CLINICAL PRACTICE GUIDELINE

Transcription

1 This Clinicl Prctice Guideline (CPG) nd ccompnying ptient eduction were developed by multidisciplinry tem, under the ledership of Nebrsk Helth Network s Primry Cre Clinicl Integrtion Workgroup. MAY 2016 Bsed on ntionl guidelines nd emerging evidence nd shped by expert locl opinion, this CPG provides prcticl strtegies for erly recognition, dignosis nd effective tretment of hypertension. CLINICAL PRACTICE GUIDELINE Mngement of Hypertension/High Blood Pressure GOALS This Clinicl Prctice Guideline helps Primry Cre tems chieve clinicl qulity mesures for hypertension. Indequte tretment for chronic hypertension plces ptients t undue risk for helth complictions. Overview 1 High blood pressure puts individuls t risk for hert disese nd stroke, which re leding cuses of deth in the United Sttes. Approximtely 29% of Americn dults hve high blood pressure tht s 1 in every 3 dults. About 1 in 3 Americn dults hs prehypertension blood pressure numbers tht re higher thn norml but not yet in the high blood pressure rnge. Only bout hlf (52%) of people with high blood pressure hve their condition under control. High blood pressure costs the ntion lmost $46 billion nnully in direct medicl expenses nd $3.6 billion in lost productivity. HIGH BLOOD PRESSURE 1 IN 3 $46 BILLION INSIDE 1 OVERVIEW/GOALS 2 TREATMENT 3 CLINICAL ALGORITHM 4 PHARMACOLOGICAL TREATMENT 5 TEAM MEMBERS 5 PATIENT EDUCATION 6 RESOURCES & REFERENCES Acknowledgements/Development Tem: Ivn Abdouch, MD (co-chir) Mrk Omr, MD (co-chir) Brent Crouse, MD Andrew Vsey, MD Amber Tyler, MD Tnvir Hussin, MD Dle Agner, MD Thoms McElderry, MD Jennifer Fillus, DO John Smith, MD Julie Nieveen, APRN Jessic Livingston, RN Ann Blnchrd, RN Kr Tomlinson, RN Eline McCord, RN, MSN Jn Urysz, RN, MSN NHN Phrmcy nd Therpeutics Committee Disclimer: Nebrsk Helth Network (NHN) clinicl prctice guidelines re developed to ssist clinicins by providing n nlyticl frmework for the evlution nd tretment of selected common problems encountered in ptients. They re not intended to estblish protocol for ll ptients with prticulr condition. Clinicins must exercise independent judgment nd mke decisions bsed upon the sitution presented. While gret cre hs been tken to ssure the ccurcy of the informtion presented, the reder is dvised tht NHN cnnot be responsible for continued currency of the informtion, for ny errors or omissions in this guideline, or for ny consequences rising from its use. This clinicl prctice guideline should not be used or reprinted without written consent from the Nebrsk Helth Network. Approved Dte: 4/2016 Review Dte: 4/2018

2 TREATMENT Key Points 2-5 Ambultory BP Monitoring (ABPM) nd Home BP Monitoring 6 1 Hypertension is mjor risk fctor for crdiovsculr disese nd microvsculr complictions in ptients with dibetes. 2 Encourge hert helthy lifestyle modifictions for ll dults including helthy weight, regulr physicl ctivity, tobcco cesstion, limited lcohol consumption, nd dietry modifiction (DASH-style diet). 3 Most ptients will require >2 phrmcologic therpies to chieve trget blood pressure - Angiotensin-converting enzyme inhibitor (ACE-I) plus thizide-type diuretic single-pill combintion preferred. COMPARISON OF BLOOD PRESSURE MEASUREMENT METHODS Office BP ABPM Home BP Predicts events Yes Yes Yes Dignostic utility Yes Yes Yes Detects white-cot nd msked HTN No Yes Yes (limited) Evlutes the circdin rhythm of BP No Yes (limited repet uses) No Evlutes therpy Yes Yes Yes Norml limit for verge-risk ptients, mmhg 140/90 130/80(24 hour) 135/85 (wke) 120/75 (sleep) 135/85 Cost Low High Low Reimbursement Yes Prtil No Lifestyle Modifictions 2-5 Weight Reduction Trget BMI <25kg/m 2 Diet Moderte sodium (<2300mg/dy) 8, low ft diry, rich in fruits/vegetbles (DASH). Reinforce importnce of helthy diet nd refer to dieticin s necessry. Moderte Alcohol Consumption Limit of one lcoholic beverge (women) or two lcoholic beverges (men) per dy. Smoking Cesstion Aerobic Activity 150 minutes/week Mediction Adherence 2,3 Regulr ssessment of mediction complince Utilize one-dily nd combintion products, whenever possible Address depression nd nxiety when pproprite Initil Lb nd Dignostic Workup 7,8 Lb nd Dignostic recommendtions for gol of mnging hypertension nd risk fctors ssocited with crdiovsculr disese. Initil Lb nd Dignostic Workup 9 BMP Fsting glucose Lipids Hemoglobin/Hemtocrit Liver function tests Urinlysis EKG TSH Significnce Potssium levels my indicte renl disese nd ldosterone excess. Serum Cretinine nd BUN levels my indicte kidney disese. Identifies glucose intolernce or dibetes, consider further testing s necessry. Abnorml LDL/HDL levels re ssocited with n incresed risk of crdiovsculr disese. Cn identify issues beyond CVD; including sickle cell nemi nd CKD. Consider for mediction side effects; identifies ftty liver disorder in obese ptients. Albuminuri my be indictive of kidney disese. Red/white cells my identify potentil urinry trct conditions. Assists in identifying previous myocrdil infrctions, ventriculr hypertrophy, rrhythmis. Add in specific situtions, e.g. elevted BMI or concern for thyroid disese.

