Guidelines from the British Hypertension Society

Editor—If the new British Hypertension Society (BHS) guidelines¹ are evidence based I'll eat my ALLHAT.² This and other evidence points to thiazide-type diuretics as the initial treatment of choice. New US guidelines reflect this,³ but the BHS recommends a range of initial drug types for hypertension.

The BHS recommends primary prevention use of statins for those with sustained “starting” blood pressure > 140 mm Hg systolic or > 90 mm Hg diastolic, or both, and an estimated risk of cardiovascular disease > 20% over the next 10 years. The set target is to lower total cholesterol by 25% or low density lipoprotein cholesterol by 30% or to reach < 4.0 mmol/l or < 2.0 mmol/l respectively, whichever is the greater.

Figure 1.

Blood pressure thresholds for intervention

Where is the evidence? The BHS cites Scandinavian cardiac outcomes trial-lipid lowering arm (ASCOT-LLA)⁴ and the heart protection study.⁵ In ASCOT-LLA subjects were chosen with high risk and higher blood pressure (> 160/> 100 mm Hg), or treated hypertension (> 140/> 90 mm Hg).⁴ Most participants in the heart protection study had established vascular disease or diabetes.⁵ The effect of the set statin dose achieved an average total cholesterol of 4.2 mmol/l in ASCOT-LLA⁴; around 50% had higher cholesterol. These studies did not chase a cholesterol target. Thus the BHS encourages unproved, aggressive treatment.

These proposals beggar belief and could beggar the NHS: 20% of the adult population could be given both blood pressure drugs and high dose statins. Society needs to decide whether it wishes to medicalise risks that largely relate to poor lifestyle choices. There is a need for political decisions based on affordability. The BHS compounds its dodgy interpretation of the evidence by dodging the wider implications of its recommendations.