What are the guidelines for managing hypertension in the UK?

UK Hypertension Management Guidelines

The British Hypertension Society recommends initiating antihypertensive drug therapy if sustained systolic blood pressure is ≥160 mm Hg or sustained diastolic blood pressure is ≥100 mm Hg, while patients with BP 140-159/90-99 mm Hg should receive treatment if they have cardiovascular disease, target organ damage, diabetes, or a 10-year cardiovascular disease risk ≥20%. 1

Diagnosis and Assessment

• Blood pressure should be measured following European recommendations:

  • Use validated devices with proper cuff size
  • Measure seated BP with arm at heart level
  • Take at least two readings at each visit
  • Confirm hypertension with multiple visits 1

• Classification of blood pressure levels:

  Category	Systolic BP (mm Hg)	Diastolic BP (mm Hg)
  Optimal	<120	<80
  Normal	<130	<85
  High normal	130-139	85-89
  Grade 1 (mild)	140-159	90-99
  Grade 2 (moderate)	160-179	100-109
  Grade 3 (severe)	≥180	≥110

• Consider ambulatory BP monitoring when:

  • Clinic BP shows unusual variability
  • Hypertension is resistant to treatment
  • Symptoms suggest hypotension
  • To diagnose "white coat hypertension" 1

Treatment Thresholds and Targets

When to Initiate Treatment

1. Start drug treatment immediately if:

   • Sustained systolic BP ≥160 mm Hg or diastolic BP ≥100 mm Hg 1

2. For BP 140-159/90-99 mm Hg, initiate treatment if:

   • Cardiovascular disease present
   • Target organ damage present
   • Diabetes mellitus present
   • 10-year cardiovascular disease risk ≥20% 1

Blood Pressure Targets

• For non-diabetic patients:

  • Optimal target: <140/85 mm Hg
  • Minimum acceptable control (audit standard): <150/90 mm Hg 1

• For patients with diabetes, chronic renal disease, or established cardiovascular disease:

  • Optimal target: <130/80 mm Hg
  • Audit standard: <140/80 mm Hg 1

Treatment Approach

Non-Pharmacological Interventions

All patients with hypertension or borderline hypertension should receive lifestyle advice:

• Weight reduction to achieve ideal body weight
• Regular physical exercise (predominantly dynamic like brisk walking)
• Limited alcohol consumption (<21 units/week for men, <14 units/week for women)
• Reduced salt intake (eliminate table salt and salty foods)
• Increased consumption of fruits and vegetables
• Smoking cessation
• Reduced intake of saturated fats 1

Pharmacological Treatment

Most patients will require at least two blood pressure lowering drugs to achieve recommended goals 1. The treatment algorithm should follow these steps:

1. First-line therapy options:

   • Low-dose thiazide diuretics or β-blockers are preferred as first-line treatment when no compelling indications for other agents exist 1

2. Consider specific drug classes based on compelling indications:

   • Heart failure: ACE inhibitors
   • Post-myocardial infarction: ACE inhibitors
   • Type 1 diabetic nephropathy: ACE inhibitors
   • Type 2 diabetic nephropathy: ARBs
   • ACE inhibitor intolerance: ARBs
   • Benign prostatic hypertrophy: α-blockers 1

3. Fixed drug combinations are recommended when no cost disadvantages exist 1

Additional Cardiovascular Risk Reduction

Primary Prevention

1. Aspirin (75 mg daily) for:

   • Patients aged ≥50 years
   • BP controlled to <150/90 mm Hg
   • With target organ damage, diabetes, or 10-year CVD risk ≥20% 1

2. Statins for:

   • Patients up to at least 80 years
   • 10-year CVD risk ≥20%
   • Total cholesterol ≥3.5 mmol/l 1

Secondary Prevention

1. Aspirin for all patients unless contraindicated 1

2. Statins for:

   • Patients up to at least 80 years
   • Total cholesterol ≥3.5 mmol/l 1

Follow-up and Monitoring

• Six-monthly review is usually sufficient when treatment and BP are stable
• Follow-up visits should include:
  • BP and weight measurement
  • Inquiry about general health and side effects
  • Reinforcement of lifestyle advice and medication adherence
  • Annual testing for proteinuria 1

Common Pitfalls to Avoid

• Failing to confirm hypertension with multiple readings before initiating treatment
• Not considering ambulatory or home BP monitoring when appropriate
• Overlooking orthostatic hypotension in elderly or diabetic patients
• Neglecting lifestyle modifications when initiating drug therapy
• Underestimating the need for multiple drugs to achieve target BP
• Not addressing overall cardiovascular risk alongside BP management
• Prescribing vitamins for cardiovascular risk reduction (no benefit shown) 1

The implementation of these guidelines requires multidisciplinary teams working systematically to advise, educate, and support patients, with extended roles for nurse practitioners, pharmacists, and other healthcare professionals 1.