3 TREATMENT OF HYPERTENSION in Adults with or without Dibetes 9-12 SUSPECTED DIAGSIS: Consider confirming with Ambultory BP Monitoring OR Home BP Monitoring Blood Pressure 140/90 mmhg ge 18-79, nd >80 with dibetes For ge 80 yers without dibetes, pressure 150/90 ( 140/90 if high risk) SPECIAL CASES: -Coronry Disese -Stroke History -Hert Filure -Kidney Disese CONFIRMED DIAGSIS: Lb nd Dignostic Workup, Recommend Home BP Monitoring INITIATE LIFESTYLE MODIFICATIONS BP 160/100? STAGE /90-99 mmhg STAGE 2 160/100 mmhg DIABETES WITH ALBUMINURIA OR CKD? OR Thizide* OR CCB* *Preferred in Blck Ptients NHN Preferred Drug List NHN Preferred Drug List INITIATE DUAL MEDICATION THERAPY: + CCB or Thizide *Single Pill Combintion Preferred NHN Preferred Drug List AT GOAL? AT GOAL? AT GOAL? Add OR Thizide* OR CCB* Single Pill Combintion Preferred Add Thizide OR CCB Single Pill Combintion Preferred AT GOAL? AT GOAL? Triple Drug Therpy: CCB + Thizide + ACEI (or ARB) Hypertension Mngement Principles in ALL CASES: - Ressess redings nd titrte mediction q2-4 weeks until control chieved - Assess mediction dherence during ech ptient encounter - Encourge lifestyle modifictions during ech ptient encounter - Monitor lbs s needed bsed on mediction regimen - When trget BP chieved, follow-up every 6 months AT GOAL? If not t trget on 3 drug optiml regimen: - Assess Mediction Adherence - Consider Ambultory Blood Pressure Monitoring to check for resistnt HTN - Consider dding spironolctone, centrlly cting gents, -blockers If control not chieved or if complictions, evlute for secondry cuses OR refer to HTN specilist

