5. Address Other Cardiovascular Risk Factors

   Objective

   Evaluate and address all modifiable cardiovascular risk factors.

   Recommendations

   1. Screening lipid profile should be done per the VHA/DoD Clinical Practice Guideline for the Management of Dyslipidemia
   2. Screening for diabetes mellitus should be done per the VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus
   3. Reduction/cessation of the use of tobacco and cigarette should be addressed per the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use
   4. A heart-healthy lifestyle including optimum weight maintenance (and/or weight loss, when needed), diet rich in fruits, vegetables, and low fat dairy products, and an exercise program emphasizing daily or near daily aerobic activity should be recommended.
   5. Aspirin should be recommended to patients who have hypertension and diabetes mellitus (DM) (see the VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus) or ischemic heart disease (IHD) (see the VA/DoD Clinical Practice Guideline for Management of Ischemic Heart Disease) and should be recommended to patients who already have vascular disease (e.g., cerebrovascular disease or cardiovascular disease).

6. SBP >140 or DBP >90 or DBP >80 with DM?

   Recommendation

   1. The diagnosis of hypertension (HTN) should be determined by BP readings on two separate patient visits. A minimum of two BP measurements should be performed during a patient visit:
      • Patients with SBP >140 or DBP >90 (Stage 1 hypertension) or with DBP >80 mm Hg and concomitant diabetes mellitus or chronic kidney disease should have their blood pressure confirmed generally within 1 to 2 months.
      • Patients with SBP >160 or DBP >100 (Stage 2 hypertension) should be appropriately evaluated by a healthcare provider, typically within 1 month--or sooner if the clinical situation warrants.

7. Initiate Lifestyle Modification

   Objective

   Provide dietary and lifestyle changes to help treat HTN and assist in reducing risk factors for cardiovascular disease.

   Recommendations

   1. Lifestyle modifications (LSM) aimed at controlling hypertension should be recommended in all cases. These methods can be used by themselves or in combination with drugs. (B)
   2. Individual LSM are effective; however, addressing multiple modifications may have a greater effect on reducing blood pressure. (B)
   3. Successful implementation will require multiple visits and close follow-up. (B)
   4. Education may take place in either individual or group settings involving allied health professionals. (B)
   5. Clinician empathy increases patient trust, motivation, and adherence to therapy.
   6. Physicians should consider their patients' cultural beliefs and individual attitudes in formulating therapy.

QE = Quality of Evidence; R = Recommendation (see Appendix E in original guideline document)

8. Obtain History

   Objective

   Elicit historical features that may influence clinical decision-making.

   Recommendations

   The patient's medical history pertinent to hypertension should include:

   1. Duration, levels, and nature of BP elevation
   2. History or symptoms to rule out coronary heart disease (CHD), heart failure, cerebrovascular disease, peripheral vascular disease, renal disease, DM, dyslipidemia, and gout
   3. Survey for baseline symptoms of sexual dysfunction, depression, cough, and angioedema
   4. Family history of hypertension, premature CHD, cerebrovascular accident (CVA), DM, dyslipidemia, or renal disease
   5. Other symptoms suggesting other causes of elevated BP
   6. Results and adverse effects of any previous antihypertensive therapy
   7. History of recent change in weight, physical activity, tobacco use
   8. Dietary assessment, including intake of sodium, saturated fat, and caffeine
   9. History of all prescribed and over-the-counter medications, herbal remedies, and dietary supplements, some of which may raise blood pressure or interfere with the effectiveness of antihypertensive medications
   10. History of alcohol and illicit drug use (especially cocaine and other stimulants)
   11. Psychosocial and environmental factors (e.g., family situation, employment status and working conditions, level of comprehension) that may influence HTN control

   The following major risk factors are the components of cardiovascular risk in patients with hypertension:

   1. Tobacco use
   2. Dyslipidemia
   3. Diabetes Mellitus
   4. Obesity (body mass index [BMI] > 30)
   5. Physical inactivity
   6. Microalbuminuria or estimated glomerular filtration rate (GFR) <60 mL/min
   7. Age (>55 years for men, >65 years for women)
   8. Family history of cardiovascular disease for women younger than 65 or men younger than 55

9. Perform Physical Examination

   Objective

   Elicit physical signs that may influence clinical decision-making.

