Practice Guidelines and Principles: Guidelines and principles are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines and principles should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. Purpose: Hypertension usually does not have any signs and symptoms and is often referred to as a silent killer. It leads to heart failure, stroke, kidney damage and more. The purpose of this guideline is to offer health care providers a clear approach for the evaluation and treatment of adults presenting with hypertension. KEY MESSAGES Risk of cardiovascular disease beginning at 115/75 mmhg doubles with every 20/10mm Hg increase. (Grade B) Lifestyle modification in all patients with hypertension and pre-hypertension should be prescribed. (Grade A) In a person > 50 years of age, systolic BP > 140 is a more important risk factor than diastolic BP. (Grade C) Thiazide-type diuretics should be considered for most patients with uncomplicated hypertension either alone or in combination with drugs from other classes. (Grade B) Most patients with hypertension will require two or more drugs to achieve goal. (Grade A) Goal for patients with uncomplicated HTN is <140/90. (Grade A) High Risk Populations/Disparities: Blacks have a higher prevalence of HTN than whites. The prevalence of HTN was reported at 50% for white men and 55% for white women aged 70 years and older. The age related blood pressure rise for women exceeds that of men. References: Chobanian, A.V.; Bakris, G.L.; Black, H.R.; et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: The JNC 7 Report. JAMA, May 21, 2003; 289(19): 2560-71. Stewart, Kerry J., EdD Exercise Training and the Cardiovascular Consequences of Type 2 Diabetes and Hypertension: Plausible Mechanisms for Improving Cardiovascular Health. JAMA, October 2, 2002; 288 (13) (Reprinted). Hyman, D., & Pavlik, V.. Characteristics of Patients with Uncontrolled Hypertension in the United States. NEJM, August 16, 2001; 345 (7). Hajjar, I. and Kotchen, T. Trends in Prevalence, Awareness, Treatment and Control of Hypertension in the United States, 1988-2000. JAMA, July 9, 2003: 290 (2): 199-206. Veterans Health Administration, Department of Veterans Affairs, and Health Affairs, Department of Defense. Diagnosis and Management of Hypertension in the Primary Care Setting. Washington, DC: Page 1 of 5
VA/DoD Evidence- based Clinical Practice Guideline Working Group, Office of Quality and Performance Publication 10Q- CPG/HTN 99, June 2004. Distributed to: Primary Care Physicians, including Internists, General Practice and Family Practice physicians, Obstetricians/Gynecologists. Developed by: Norm Lindenmuth, MD, Internal Medicine (Chair); Paul Bernstein, MD, Nephrology; James Haley, MD, Internal Medicine; Maurice Varon, MD, Cardiology; Ruth Weinstock, MD, Endocrinology & Metabolism; Richard Vienne, Jr., DO, Internal Medicine; David J. Martinke, DO, Family Practice; Andrew Ho, MD, Cardiology. Approved by: The Rochester Health Commission s Community-wide Clinical Guidelines Committee on October 17, 2005. Next scheduled update by October 2007. Quality Oversight Committee October 7, 2005 Page 2 of 5
GRADING SYSTEM Grades of Recommendations: A = Good evidence to support the recommendation that the condition or intervention be specifically considered in a clinical practice guideline. B = Fair evidence to support the recommendation that the condition or intervention be specifically considered in a clinical practice guideline. C = Poor evidence regarding inclusion or exclusion of a condition or intervention in a clinical practice guideline, but recommendation made on other grounds. D = Fair evidence to support the recommendation that the condition or intervention be specifically excluded from consideration in a clinical practice guideline. E = Good evidence to support the recommendation that the condition or intervention be specifically excluded from consideration in a clinical practice guideline. Quality of Published Evidence: For Grade A: I - Evidence from at least one properly randomized controlled trial. For Grade B: II 1 Evidence from well-designed controlled trials without randomization. II 2 Evidence from well-designed cohort or case-control analytic studies, preferably from more than one center or research group II 3 Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here. For Grade C: III - Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees. Page 3 of 8
ALGORITHM FOR TREATMENT OF HYPERTENSION LIFESTYLE MODIFICATIONS Not at Goal Blood Pressure (<140/90 mmhg) (<130/80 mmhg for patients with diabetes or chronic kidney disease) INITIAL DRUG CHOICE Without Compelling Indications With Compelling Indications Stage 1 Stage 2 Drug(s) for the Hypertension Hypertension compelling indications (SBP 140-159 or DBP (SBP >160 or DBP 90-99 mmhg) >100 mmhg) Thiazide-type Two-drug combination Other antihypertensive diuretics for most. for most (usually thiazide- drugs (diuretics, ACEI, May consider ACEI, type diuretic and ACEI, or ARB, BB, CCB) as needed. ARB, BB, CCB or ARB, or BB, or CCB). Combination. NOT AT GOAL BLOOD PRESSURE Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. DBP, diastolic blood pressure; SBP, systolic blood pressure Drug abbreviations: ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; BB, beta-blocker; CCB, calcium channel blocker. CLASSIFICATION AND MANAGEMENT OF BLOOD PRESSURE FOR ADULTS AGED 18 YEARS OR OLDER Page 4 of 8
