testimet insuf. e zemres.doc

8/10/2019 testimet insuf. e zemres.doc

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doi:10.1136/bmj.328.7440.6342004;328;634-640 BMJMcInnes, John F Poe!, Pee! " "e#e! $nd "imon Mc% &hom'!($n )i**i$ms, +ei* Po*e!, Mo!!is J '!on, M$! $#is, %o!don &

summaryhypertension management 2004 (BHS-IV):British Hypertension Society guidelines forhttp:!m"#comcgicontentfull$2%&440'$4d$ed ino!m$ion $nd se!#ices c$n be ond $:These include:

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Education and debateBritish Hypertension Society guidelines forhypertensionmanagement 2004 (BHS-IV): summaryBryan Williams, Neil R Poulter, Morris J Brown, Mark Davis, Gordon T Mcnnes, Jo!n " Potter,Peter # #ever, #imon McG T!om$ t!e B%# &uidelines workin& 'arty, (or t!eBritis! %y'ertension #ociety

Introduction


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Muc! new evidence !as emer&ed on t!e im'ortance o(blood 'ressure as a risk (actor (or cardiovasculardisease$ t!e im'ortance o( li(estyle measures (or t!e'revention and treatment o( !y'ertension$ t!e e)cacyand sa(ety o( di*erent dru& classes$ mana&ement o(!y'ertension in &rou's at !i&!er risk, includin& 'eo'lewit! diabetes$ t!e im'ortance o( assessin& t!e total risko( cardiovascular disease$ and additional bene+ts associatedwit! t!e use o( statins-oncern remains t!at national surveys continue tos!ow substantial underdia&nosis, undertreatment, and'oor rates o( blood 'ressure control in t!e .nited/in&dom0 1 key reason (or t!is is t!e 'redominant useo( monot!era'y by most doctors0To im'rove t!is subo'timaltreatment, t!e Britis! %y'ertension #ocietyrecommends a treatment al&orit!m based on t!e1B2-D rule3Treatment o( blood 'ressure alone will leave many!y'ertensive 'atients at unacce'tably !i&! risk o(cardiovascular com'lications and deat! T!is &uidelinerein(orces t!e view t!at doctors s!ould not (ocus solelyon blood 'ressure but must also (ormally assess totalrisk o( cardiovascular disease and use multi(actorial

interventions, includin& statins and as'irin, to reduce itMost mana&ement o( blood 'ressure and risk o(cardiovascular disease will take 'lace in 'rimary care,and t!ese &uidelines are intended (or &eneral'ractitioners, 'ractice nurses, and &eneralists in !os'ital'ractice Detailed advice on im'lementation andt!e im'lications o( t!e national service (rameworksand t!e &eneral medical services contract arecontained in t!e (ull document 4wwwb!socor&56T!ese &uidelines !ave been 're'ared by t!e &uidelinesworkin& 'arty o( t!e Britis! %y'ertension #ocietyon be!al( o( t!e society T!e workin& 'arty reviewednew data t!at !ave become available since t!e 'revious&uidelines were 'ublis!ed7 and amended t!e recommendationsaccordin&ly Dra(ts o( t!e (ull documentwere im'roved by consultation wit! national stake!olderor&anisations 4a''endi8 05 T!e evidencesu''ortin& t!e recommendations contained inB%#9: is &raded by usin& t!e criteria o( t!e Nort! o(En&land &rou' 4see bo8 on bm;com5.ME 63A 06 M1R-% 3@@7 bm;com

on 21 +o#embe! 200 bmj.com on*o$ded !omrecommended as t!ey may com'lement t!e blood'ressure lowerin& e*ects o( dru&s and t!us reduce t!e

dose or number o( dru&s reuired to control blood'ressure Bo8 s!ows li(estyle measures t!at lowerblood 'ressure and 're9em't t!e rise o( blood'ressure wit! a&ei(estyle measures t!at reduce risk o( cardiovasculardisease include smokin& cessation, reducin&intake o( total and saturated (ats, re'lacement o( saturatedwit! monounsaturated (ats 4suc! as olive oil,ra'eseed oil5, and increasin& consum'tion o( +s!E*ective im'lementation o( t!ese li(estyle measuresreuires knowled&e, ent!usiasm, 'atience, considerable


