What are the UK guidelines for managing hypertension?

UK Guidelines for Managing Hypertension

According to the British Hypertension Society guidelines, drug treatment should be started in all patients with sustained systolic blood pressure ≥160 mm Hg or sustained diastolic blood pressure ≥100 mm Hg despite non-pharmacological measures, while patients with sustained blood pressures of 140-159/90-99 mm Hg should receive treatment if they have target organ damage, established cardiovascular disease, diabetes, or a 10-year cardiovascular disease risk ≥20%. 1

Diagnosis and Measurement

• Use a validated device with proper maintenance and calibration
• Patient should be seated with arm at heart level
• Adjust bladder size for arm circumference
• Deflate cuff at 2 mm/s and measure BP to nearest 2 mm Hg
• Record diastolic pressure at disappearance of sounds (phase V)
• Take at least two measurements at each visit over several visits 1

Thresholds for Intervention

Immediate Drug Treatment Required:

• Accelerated hypertension (severe hypertension with grade III-IV retinopathy)
• Particularly severe hypertension (>220/120 mm Hg)
• Impending complications (e.g., TIA, left ventricular failure) 1

Standard Treatment Thresholds:

• Sustained SBP ≥160 mm Hg or DBP ≥100 mm Hg despite lifestyle measures
• Sustained SBP 140-159 mm Hg or DBP 90-99 mm Hg with:
  • Target organ damage
  • Established cardiovascular disease
  • Diabetes
  • 10-year cardiovascular disease risk ≥20% 1

Blood Pressure Targets

• Standard target: ≤140 mm Hg systolic and ≤85 mm Hg diastolic
• High-risk patients (diabetes, renal impairment, established cardiovascular disease): ≤130/80 mm Hg
• Minimum acceptable control (audit standard): <150/90 mm Hg
• For ambulatory or home readings, targets should be approximately 10/5 mm Hg lower than office equivalents 1

Lifestyle Modifications

All patients with high blood pressure, borderline or high-normal blood pressure should receive advice on lifestyle modifications:

• 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 and elimination of excessively salty foods
• Increased consumption of fruits and vegetables
• Smoking cessation
• Reduced intake of saturated fats, replaced with monounsaturated fats
• Increased consumption of fish 1

These lifestyle measures can reduce the need for drug treatment or decrease the number/dose of medications required 2.

Pharmacological Therapy

First-line Treatment:

When no special considerations apply, initial drug selection should follow the AB/CD algorithm:

• A: ACE inhibitor or Angiotensin receptor blocker
• B: Beta-blocker
• C: Calcium channel blocker
• D: Diuretic (thiazide or thiazide-like) 1

For patients of African-Caribbean descent or with features of metabolic syndrome, calcium channel blockers or diuretics are preferred first-line agents 1.

Drug Dosage:

• Use medications effective for 24 hours as a single daily dose
• Allow at least 4 weeks to observe full response (unless urgent BP lowering needed)
• Titrate dose according to manufacturers' instructions 1

Special Considerations

Referral to Specialist:

• Accelerated hypertension or impending complications
• Suspected underlying cause (e.g., Conn's syndrome, elevated creatinine)
• Resistant hypertension (≥3 drugs)
• Young patients (<30 years needing treatment)
• Unusual BP variability or white coat hypertension
• Hypertension in pregnancy 1

Additional Cardiovascular Risk Management:

• Aspirin: 75 mg daily for secondary prevention and for primary prevention in patients ≥50 years with BP controlled to <150/90 mm Hg and either target organ damage, diabetes, or 10-year CVD risk ≥20% 1
• Statins: For patients with established cardiovascular disease or 10-year CVD risk ≥20% and total cholesterol ≥3.5 mmol/l 1

Common Pitfalls to Avoid

• Inadequate BP measurement technique
• Overlooking white coat hypertension
• Insufficient lifestyle counseling
• Ignoring overall cardiovascular risk
• Setting suboptimal BP targets 3

Most hypertensive patients will require at least two blood pressure lowering drugs to achieve recommended goals. When no cost disadvantages exist, fixed drug combinations are recommended 1.