   Recommendation

   A physical exam should evaluate for signs of secondary HTN or hypertensive organ damage. At a minimum, vital signs should include height, weight, and two or more blood pressure readings with the patient seated.

   If the patient is at risk for postural hypotension or has symptoms of orthostasis, a standing blood pressure should also be measured in addition to seated or supine. The two blood pressure measurements should be separated by 2-minute intervals.

   A focused examination should include the following:

   1. Fundoscopy
      1. Arteriovenous (AV) nicking or arterial narrowing
      2. Hemorrhages
      3. Exudates
      4. Papilledema
   2. Neck
      1. Carotid bruits and pulses
      2. Jugular venous distention
      3. Thyromegaly
   3. Heart
      1. Normal rate and regular rhythm
      2. Apical impulse
      3. Precordial heave
      4. Clicks, murmurs, third or fourth heart sounds
   4. Lungs
      1. Crackles
      2. Wheezes or rhonchi
   5. Abdomen
      1. Masses (e.g., aortic aneurysm, polycystic kidneys)
      2. Bruits
   6. Extremities
      1. Peripheral arterial pulses
      2. Femoral bruits
      3. Edema
   7. Central and peripheral nervous systems
      1. Signs of prior cerebrovascular accident (CVA)
      2. Signs or symptoms of dementia

   Target organ damage associated with clinical cardiovascular diseases includes:

   1. Heart diseases
      1. Left ventricular hypertrophy
      2. Angina or prior myocardial infarction
      3. Prior coronary revascularization
      4. Heart failure
   2. Stroke or transient ischemic attack
   3. Chronic kidney disease (nephropathy)
   4. Peripheral arterial disease
   5. Retinopathy

10. Perform Laboratory and Other Diagnostic Procedures

    Objective

    Determine the baseline data on patient's health status, the existence of secondary causes of HTN, and the risk factors contributing to the disease process.

    Recommendations

    Routine laboratory tests for the investigation of all patients with hypertension

    1. Urinalysis (UA)
    2. Blood chemistry (potassium, sodium, blood urea nitrogen [BUN], creatinine, fasting glucose)
    3. Fasting lipid profile (total cholesterol [TC], high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], triglycerides [TG])
    4. 12-lead electrocardiography

    Optional Laboratory Tests*

    1. Hematocrit, complete blood cell count
    2. Glomerular filtration rate (GFR) estimated by Modification of Diet in Renal Disease Study Group (MDRD) equation**
    3. Blood calcium
    4. Urinary protein excretion (24-hour urine collection or spot urine for protein/creatinine ratio)
    5. Uric acid
    6. Glycosylated hemoglobin (HbA1c)
    7. Thyroid-stimulating hormone (thyrotropin) (TSH)
    8. Transthoracic echocardiography to determine the presence of left ventricular hypertrophy

    * May have clinical utility in certain instances

    ** Calculators and modeling aids. Available at: http://www.nkdep.nih.gov/healthprofessionals/tools/gfr_adults.htm

    Estimation of proteinuria and creatinine clearance (Clcr) may be done by single urine and blood tests instead of collecting 24-hour urines. To estimate urinary protein excretion, obtain a single urine specimen for protein concentration (in mg/dL) and creatinine concentration (in mg/dL). The protein-to-creatinine ratio (protein concentration divided by the creatinine concentration) estimates the 24-hour protein excretion in grams per day (see original guideline document for example).

    There are now several formulas available to estimate Clcr. One of the simplest uses the patient's age, serum creatinine (Scr), weight in kilograms, and sex to estimate Clcr. Normal Clcr is >100 cc/min, but diminishes with age. The estimation formula is (140-age)/Scr x wt/72 x 1.0 (if male) or 0.85 (if female) (see original guideline document for example).

QE = Quality of Evidence; R = Recommendation (see Appendix E in original guideline document)

11. Is a Secondary Cause Suspected?

    Objective

    Detect underlying disease(s) responsible for secondary HTN using additional laboratory tests.

