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  • British Hypertension Society Guidelines
  • Published:

Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004—BHS IV

Journal of Human Hypertension volume 18, pages 139–185 (2004)Cite this article

Abstract

Summary of recommendations

  • Provide advice on life-style modifications for all people with high blood pressure (BP) and those with borderline or high-normal BP. Advice on effective nonpharmacological interventions is provided (A).

  • Initiate antihypertensive drug therapy in people with sustained systolic BP (SBP) ⩾160 mmHg or sustained diastolic BP (DBP) ⩾100 mmHg (A).

  • Make treatment decisions in people with sustained SBP between 140 and 159 mmHg and/or sustained DBP between 90 and 99 mmHg according to the presence or absence of cardiovascular disease, other target organ damage, or an estimated cardiovascular disease (CVD) risk of ⩾20% over 10 years, according to the Joint British Societies CVD risk assessment programme/risk chart (A).

  • CVD risk replaces 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.

  • In people with diabetes mellitus, initiate antihypertensive drug therapy if SBP is sustained ⩾140 mmHg and/or DBP is sustained ⩾90 mmHg (B).

  • In nondiabetic people with hypertension, the optimal BP treatment goals are: SBP <140 mmHg and DBP <85 mmHg. The minimum acceptable level of control (Audit Standard) recommended is <150/<90 mmHg. Despite the best practice, these levels will be difficult to achieve in some hypertensive people (B).

  • In people with diabetes and high BP, optimal BP goals are: SBP <130 mmHg and DBP <80 mmHg. The minimum acceptable level of control (Audit Standard) recommended is <140/<80 mmHg. Despite the best practice, these levels will be difficult to achieve in some people with diabetes and hypertension (B).

  • Meta-analyses of BP-lowering trials have confirmed that, in general, the main determinant of benefit from BP-lowering drugs is the achieved BP, rather than choice of therapy. In some circumstances, there are compelling indications and contraindications for specific classes of antihypertensive drugs, and these are specified (A).

  • Most people with high BP will require at least two BP-lowering drugs to achieve the recommended BP goals. A treatment algorithm (AB/CD) is provided to advise on the sequencing of drugs and logical drug combinations (C). When there are no cost disadvantages, fixed drug combinations are recommended to reduce the number of medications, which may enhance adherence to treatment (C).

  • Other drugs that reduce CVD risk must also be considered, notably, low-dose aspirin and statin therapy (A).

  • Unless contraindicated, low-dose aspirin (75 mg/day) is recommended for all people needing secondary prevention of ischaemic CVD, and primary prevention in people with hypertension over the age of 50 years who have a 10-year CVD risk ⩾20% and in whom BP is controlled to the audit standard (A).

  • Statin therapy is recommended for all people with high BP complicated by CVD, irrespective of baseline total cholesterol or low-density lipoprotein (LDL)-cholesterol levels. Similarly, statin therapy is also recommended for primary prevention in people with high BP who have a 10-year CVD risk ⩾20%, estimated from the Joint British Societies CVD risk-assessment programme/chart. Optimal cholesterol lowering should reduce the total cholesterol by 25% or LDL-cholesterol by 30% or achieve a total cholesterol of <4.0 mmol/l or LDL-cholesterol of <2.0 mmol/l, whichever is the greatest reduction (A).

  • Glycaemic control should be optimised in people with diabetes, for example, HbA1c <7% (A).

  • Advice is provided on the clinical management of hypertension in specific patient groups, that is, the elderly, ethnic minorities, people with diabetes mellitus, chronic renal disease, and in women (pregnancy, oral contraceptive use and hormone-replacement therapy).

  • Suggestions for the improved implementation and audit of these guidelines in primary care are provided.

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Acknowledgements

The BHS guidelines working party acknowledge the outstanding administrative assistance in preparing this guideline, provided by Dr Emma Fluck, the Information Officer for the BHS. The BHS also gratefully acknowledges the work done by the representatives of the many stakeholder organisations who reviewed the guideline (Appendix A) and whose comments greatly improved the final version. We gratefully acknowledge the contribution of the University of Mancester, Department of Medical Illustration, Mancester Royal Infirmacy regarding the illustration of the Joint British Societies CVD risk prediction chart.

