British Hypertension Society Guidelines
The latest British Hypertension Society (BHS) summary
guidelines 1 quite rightly aim to address the ‘incomplete detection,
treatment and control of hypertension’ prevalent across all sections of
the community. The emphasis on the assessment and reduction of
cardiovascular risk rather than just the maintenance of an optimal blood
pressure is certainly to be welcomed.
Curiously, however, there is one high-risk group hardly mentioned. It has
long been recognised that sections of the ethnic community, particularly
Afro-Caribbeans and South Asians are at greatly increased risk of
hypertensive end-organ damage. They also exhibit an increased incidence of
concomitant cardiovascular risk factors such as diabetes and obesity.
Other than noting that ‘differences in average response between drug
groups are related to ethnic group’, the reader is simply referred to the
full report 2. Although the BHS sees ethnic background as neither a
possible or compelling indication for any particular class of therapy, it
supports the widely held view that such patients are best treated with
thiazide or calcium antagonist monotherapy 3. In reality, this rarely
lowers blood pressure below 140/80 mmHg. It also causes deleterious renin-
system activation. Combining a thiazide or calcium antagonist with either
an ACE-inhibitor or a beta-blocker helps preserve neuro-hormonal balance.
This is also far more efficacious in terms of response rates, blood
reduction and presumably reduced cardiovascular risk 4.
The increasingly recognised benefits of ACE-inhibitors, both in terms
of the reduction of cardiovascular risk and the prevention of the
development and/or progression of diabetes, were highlighted in the Heart
Outcomes Prevention Evaluation (HOPE) study recently reported at the
European Society of Cardiology 5. These effects seem independent from and
additive to the benefits of blood pressure reduction. Extrapolation of the
evidence from the trials of beta-blockade post-myocardial infarction and
in heart failure suggests analogous benefits for beta-blockers. To not
use treatment based around an ACE-inhibitor or a beta-blocker in those at
greatest cardiovascular risk is to deprive those who would be expected to
The rationale for first-line combination therapy in ethnic patients
is clear, the evidence in favour persuasive and the implications in terms
of reductions in morbidity and mortality considerable. The BHS guidelines
missed an important opportunity to address the disparity in treatment and
outcomes in an important sector of the community. Unfortunately, in this
area at least, it seems that the guidelines will be rapidly superseded.
1. Ramsay LE, Williams B, Johnston GD, MacGregor GA, Poston L. Potter
JF, Poulter NR, Russell G. British Hypertension Society guidelines for
hypertension management 1999: Summary. BMJ 1999; 319: 630-5.
2. Ramsay LE, Williams B, Johnston GD, MacGregor GA, Poston L,
Potter JF, Poulter NR, Russell G for the British Hypertension Society.
Guidelines for the management of Hypertension: Report of the third working
party of the
British Hypertension Society. J Hum Hypertens, 1999; 13: 569-592.
3. Gibbs CR, Beevers GD, Lip GY. The management of hypertensive
disease in black patients. QJM 1999 Apr; 92 (4): 187-92.
4. Radevski IV, Valtchanova SP, Candy GP, Tshele EF, Sareli P.
Comparison of acebutolol with and without hydrochlorothiazide versus
Carvedilol with and without hydrochlorothiazide in black patients with
mild to moderate systemic hypertension. Am J Cardiol 1999 Jul; 84 (1): 70
5. Kleinert S. HOPE for cardiovascular disease prevention with
ACE-inhibitor ramipril. Heart Outcomes Prevention Evaluation. Lancet 1999
Sep 4; 354(9181): 841.
Dr Garfield Drummond,
Specialist Registrar in Clinical Pharmacology,
Department of Clinical Pharmacology,
Division of Medicine ands Therapeutics,
Leicester Royal Infirmary / Leicester University,
Robert Kilpatrick Clinical Sciences Building,
PO Box 65,
Competing interests: No competing interests