4 PHARMACOLOGICAL TREATMENT First-Line Drug Tretment 2 Generl nonblck popultion, including those with dibetes Thizide-type diuretic, clcium chnnel blocker (CCB), ngiotensin-converting enzyme inhibitor (ACEI), ngiotensin receptor ntgonist (ARB) Generl blck popultion, including those with dibetes Thizide-type diuretic or CCB Age 18 yers with chronic kidney disese (CKD) NHN Antihypertensive Preferred Drug List (current s of ) Antihypertensive Mediction* Thizide-type Diuretics Aldosterone Antgonist Diuretic Combintions Angiotensin Converting Enzyme Inhibitors (ACEI) ACEI/Thizide-type Diuretic Combintions Angiotensin II Receptor Blockers (ARB) ARB/Thizide-type Diuretic Combintions Clcium Chnnel Blocker (Long Acting Dihydropyridine) Chlorthlidone Hydrochlorothizide (HCTZ) Indpmide Spironolctone Eplerenone HCTZ/Trimterene Spironolctone/HCTZ Lisinopril Enlpril Benzepril Lisinopril/HCTZ Enlpril/HCTZ Benzepril/HCTZ Losrtn Irbesrtn Vlsrtn Losrtn/HCTZ Irbesrtn/HCTZ Vlsrtn/HCTZ Amlodipine Nifedipine (long cting) Usul Dosge Rnge (Hypertension) mg dily mg dily mg dily mg dily, in 1-2 divided doses mg dily, in 1-2 divided doses 25/37.5mg, 1-2 tbs dily 25/25mg, 1-4 tbs dily, in 1-2 divided doses 10-40mg dily 10-40mg dily, in 1-2 divided doses 10-80mg dily 20/25mg, ½-2 tbs dily 10/25mg, ½-2 tbs dily 10/12.5mg, ½-2 tbs dily mg dily mg dily mg dily 50/12.5mg, 1-2 tbs dily 150/12.5mg, 1-2 tbs dily 160/12.5mg, 1-2 tbs dily mg dily 30-90mg dily CCB/ACEI Combintions Amlodipine/Benzepril 5/10mg, ½-2 tbs dily Bet-Blockers (BB) Atenolol Bisoprolol Crvedilol IR Lbetlol Metoprolol Metoprolol XR Ndolol Proprnolol IR mg dily 5-20mg dily mg twice dily mg twice dily mg dily, in 1-2 divided doses mg dily 40-80mg dily mg dily, in 2-3 divided doses Mediction Monitoring (Lbortory) 13 Antihypertensive Mediction* Lb Monitoring Frequency Diuretic nd/or Aldosterone Antgonist Bet-Blockers nd/or CCBs Potssium nd Cretinine Potssium nd Cretinine Sodium No routine lb monitoring required Before inititing therpy nd within 1-2 weeks of initition or dose increse nd nnully Before inititing therpy nd within 1-2 weeks of initition or dose increse nd nnully Before inititing nd consider t time periods bove Not Applicble

5 TEAM MEMBERS The Triple Aim of the Nebrsk Helth Network is to improve the qulity nd sfety of our ptient cre nd improve the ptient experience while enhncing ffordbility. The gol of the NHN is to stndrdize tretment cross our helth systems nd providers. Clinicl Prctice Guidelines (CPGs) nd resources re developed by NHN physicin workgroups to implement evidence-bsed cre nd best prctice stndrds within our network. Tem Roles: There is n ongoing commitment from NHN to develop nd implement current evidence-bsed CPGs. Educting yourself nd your ptients on these best prctice guidelines helps your office chieve the Triple Aim. Tem Resources: Ptient-centered tems work more efficiently nd effectively to provide high-qulity cre tht s known to improve helth outcomes nd ptient stisfction. 14 PATIENT EDUCATION Ptient Eduction is essentil for improving helth behviors nd overll helth outcomes. GOALS 1 Simplify communiction nd confirm understnding (tech-bck). 2 Support ptients efforts to improve their helth (shred decision mking). 3 SUGGESTED TEACHING RESOURCES: StyWell Helthsheets: High Blood Pressure, New, Begin Tretment & Controlling High Blood Pressure Dischrge Instructions: Tking Blood Pressure Medictions ExitCre Eduction Leflets: Hypertension Hypertension (Esy to Red) Mnging your High Blood Pressure Additionl Resources: Centers for Disese Control nd Prevention ConsumerEd_HBP.pdf Helth Litercy Universl Precutions: 15 Assume ll ptients hve difficulty comprehending helth informtion nd ccessing helth services. This section provides key tlking points to support helth litercy. 16 Definitions: Blood pressure is the force of blood ginst the rtery wlls s it circultes through the body. It is mesured using two numbers: Systolic blood pressure (the first number) mesures the pressure in blood vessels when the hert bets. Distolic blood pressure (the second number) mesures the pressure in your blood vessels when the hert rests between bets. Risk Fctors: Age: The risk for high blood pressure increses with ge. Rce or ethnicity: Africn Americns re t n incresed risk for high blood pressure nd develop the condition erlier in life. Lifestyle: Excessive lcohol use, tobcco use, unhelthy diet, nd physicl inctivity increses risk. Genetics nd fmily history: High blood pressure cn run in fmilies. Signs nd Symptoms: High blood pressure usully hs no wrning signs or symptoms. Ptients often mistkenly believe they would feel when their blood pressure is high (i.e. hedches). Dignosis nd Testing: Dignosis is bsed on the mesurement in the office nd my require more thn one reding to confirm. Redings >140/90 mmhg = high blood pressure - Prehypertension: /80-89 mmhg - Stge 1 hypertension: /90-99 mmhg - Stge 2 hypertension: 160/100 mmhg Ptients my be encourged to try lifestyle chnges first, or be sked to monitor their blood pressure more often. If mediction is recommended, ptients should tke s prescribed nd not skip doses. If side effects re concerning, instruct ptient to cll the office. Schedule doctor s visit bout every 2-4 weeks until controlled. Prevention nd Lifestyle Modifictions: Limit lcohol to 1 drink/dy for women, 2 drinks/dy for men. Diet (DASH) - Helthy eting to include fruits, vegetbles nd whole grins. Exercise pproximtely 150 minutes/week with the doctor s pprovl. Avoid dding slt to food. Limit processed, cnned, dried nd fst foods. Mintin helthy weight. Do not smoke or use tobcco products.