Author information

Authors and Affiliations

  1. Department of Cardiovascular Sciences, Clinical Sciences Building, Leicester Royal Infirmary, University of Leicester, Leicester, UK

    B Williams

  2. International Centre for Circulatory Health, Imperial College London & St Mary's Hospital, London, UK

    N R Poulter, P S Sever & S McG Thom

  3. Clinical Pharmacology Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK

    M J Brown

  4. Moorfield House Surgery, Garforth, Leeds, UK

    M Davis

  5. Division of Cardiovascular and Medical Sciences, Section of Clinical Pharmacology and Stroke Medicine, Gardiner Institute, Western Infirmary, University of Glasgow, Glasgow, UK

    G T McInnes

  6. Department of Cardiovascular Sciences, Ageing and Stroke Medicine Section, Glenfield Hospital, University of Leicester, Leicester, UK

    J F Potter

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  1. B Williams
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  2. N R Poulter
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  3. M J Brown
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  4. M Davis
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  5. G T McInnes
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  7. P S Sever
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  8. S McG Thom
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Corresponding author

Correspondence to B Williams.

Additional information

Guideline Working Party Chairman: Professor Bryan Williams, MD FRCP, University of Leicester. Guideline Working Party Members: Professor Neil R Poulter, MSc FRCP, Imperial College London. Professor Morris J Brown, MD FRCP FMedSci, University of Cambridge. Dr Mark Davis, MRCGP, General Practitioner, Leeds. Professor Gordon T McInnes, MD FRCP, University of Glasgow. Professor John F Potter, MD FRCP, University of Leicester. Professor Peter S Sever, PhD FRCP, Imperial College London. British Hypertension Society member: Dr Simon McG Thom, MD FRCP, Imperial College London.

Appendices

Appendix A

Stakeholders who reviewed the guidelines

  • Blood Pressure Association

  • Nurses Hypertension Association

  • Diabetes UK

  • British Cardiac Association

  • Renal Association

  • Heart UK

  • Primary Care Cardiovascular Society

  • London Hypertension Society

  • British Heart Foundation

  • Royal College of General Practitioners

  • Friends of the British Hypertension Society

  • Department of Health

Appendix B

Categories of strength used in statements (based on North of England evidence-based guidelines, BMJ 1998) (51)

Strength of evidence

  • 1a-Evidence from meta-analysis of randomised controlled trials.

  • 1b-Evidence from at least one randomised controlled study.

  • IIa-Evidence from at least one controlled study without randomisation.

  • IIb-Evidence from at least one other type of quasi-experimental study.

  • III-Evidence from descriptive studies, such as comparative studies, correlation studies, and case-controlled studies.

  • IV-Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both.

Strength of recommendation

  • A-Directly based on category I evidence.

  • B-Directly based on category II evidence or extrapolated recommendation from category I evidence.

  • C-Directly based on category III evidence or extrapolated recommendation from category I or II evidence.

  • D-Directly based on category IV evidence or extrapolated recommendation from category I, II or III evidence.

Appendix C

Available from the British Hypertension Society Information Service

  • Blood Pressure Unit

  • St George's Hospital Medical School

  • Cranmer Terrace

  • London SW17 0RE, UK

  • Tel: +44 020 8725 3412

  • Fax: +44 020 8725 2959

  • E-mail: bhsis@sghms.ac.uk

  • Website: http://www.bhsoc.org

  • CD-ROM BP measurement available to download from the website http://www.abdn.ac.uk/medical/bhs

  • Poster illustrating the ABCD drug treatment algorithm

  • Poster illustrating guidance for measuring BP using a mercury sphygmomanometer

  • Poster illustrating guidance for measuring BP using a digital BP monitor

  • Lists of validated BP monitors

  • Nurse distance learning pack available to download from the website http://www.bhsoc.org