BP Classification Systolic BP, mm Hg* Diastolic BP, mm Hg* Lifestyle Modificatio n Without Compelling Indication Management Initial Drug Therapy With Compelling Indications Follow-Up Normal <120 and <80 Encourage --- ------ Re-check 2 year Pre hypertension 120-139 or 80-89 Yes No antihypertensive Drug(s) for the compelling Re-check 1 drug indicated indications*** year **** Stage 1 hypertension Stage 2 hypertension 140-159 or 90-99 Yes Thiazide-type diuretics for most; may consider ACE inhibitor, ARB, betablocker, CCB, or combination greater than or equal to 160 or greater than or equal to 100 Yes 2-Drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or beta-blocker or CCB)** * Treatment determined by highest BP category ** Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension *** Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmhg **** Modify the scheduling of follow-up based on reliable information based on past blood pressure Blood Pressure Measurement Life Style Modifications (Grades A/B Evidence) Goal (Grades A/B Evidence) Patient should: Rest for 5 minutes before measurement. Refrain from smoking or ingesting caffeine for 30 minutes prior to measurement. Be seated with feet flat on floor, back and arm supported, arm at heart level. [Self monitor if appropriate]. Drug(s) for the compelling indications*** Other antihypertensive drugs (diuretics, ACE inhibitor, ARB, betablocker, CCB) as needed Drug(s) for the compelling indications*** Other anti-hypertensive drugs (diuretics, ACE inhibitor, ARB, betablocker, CCB) as needed Clinician should: Use the appropriate size cuff for the patient; the bladder should encircle at least 80 percent of the upper arm. Average two or more readings, separated by at least 2 minutes. Encourage patients to make healthy lifestyle choices: Quit smoking. Lose weight [when appropriate]. -Confirm within 1-2 months -once medication started, monthly intervals until BP at target -Evaluate or refer to source of care immediately or within one month, or sooner, depending on clinical situation - After BP stable, f/u visits can be 3 to 6 month intervals Restrict sodium intake to no more than 2.4 grams per day. Limit alcohol intake to no more than 2 drinks per day for men or 1 drink per day for women/light weight person. Get at least 30-45 minutes of aerobic activity on most days. Maintain adequate potassium intake-about 90 meq per day [(3.5 grams)]. Reduce saturated fat, eating a diet rich in fruits/vegetables, and low fat dairy products (DASH* eating plan). Set a clear goal of therapy based on patient s risk. Control blood pressure to below: <140/90 mm Hg for patients with uncomplicated hypertension; set a lower goal for those with target organ damage or clinical cardiovascular disease. <130/80 mm Hg for patients with diabetes, renal insufficiency and heart failure. <125/75 mm Hg for patients with renal failure with proteinuria > 1 gram/24 hours. *DASH Dietary Approaches to Stop Hypertension DRUG THERAPY Page 5 of 8
Uncomplicated Hypertension Thiazide-Type Diuretics Compelling Indications with Co-Morbidities Diabetes: Start with ACE inhibitor or ARB, combinations of two drugs usually needed to achieve 130/80 target. Thiazide-type diuretics are beneficial, either alone or as part of a combined regime. Heart failure: In asymptomatic individuals, use ACE inhibitor and beta-blocker. In individual with symptomatic ventricular dysfunction or end-stage heart disease, ACEIs/ARBs, beta blockers and aldosterone antagonists are recommended along with loop diuretics. Myocardial infarction: Beta-blocker (non-intrinsic sympathomimetic activity) after MI; consider addition of ACE inhibitor. Post stroke: Recurrent stroke rates are lowered by the combination of an ACE inhibitor and thiazidetype diuretic. Chronic kidney disease: Recommend target BP of <130/80, need for more than 1 hypertensive drug to achieve goal, ACE inhibitors/arb have a renal sparing effect, may require a loop diuretic rather than a Thiazide, monitor serum creatinine. Special Populations Considerations Elderly Begin with low doses important to treat systolic hypertension. Pregnancy Methyldopa, beta-blockers, and vasodilators are preferred medications. ACEI and ARBs should not be used during pregnancy and should be avoided in women who are likely to become pregnant. Minority populations Differential responses are largely diminished by drug combinations that include adequate doses of a diuretic. Blacks Thiazide-type diuretic, ACEI preferred agents Women Regular monitoring of BP throughout contraceptive therapy is recommended. Additional Considerations Osteoporosis Thiazide-type diuretics useful in slowing demineralization in osteoporosis. LVH Regression of LVH occurs with aggressive BP management, including weight loss, sodium restriction, and treatment with all classes of antihypertensive agents except the direct vasodilators hydralazine, and minoxidil. Asthma / reactive Avoid beta blockers. airways disease / 2 0 or 3 0 heart block Metabolic Syndrome Vast majority is categorized as pre-hypertension or Stage HTN, cornerstone of treatment is appropriate lifestyle changes. Page 6 of 8