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time s'ent wit! 'atients and ot!er (amilymembers, and rein(orcement t is best undertaken bywell trained !ealt! 'ro(essionals suc! as 'ractice orclinic nurses and s!ould be su''orted by clear writtenin(ormation 4wwwb'assocor&uk5&hoice of antihypertensi#e drug therapy"or eac! ma;or class o( anti!y'ertensive dru&com'ellin& indications e8ist (or use in s'eci+c &rou'so( 'atients and also com'ellin& contraindicationsT!ere are also indications, contraindications, andcautions t!at are less clear cut and t!at are &ivendi*erent wei&!t by di*erent doctors 4table 35 W!ennone o( t!e s'ecial considerations a''ly, initial dru&selection s!ould (ollow ste' 0 o( t!e 1B2-Dal&orit!m 4+& 353eta-analyses of !lood pressure loering trials#ince 0 7 many lar&e scale morbidity and mortalitytrials !ave com'ared di*erent classes o( anti!y'ertensivedru&s T!e Blood Pressure owerin& TrialistsH -ollaboration!as conducted two ma;or meta9analyses o(blood 'ressure lowerin& dru&s0C 0T!e +rst com'aredt!e e*ectiveness o( Knewer t!era'ies,L suc! astreatments based on an&iotensin convertin& enFyme

in!ibitors or calcium c!annel blockers, wit! conventionalt!era'ies 4based on diuretics or blockers5 and$hresholds for inter#entionnitial blood 'ressure 4mm %&5Reassessyearly>bserve, reassess risk o(cardiovascular disease yearlyReassessin < yearsTar&et or&an dama&e orcardiovascular com'lications ordiabetes or 0@ year risk o(cardiovascular diseaseS . 3@No tar&et or&an dama&e andno cardiovascular com'licationsand no diabetes and 0@ year risko( cardiovascular diseaseS ? 3@0A@200@Treat0C@90

0@@90@ @9 A


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"or most 'atients a tar&et o( . 07@ mm %& systolic

blood 'ressure and . A< mm %& diastolic blood'ressure is recommended 4B5 "or 'atients wit!diabetes, renal im'airment or establis!ed cardiovascular

disease a lower tar&et o( . 06@2A@ mm %& isrecommended

W!en usin& ambulatory blood 'ressure readin&s,mean daytime 'ressures are 're(erred and t!is value

would be e8'ected to be a''ro8imately 0@2< mm %&lower t!an t!e o)ce blood 'ressure euivalent (orbot! t!res!olds and tar&ets #imilar ad;ustments arerecommended (or avera&es o( !ome blood 'ressurereadin&s

Bo. 9: ifestyle measures Maintain normal wei&!t (or adults 4body mass inde8

3@93< k&2m35 Reduce salt intake to ? 0@@ mmol2day 4 ? C& Na-l

or ?37 & Na+2day5 imit alco!ol consum'tion to . 6 units2day (or men

and . 3 units2day (or women

En&a&e in re&ular aerobic '!ysical e8ercise 4brisk

walkin& rat!er t!an wei&!tli(tin&5 (or . 6@ minutes 'erday, ideally on most o( days o( t!e week but at least ont!ree days o( t!e week

-onsume at least +ve 'ortions2day o( (res! (ruit and

ve&etables Reduce t!e intake o( total and saturated (at

Qoun&er 4?lder 4.


