Unifying Concepts

Summary of Recommendations for Management of Hypertension in BHS-IV

  • Provide advice on life-style modifications for all people with high blood pressure (BP) and those with borderline or high-normal BP.
  • Initiate antihypertensive drug therapy in people with sustained systolic BP (SBP) >/= 160 mmHg or sustained diastolic BP (DBP) >/= 100 mmHg.
  • 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 (CVD), other target organ damage (TOD), or an estimated CVD risk of >/= 20% over 10 years, according to the Joint British Societies CVD risk assessment programme or risk chart.
  • In people with diabetes mellitus, initiate antihypertensive drug therapy if SBP is sustained >/= 140 mmHg and/or DBP is sustained >/= 90 mmHg.
  • In non-diabetic people with hypertension, optimal BP treatment goals are: SBP < 140 mmHg and DBP < 85 mmHg. The recommended minimum acceptable level of control (audit standard) is < 150/< 90 mmHg.
  • In hypertensive people with diabetes, chronic renal disease or established CVD, optimal BP goals are lower: SBP < 130 mmHg and DBP < 80 mmHg. The audit standard is < 140/ < 80 mmHg.
  • Meta-analyses of BP-lowering trials suggest 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.
  • 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. 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. Vitamin supplements are not recommended.
  • Unless contraindicated, low-dose aspirin (75 mg/day) is recommended for the secondary prevention of ischaemic CVD, and primary prevention in people over the age of 50 years who have a 10-year CVD risk >/= 20% and in whom BP is controlled to the audit standard.
  • 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%. Optimal cholesterol lowering should reduce 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). A more conservative audit standard is suggested of < 5.0 mmol/L (190 mg/dl) and < 3.0 mmol/L (for total- and mg/dl) LDL-cholesterol respectively.



  1. Duerden MG; British Hypertension Society. Guidelines from the British Hypertension Society: BHS is set to bankrupt NHS. BMJ. 2004 Sep 4;329(7465):569-70 [Medline]
  2. Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, Sever PS, Thom SM; BHS guidelines working party, for the British Hypertension Society. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ. 2004 Mar 13;328(7440):634-40. [Medline]


Created: Apr 11, 2005

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