatment are: systolic blood pressure < 140 mm Hg and diastolic blood pressure < 85 mm Hg.
    • audit standard is < 150/ < 90 mm Hg

  • patients with diabetes mellitus:
    • initiate antihypertensive drug treatment if systolic blood pressure is sustained 140 mm Hg or diastolic blood pressure is sustained 90 mm Hg
    • in hypertensive patients with diabetes, chronic renal disease, or established cardiovascular disease
      • optimal blood pressure goals are systolic blood pressure < 130 mm Hg and diastolic blood pressure < 80 mm Hg
      • audit standard < 140/ < 80 mm Hg

  • the majority of patients with high blood pressure will require at least two blood pressure lowering drugs to achieve the recommended goals. When no disadvantages of cost exist, fixed drug combinations are recommended

  • low dose aspirin (75 mg/day) is recommended for secondary prevention of ischaemic cardiovascular disease and for primary prevention, in people over the age of 50 who have a 10 year risk of cardiovascular disease of 20% and in whom blood pressure is controlled to the audit standard

  • statin treatment is recommended for all people with high blood pressure complicated by cardiovascular disease, irrespective of baseline concentrations total cholesterol or low density lipoprotein (LDL) cholesterol

  • statin treatment is also recommended for primary prevention in people with high blood pressure who have a 10 year risk of cardiovascular disease of 20%

  • choice of antihypertensive drug therapy (1,2):
    • for each major class of antihypertensive drug compelling indications exist for use in specific groups of patients and also compelling contraindications
    • meta-ananlyses confirm that, in general, the main determinant of benefit from BP-lowering drugs is the achieved BP, rather than the choice of antihypertensive therapy
    • when no special considerations apply, initial drug selection should follow step 1 of the A/CD algorithm (linked item)
  • cardiovascular risk reduction in patients with diabetes (1):
    • statin treatment - routine use of statin therapy is recommended in people with type II diabetes complicated by hypertension. For people with type I diabetes, there is insufficient data to guide practice with regard to statins...seems reasonable to treat as per type II diabetes (1)
    • low-dose aspirin is indicated for primary prevention of cardiovascular disease in patient aged over 50 years when BP is controlled to <150/90 mmHg and when 10-year CVD risk exceeds 20%

* CVD risk replaces coronary heart disease (CHD) risk estimation to reflect the importance of stroke prevention as well as CHD prevention. The new CVD risk threshold of >= 20% is equivalent to a CHD risk of approximately >=15% over 10 years


  1. Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004;18: 139-85

  2. NICE (June 2006). Management of adults with hypertension in primary care