6 REFERENCES & RESOURCES 1. High Blood Pressure Fct Sheet. Centers for Disese Control nd Prevention website. Accessed Mrch Chobnin AV, Bkris GL, Blck HR, et l; Ntionl Hert, Lung, nd Blood Institute Joint Ntionl Committee on Prevention, Detection, Evlution, nd Tretment of High Blood Pressure; Ntionl High Blood Pressure Eduction Progrm Coordinting Committee. The seventh report of the Joint Ntionl Committee on Prevention, Detection, Evlution, nd Tretment of High Blood Pressure: the JNC 7 report. JAMA.2003;289(19): doi: /jm Jmes, PA, Opril S, et l Evidence-Bsed Guideline for the Mngement of High Blood Pressure in Adults: Report from the Pnel members Appointed to the Eight Joint Ntionl Committee. JAMA 2014;311(5): Americn Dibetes Assocition. Crdiovsculr disese nd risk mngement. Sec. 8. In Stndrds of Medicl Cre in Dibetes Dibetes Cre 2015; 38(Suppl. 1): S49 S Eckel RH, Jkicic JM, Ard, JD, Hubbrd VS, de Jesus JM, Lee IM, Lichtenstein AH, Lori CM, Millen BE, Houston Miller N, Nons CA, Scks FM, Smith SC Jr, Svetkey LP, Wdden TW, Ynovski SZ AHA/ ACC guideline on lifestyle mngement to reduce crdiovsculr risk: report of the Americn College of Crdiology Americn/Hert Assocition Tsk Force on Prctice Guidelines. Circultion. 2013;00: Pickering, TG & White, WB. ASH position pper: Home nd mbultory blood pressure monitoring when nd how to use self (home) nd mbultory blood pressure monitoring. Journl of Clin Hypertension 2008;10(11): doi: /j x. 7. Weber et l. (2014). Clinicl Prctice Guidelines for the Mngement of Hypertension in the Community. Journl of Clin Hypertension. 16(1). DOI: /jch JNC 7. Ntionl High Blood Pressure Eduction Progrm. The seventh report of the Joint Ntionl Committee on Prevention, Detection, Evlution, nd Tretment of High Blood Pressure. U.S. Dept of Helth nd Humn Svcs Accessed Jnury Kiser Permnente. Ntionl Adult Hypertension Guideline Clinicin Guide 2014.Avilble online t: Accessed Mrch Group Helth Coopertive. Hypertension dignosis nd tretment guidelines Avilble online t: Accessed Mrch Evidence bsed tretment protocols for improving blood pressure control. Million Herts Cmpign Website. Accessed July Weber M, Schiffrin E, White W, et l. Clinicl prctice guidelines for the mngement of hypertension in the community: A sttement by the Americn Society of Hypertension nd the Interntionl Society of Hypertension. J Hypertens. 2014;32(1):3-15. doi /HJH Accessed June Kidney Disese: Improving Globl Outcomes (KDIGO) Blood Pressure Work Group. KDIGO Clinicl Prctice Guideline for the Mngement of Blood Pressure in Chronic Kidney Disese. Kidney inter., Suppl. 2012; 2: & 2012 KDIGO Tem-Bsed Cre. Ntionl Institute of Dibetes nd Digestive nd Kidney Diseses Website. niddk.nih.gov/helth-informtion/helth-communiction-progrms/ndep/helth-cre-professionls/prcticetrnsformtion/tem-bsed-cre/pges/defult.spx Accessed My Helth litercy universl precutions toolkit. Agency for Helthcre Reserch nd Qulity Website. hrq.gov/professionls/qulity-ptient-sfety/qulity-resources/tools/litercy-toolkit/index.html. Reviewed My Accessed My About High Blood Pressure. Centers for Disese Control nd Prevention Website. Updted July Accessed My 2016.