Ceclor

* CLINICAL QUESTION

How should hypertension be managed?

* BOTTOM LINE

The British Hypertension Society guidelines (BHS-IV) and the American Joint National Committee guidelines (JNC-7) are very similar in treatment goals. However, the BHS-IV guidelines do not require treatment until both the systolic and diastolic numbers are greater than 160/100 mm Hg, respectively, for patients without cardiovascular disease, diabetes, or other organ damage, whereas the JNC-7 guidelines start drug treatment in all patients with both numbers greater than 140/90 mm Hg. The BHS-IV suggests initial treatment with any 1 of 4 drugs (see the ABCD rule in the synopsis), whereas the bedrock of treatment recommended by the JNC-7 is diuretics, primarily because of the lower cost. (LOE=5)

* STUDY DESIGN

Practice guideline

* SETTING

Various (guideline)

* SYNOPSIS

The British Hypertension Society has issued their fourth update on the treatment of hypertension (BHS-IV). The guidelines give a strength of recommendation 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 recommend suggesting lifestyle modification for patients with high normal blood pressure, defined as a 130-139/ 85-89 mm Hg (strength of recommendation [SOR]=A). Treatment of blood pressure in the range of 140-159/90-99 mm Hg requires consideration of the presence of cardiovascular disease, other target organ damage, diabetes mellitus, or an estimated cardiovascular disease risk of at least 20% over 10 years (SOR=A). Drug therapy should begin when the blood pressure is >160/100 mm Hg (SOR=A). The goal of treatment should be a blood pressure of >140/85 mm Hg for nondiabetic patients, and >130/80 mm Hg in diabetic patients (SOR=B).

Initial treatment should be based on the ABCD rule, a mnemonic for remembering that younger (aged <55 years) and nonblack patients will respond better to an Angiotensin-converting enzyme inhibitor or a Beta-blocker, and 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 (that is, a patient on an A or B drug should have a C or D drug added, and vice-versa). Many patients will need at least 2 drugs to obtain the necessary blood pressure control.

DRUG BRAND NAMES

Azithromycin * Zithromax

Cefaclor * Ceclor

Clarithromycin * Biaxin

Loracarbef * Lorabid

Metronidazole * Flagyl

0meprazole * Prilosec

Simvastatin * Zocor

Williams B, Poulter NR, Brown MJ, et al. British hypertension society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ 2004; 328:634-640.

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