Clinical Question: How should hypertension be managed?

Setting: Various (guideline)

Study Design: Practice guideline

Synopsis: The British Hypertension Society has issued its fourth update on the treatment of hypertension (BHS-IV). The guidelines give a strength-of-recommendation (SOR) level on the basis of the quality of evidence, ranging from A (directly based on a meta-analysis of controlled trials) to D (expert recommendation or extrapolation from other data).

The guidelines suggest lifestyle modification for patients with high normal blood pressure, defined as 130/85 to 139/85 mm Hg (SOR = A). Treatment of blood pressure in the range of 140/90 to 159/99 mm Hg requires consideration of the presence of cardiovascular disease, other target organ damage, diabetes mellitus, or an estimated risk of cardiovascular disease of at least 20 percent over 10 years (SOR = A). Drug therapy should begin when the patient’s blood pressure is greater than 160/100 mm Hg (SOR = A). The goal of treatment should be a blood pressure of less than 140/85 mm Hg for patients without diabetes, and less than 130/80 mm Hg in patients with diabetes (SOR = B).

Initial treatment should be based on the “ABCD” rule, a mnemonic for remembering that patients younger than 55 years and nonblack patients will respond better to treatment with an Angiotensin-converting enzyme (ACE) inhibitor or a Beta blocker, while older patients and blacks of any age will respond better to a Calcium channel blocker or a Diuretic (SOR = C). If a second drug is needed, it should be from the other category (i.e., a patient taking an ACE inhibitor or beta blocker should add a calcium channel blocker or diuretic, and vice versa). Many patients will need at least two drugs to obtain the necessary blood pressure control.

Bottom Line: The BHS-IV guidelines and the American Joint National Committee guidelines (JNC-7) are similar with regard to treatment goals. However, the BHS-IV guidelines do not require treatment until the systolic and diastolic numbers are greater than 160/100 mm Hg, respectively, in patients without cardiovascular disease, diabetes, or other organ damage, whereas the JNC-7 guidelines start drug treatment in all patients when both numbers are greater than 140/90 mm Hg. The BHS-IV suggests initial treatment with any one of four drugs (see the ABCD rule in the synopsis), whereas the treatment recommended by the JNC-7 is diuretics, primarily because of the lower cost. (Level of Evidence: 5)