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blockers may !ave 'ossibly lar&er bene+ts wit! re&ardto stroke 'revention "ourt!ly, s'eci+c dru& classesmay !ave com'ellin& indications 4table 35$he *B&' algorithmMost 'eo'le reuire more t!an one dru& to controlblood 'ressure -linical trials !ave clearly s!own t!attreatment al&orit!ms deliver better blood 'ressurecontrol t!an current clinical 'ractice0 0T!e Britis!%y'ertension #ociety recommends t!e use o( atreatment al&orit!m based on t!e 1B2-D rule toin(orm t!e better use o( lo&ical combinations o( dru&s 3Eac! letter re(ers to a blood 'ressure lowerin& dru&class 4+& 35T!e t!eory under'innin& t!e 1B2-D al&orit!m ist!at !y'ertension can be broadly classi+ed as K!i&!reninL or Klow reninL and is t!ere(ore best treated initiallywit! one o( two cate&ories o( anti!y'ertensivedru&=t!ose t!at in!ibit t!e renin9an&iotensin system4an&iotensin convertin& enFyme in!ibitors or an&iotensinrece'tor blockers 415 or blockers 4B55, andt!ose t!at do not 4calcium c!annel blockers 4-5 ordiuretics 4D55 Peo'le w!o are youn&er t!an


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Pre&nancyRenovascular diseaseS1n&iotensin rece'torblockers1n&iotensin convertin& enFyme in!ibitorintoleranceTy'e 3 diabetic ne'!ro'at!y%y'ertension wit! le(t ventricular !y'ertro'!y%eart (ailure in an&iotensin convertin& enFymeintolerant 'atients, a(ter myocardial in(arctione(t ventricular dys(unction a(ter

myocardial in(arctionntolerance o( ot!er anti!y'ertensivedru&sProteinuric renal disease, c!ronic renaldiseaseU%eart (ailureRenal im'airmentUPeri'!eral vascular diseaseXPre&nancyRenovascular diseaseS blockers Myocardial in(arction, an&ina %eart (ailure %eart (ailurePeri'!eral vascular disease,Diabetes 4e8ce't wit! coronary !eartdisease51st!ma or c!ronic obstructive'ulmonary disease,%eart block-alcium c!annel blockers4di!ydro'yridine5Elderly 'atient, isolated systolic !y'ertension 1n&ina = =-alcium c!annel blockers4rate limitin&5

1n&ina Elderly 'atient -ombination wit! blockade %eart block, !eart (ailureT!iaFides or t!iaFide9likediureticsElderly 'atient, isolated systolic !y'ertension,!eart (ailure, secondary stroke 'revention= = GoutUUn !eart (ailure w!en used as monot!era'yU 1n&iotensin convertin& enFyme in!ibitors or an&iotensin rece'tor blockers may be bene+cial in c!ronic renal (ailure but s!ould only beused wit! caution, close su'ervision, and s'ecialistadvice w!en t!ere is establis!ed and si&ni+cant renal im'airmentX-aution wit! an&iotensin convertin& enFyme in!ibitors and an&iotensin rece'tor blockers in 'eri'!eral vascular disease because o(association wit! renovascular diseaseS1n&iotensin convertin& enFyme in!ibitors and an&iotensin rece'tor blockers are sometimes used in 'atients wit! renovascular diseaseunder s'ecialist su'ervisionn combination wit! a t!iaFide or t!iaFide9like diuretic blockers are used increasin&ly to treat stable !eart (ailure but may worsen !eart (ailureUUT!iaFides or t!iaFide9like diuretics may sometimes be necessary to control blood 'ressure in 'eo'le wit! a !istory o( &out, ideally used incombination wit! allo'urinol

Education and debateC6A B :>.ME 63A 06 M1R-% 3@@7 bm;com

on 21 +o#embe! 200 bmj.com on*o$ded !omT!e 1B2-D al&orit!m includes B in brackets T!isis to em'!asise t!e (act t!at recent outcome trials !avere'orted an increased incidence o( diabetes in 'atientstreated wit! B or D dru&s com'ared wit! 1 or - dru&s,es'ecially w!en B and D are combined3@ We advisecaution w!en usin& B+D in 'atients at es'ecially !i&!risk o( develo'in& diabetes=(or e8am'le, 'atients wit!a stron& (amily !istory o( ty'e 3 diabetes, obesity,im'aired &lucose tolerance, (eatures o( t!e metabolicsyndrome, or o( #out! 1sian and 1(rican9-aribbeandescent'rug dosageT!e dru& or (ormulation used s!ould ideally be e*ective(or 37 !ours w!en taken as a sin&le daily dose 1ninterval o( at least (our weeks s!ould be allowed toobserve t!e (ull res'onse, unless it is necessary to lowerblood 'ressure more ur&ently T!e dru& dose 4e8ce't(or t!iaFides or t!iaFide9like diuretics, t!e ideal dose o(w!ic! is uncertain5 s!ould be titrated u' accordin& tomanu(acturersH instructions1ecommendations for use of aspirin and statinsAspirin=No new evidence to &uide 'ractice re&ardin&t!e use o( as'irin (or 'atients wit! !y'ertension!as been 'roduced since t!e 0 &uidelines o( t!eBritis! %y'ertension #ociety7 %ence recommendationsremain unc!an&ed 4bo8 A5