  • BHS live clinical trials feedback via live web casts

  • Hypertension referral centres database

  • Courses and conferences within the Hypertension field

  • Healthcare Professionals factfile information

Appendix D

How to use the coronary risk-prediction charts for primary prevention

These charts are for estimating CVD risk (nonfatal MI and stroke, coronary and stroke death and new angina pectoris) for individuals who have not already developed CHD or other major atherosclerotic disease. They are an aid to making clinical decisions about how intensively to intervene on lifestyle and whether to use antihypertensive, lipid-lowering medication and aspirin.

  • The use of these charts is not appropriate for the following patient groups. Those with:

    • CHD or other major atherosclerotic disease;

    • familial hypercholesterolaemia or other inherited dyslipidaemias;

    • chronic renal dysfunction;

    • type I and II diabetes mellitus.

    • The charts should not be used to decide whether to introduce antihypertensive medication when BP is persistently at or above 160/100 or when TOD due to hypertension is present. In both cases, antihypertensive medication is recommended regardless of CVD risk. Similarly, the charts should not be used to decide whether to introduce lipid-lowering medication when the ratio of serum total to HDL cholesterol exceeds 7. Such medication is generally then indicated, regardless of the estimated CVD risk.

  • To estimate an individual's absolute 10-year of risk developing CVD, choose the table for his or her gender, smoking status (smoker/non-smoker) and age. Within this square, define the level of risk according to the point where the coordinates for SBP and the ratio of the total cholesterol to HDL-cholesterol to meet. If no HDL cholesterol result is available, then assume this is 1.00 mmol/l and the lipid scale can be used for total serum cholesterol alone.

  • Higher risk individuals (red areas) are defined as those whose 10-year CVD risk exceeds 20%, which is approximately equivalent to the CHD risk of >15% over the same period, indicated by the previous version of these charts. As a minimum, those at highest CVD risk (greater than 30% shown by the line within the red area) should be targeted and treated now. When resources allow, others with a CVD risk of >20% should be progressively targeted.

  • The chart also assists in the identification of individuals whose 10-year CVD risk moderately increased in the range 10–20% (orange area) and those in whom the risk is lower than 10% over 10 years (green area).

  • Smoking status should reflect the lifetime exposure to tobacco and not simply tobacco use at the time of assessment. For example, those who have given up smoking within 5 years should be regarded as current smokers for the purposes of the charts.

  • The initial BP and the first random (nonfasting) total cholesterol and HDL cholesterol can be used to estimate an individual's risk. However, the decision on using drug therapy should generally be based on repeat risk factor measurements over a period of time.

  • Men and women do not reach the level of risk predicted by the charts for the three age bands until they reach the ages 49, 59 and 69 years, respectively. Everyone aged 70 years and over should be considered at higher risk. The charts will overestimate the current risk most in the under 40s. Clinical judgement must be exercised in deciding on treatment in younger patients. However, it should be recognised that BP and cholesterol tend to rise most and HDL cholesterol to decline most in younger people already possessing adverse levels. Thus untreated, their risk at the age 49 years is likely to be higher than the projected risk shown on the age-less-than 50 years chart.

  • These charts (and all other currently available methods of CVD risk prediction) are based on groups of people with untreated levels of BP, total cholesterol and HDL cholesterol. In patients already receiving antihypertensive therapy in whom the decision is to be made about whether to introduce lipid-lowering medication or vice-versa, the charts can act as a guide, but unless recent pretreatment risk factor values are available it is generally safest to assume that CVD risk factor than that predicted by current levels of BP or lipids on treatment.

  • CVD risk is also higher than indicated in the charts for:

    • those with a family history of premature CVD or stroke (male first-degree relatives aged <55 years and female first-degree relatives aged <65 years), which increases the risk by a factor approximately 1.5;

    • those with raised triglyceride levels;

    • women with premature menopause;

    • those who are not yet diabetic, but have impaired fasting glucose (6.1–6.9 mmol/l).