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Statins=Recommendations relatin& to t!e use o(statins (or 'atients wit! !y'ertension !ave beenu'dated in li&!t o( recent trial data30 33 and are in kee'in&wit! recent Euro'ean &uidanceC Bo8 A s!ows indications(or usin& statins in t!e conte8t o( 'rimary andsecondary 'revention Patients wit! ty'e 3 diabetes areconsidered as (or secondary 'revention in t!is conte8tTar&et li'id concentrations are t!e same (or 'rimaryand secondary 'revention and !ave been made morestrin&ent in li&!t o( t!e most recent trial evidence Newideal tar&ets are to lower total c!olesterol by 3


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blood 'ressure ? 06@ mm %& and diastolic blood'ressure ? A@ mm %& 1udit standard?07@2 ? A@mm%&Most 'eo'le wit! !i&! blood 'ressure will reuireat least two blood 'ressure lowerin& dru&s toac!ieve t!e recommended &oals W!en nodisadvanta&es o( cost e8ist, +8ed dru&combinations are recommendedow dose as'irin 4< m&2day5 is recommended(or secondary 'revention o( isc!aemiccardiovascular disease and (or 'rimary'revention, in 'eo'le over t!e a&e o(


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w!ose comments &reatly im'roved t!e +nal version We alsoacknowled&e t!e outstandin& administrative assistance 'rovidedby Emma "luck at t!e Britis! %y'ertension #ocietyHsin(ormation service-om'etin& interestsI 1ll aut!ors !ave received !onorariums(rom a number o( '!armaceutical com'anies (or lectures andconsultancy, and researc! &rant su''ort (or clinical tr ials (romt!e '!armaceutical industry

*ppendi. %: Sta+eholders ho re#ieed the

guidelinesBlood Pressure 1ssociationNursesH %y'ertension 1ssociationDiabetes ./Britis! -ardiac 1ssociationRenal 1ssociation%eart ./Primary -are -ardiovascular #ocietyondon %y'ertension #ocietyBritis! %eart "oundationRoyal -olle&e o( General Practitioners"riends o( t!e Britis! %y'ertension #ocietyDe'artment o( %ealt!

*ppendi. 2: &ontact detailsBritis! %y'ertension #ociety n(ormation #erviceBlood Pressure .nit, #t Geor&eHs %os'ital Medical #c!ool,-ranmer Terrace, ondon #W0 @RE 4tel @3@ A3< 6703$

(a8 @3@ A3< 3


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restriction on incidence o( !y'ertension "ypertension 3@@@$6


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&orrections and clariHBrien et al5 int!e re(erence list s!ould t!en !ave beenrenumbered and become re(erences 7 to A T!etwo re(erences cited in t!e (ootnote to table 0s!ould be renumbered as C 4Euro'ean #ociety o(%y'ertension9Euro'ean #ociety o( -ardiolo&y5and 4W%>9nternational #ociety o(%y'ertension5$ but t!e ot!er re(erences cited in t!ete8t o( t!e article are correct T!e 'd( 4but not t!e%TM5 version on bm;com !as been amended2ecent developments in secondary prevention andcardiac rehabilitation after acute myocardial infarction1s a result o( tec!nolo&y 'roblems, someamendments (rom t!e aut!ors did not make it intot!is clinical review by %asnain Dalal and collea&ues43@ Marc!, '' C695 n bo8 3, we s!ould !aveadded t!e website address (or #E1R-% 4t!e studyo( additional reductions in c!olesterol and

!omocysteine5I wwwctsuo8acuk2'ro;ects2searc!s!tml 1nd t!e 'enultimate sentence o( t!esubsection K1n&iotensin convertin& enFymein!ibitorsL s!ould !ave said t!at rates o(revascularisation 4not rates o( readmission (or !eart(ailure5 were reduced in 'atients w!o took rami'ril3bituary #eonard (4Johnnie5, 6alker>ur weekly uest to sueeFe in as many obituariesas 'ossible led to t!e last minute deletion o( anim'ortant sentence (rom t!is obituary 4BMJ3@@6$63I0305We omitted to say K-!ristianitywas an abidin& 'assion and !is (ait! directed !isli(eLWe !ave a'olo&ised to Dr WalkerHs wi(e>dds ratios wit!


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James # Dawson senior house o7cer8 9ueen:s Medical Centre8$ottingham

Pa'ers3C B :>.ME 63A 0 1PR 3@@7 bm;com

on 21 +o#embe! 200 bmj.com on*o$ded !om


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1. In he m$n$emen o ch!onic he$! $i*!e

&!e F$*se =onidence

he *oo di!eic !osemide m$( *e$d o h(e!$*$emi$

be$ b*oce!s sch $s biso!o*o*9 $!e con!$indic$ed

$nioensin-con#e!in en>(me


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indicated &e.g. hypotension' renal atery stenosis(

6alse n$nse!edhe c$!di$c *(coside dio5in is s$**( sed $si!s *ine he!$(

It is reserved for C# with )# or used in C#when other therapies are insufficient

rue n$nse!ed $nd conc!!en $!i$* ib!i**$ion he $nico$*$n$!$!in sho*d be conside!ed

To reduce the risk of a TI).

rue n$nse!edhe dose o dio5in !e@i!ed is *$!e*( dee!minedb( !en$* ncion

The dose is reduced in renal impairment toprevent to*icity.

6alse n$nse!ed

$nioensin (me


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2. )hich o he o**oin sho*d be sho*d be monio!ed boh !io! o $nd d!in!e$men ih hese d!sG

es +o


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!esc!iion is ch$ned

)hich o he o**oin $!e $!o!i$e ch$nes o his !esc!iionG

es +o


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dis!b$nces m$!s, ne$i#e m$!in9

8. )hich o he o**oin s$emens $!e !e conce!nin he in!odcion o $!$!inG

&!e F$*se


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3o n$nse!ed se o di!eic d!s

They are used to relieve the oedema

7es n$nse!ed 'e$-b*oce!s

)lthough used in sta!le C#' they maythemselves uncover compensated heart failure'hence they are used with caution

7es n$nse!ed (e!ension

) maor cause

0 out of 1

2. )hich o he o**oin sho*d be sho*d be monio!ed boh !io! o $ndd!in !e$men ih hese d!sG

=o!!ec


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6alse n$nse!edEisino!i* sho*d be !esc!ibed ih $ o$ssims*emen

This would might lead to a serious interaction&hyperkalaemia(

6alse n$nse!edEisino!i* h$s been !esc!ibed !em$!e*( $nd

sho*d be !ese!#ed o! mo!e se!ios c$ses)CIs are used first line when there is a reducedeection fraction

. 0 out of 1

6. In e!ms o conse**in hich o he o**oin oins $!e $!o!i$e:

=o!!ec


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2pwards titration is appropriate

7es n$nse!ed


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is rapidly fatal

6alse n$nse!ed&he $ien is h$#in $n $d#e!se !e$cion o hecombin$ion o !osemide $nd *isino!i*

+o' this is a standard com!ination and thesedrugs do not interact in this way

0 out of 1

10. )hich o he o**oin s$emens $!e !e conce!nin he in!odcion odio5inG

=o!!ec


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rue n$nse!ed)$!$!in is !esc!ibed o !edce he !is o!$nsien isch$emic $$cs

6alse n$nse!edI he $ien se!s $ ches inecion hene!(h!om(cin is he mos $!o!i$e $nib$ce!i$*$en o se no

rythromycin inhi!its the meta!olism of warfarinand so is less suita!le

13. 0 out of 1

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