  • In some ethnic minorities, the risk charts underestimate CVD risk, because they have not been validated in these populations. For example, in people originating from the Indian subcontinent, it is safest to assume that the CVD risk is higher than that predicted from the charts (1.5 times).

  • These charts may be used to illustrate the direction of impact of risk factor intervention on the estimated level of CVD risk. However, such estimates are crude and are not based on randomised trial evidence. Nevertheless, this approach may be helpful in motivating appropriate intervention. The charts are primarily to assist in directing intervention to those who typically stand to benefit the most.

Appendix E

Blood Pressure Association

  • Contact details:

  • Blood Pressure Association

  • 60 Cranmer Terrace

  • London SW17 0QS, UK

  • Tel: +44 020 8772 4994

  • Fax: +44 020 8772 4999

  • Website: http://bpassoc.org.uk

  • E-mail: Submit a query form through the website

  • AASK African American Study of Kidney Disease

  • AB/CD British Hypertension Society recommendations for the treatment algorithm of the combination of antihypertensive treatments

  • ABPM Ambulatory Blood Pressure Monitoring

  • ACCESS Acute Candasartan Cilexetil Therapy in Stroke Survivors

  • ACE Angiotensin-Converting Enzyme

  • ALLHAT Antihypertension and Lipid Lowering treatment to prevent Heart Attack Trial

  • ANBP2 Australian National Blood Pressure study

  • ARBs Angiotensin Receptor Blockers

  • ASCOT-LLA Anglo-Scandinavian Cardiac Outcomes Trial – Lipid Lowering Arm

  • ATPIII Adult Treatment Program III

  • BHS British Hypertension Society

  • BP Blood Pressure

  • CAPPP CAPtopril Prevention Project

  • CCBs Calcium Channel Blockers

  • CHD Coronary Heart Disease

  • CVD Cerebrovascular disease

  • DASH Dietary Approaches to Stop Hypertension

  • DBP Diastolic Blood Pressure

  • ECG Electrocardiogram

  • EUROPA EUropean trial on Reductions Of cardiac events with Perindopril in stable coronary Artery disease

  • GFR Glomerular Filtration Rate

  • GMS General Medical Services

  • GP General Practitioner

  • HDL High-Density Lipoprotein

  • HOPE Heart Outcomes Prevention Evaluation

  • HOT Hypertension Optimal Treatment

  • HPS Heart Protection Study

  • HYVET Hypertension in the Very Elderly Trial

  • INSIGHT International nifendipine once-daily study

  • ISH Isolated Systolic Hypertension

  • JNC 7 Seventh Joint National Committee

  • HRT Hormone-replacement therapy

  • LIFE Losartan Intervention for Endpoint reduction in hypertension

  • LDL Low-Density Lipoprotein

  • LVH Left Ventricular Hypertrophy

  • MI Myocardial Infarction

  • NORDIL NOrdic DILiazem study

  • NSAIDs Non-Steroidal Anti-inflammatory Drugs

  • NSFs National Service Frameworks

  • OCs Oral contraceptives

  • PCT Primary Care Trust

  • POP Progestogen-only pill

  • PROGRESS Perindopril PROtection AGainst REcurrent Stroke Study

  • PROSPER PROspective study of Pravostatin in the Elderly at Risk

  • RENAAL Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan

  • SBP Systolic Blood Pressure

  • SCOPE Study on COgnition and Prognosis in the Elderly

  • STOP2 Swedish Trial I Old Patients with hypertension 2

  • TIA Transient Ischaemic Attack

  • TOD Target Organ Damage

  • UKPDS United Kingdom Prospective Diabetes Study

  • VALUE Valsartan Antihypertensive Long-term Use Evaluation

  • WEST Women's Estrogen for Stroke Trial

  • WHO World Health Organisation

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Williams, B., Poulter, N., Brown, M. et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004—BHS IV. J Hum Hypertens 18, 139–185 (2004). https://doi.org/10.1038/sj.jhh.1001683

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