    Recommendation

    An early discussion or consultation with an appropriate specialist is encouraged when a patient is suspected of having secondary hypertension (see table below titled "Recommended Testing for Patients Suspected of Having Secondary Hypertension")

Recommended Testing for Patients Suspected of Having Secondary Hypertension

12. Initiate Treatment for Hypertension

    Objective

    Select the most effective therapy to control blood pressure.

    Recommendations

    Pharmacotherapy (see also Annotation M in the original guideline document)

    1. According to the baseline blood pressure and the presence or absence of complications, it appears reasonable to initiate therapy either with a starting dose of a single agent or with starting-doses of two agents. (See Appendix B Recommended Dosage for Selected Hypertension Drug Therapy in the original guideline document).
    2. To reach target blood pressure, it is likely that a large proportion of patients will require combination therapy with more than one agent.
    3. Drug therapy should be initiated in conjunction with LSM.
    4. Initial combination therapy with two drugs--particularly low-dose combinations--is more effective in achieving target level BP.
    5. Initial combination therapy with two drugs maybe preferable for patients in STAGE 2 HTN.

    Non-Pharmacologic Therapy (See also Annotation G in the original guideline document)

    1. Prescribe LSM in all patients with prehypertension or HTN. Certain lifestyle modifications have been shown to decrease blood pressure in randomized clinical trials; other lifestyle modifications are also important in decreasing cardiovascular risk. These non-pharmacologic measures can be sufficient to control BP or to decrease the amount of required medication.
    2. If patients with stage 1 HTN do not adhere to LSM or are adherent to LSM and show no improvement in blood pressure level for 3 to 6 months, initiate drug therapy.
    3. In addition to lifestyle modifications, drug therapy should be considered in patients with prehypertension and DM.
    4. Additional compelling indications should be considered in determining non-pharmacologic, as well as pharmacologic treatment.

Management of Elevated Blood Pressure for Adults

13. Drug Treatment

    Objective

    Determine the most appropriate drug therapy regimen based on available evidence and patient comorbidities.

    Recommendations

    1. Thiazide-type diuretics are recommended as first line therapy for drug treatment of hypertension either as monotherapy or in combination with other agents. (A)
    2. The following may be used as alternative or supplementary therapy:
       1. ACEIs (A)
       2. ARBs (A)
       3. Beta-blockers (A)
       4. Long-acting calcium channel blockers (A)

    Other Supplemental Agents

    3. Reserpine can be used as supplemental therapy when other agents do not provide clinical adequate response. (A)
    4. Other agents may be used as additional therapy in refractory hypertension or as supplementary therapy when other drugs are contraindicated or limited by adverse effects. These include:
       1. Centrally acting drugs (e.g., clonidine, methyldopa) (B)
       2. Vasodilators (e.g., hydralazine, minoxidil) (B)
       3. Aldosterone antagonists (e.g., spironolactone, eplerenone) (B)
       4. Combined alpha-beta blockers (B)
       5. Alpha blockers (B)

    Avoid use of:

    5. Alpha-blockers should be avoided as monotherapy (D), may be used as supplemental therapy. (B)
    6. Short-acting calcium channel blockers should not be used as there is no evidence of benefit. (D) Short-acting dihydropyridine (DHP) calcium channel blockers may cause harm. (D)

Preferred Agents In Patients With Uncomplicated Hypertension

Compelling Indications for Individual Drug Classes

Recommendations for initial antihypertensive therapy in patients with HTN who also have certain compelling conditions may differ from other patients with HTN but in general, these patients should still be considered for thiazide-type diuretics--in addition to the compelling medication--based on the benefit seen in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) in patients on diuretics. More specifically, the recommendations in the Table below titled "Preferred Agents in Patients with Comorbidities" include medications that have demonstrated improved outcomes or provided clinical improvement in the treatment of patients with certain conditions that may or may not be directly related to hypertension itself. These conditions addressed include: post-myocardial infarction, systolic heart failure (HF), kidney disease, diabetes, and stroke prevention.

Other specific recommendations are for choice of agent in treatment of pilots and patients whose work/duty requires special consideration (pilots, and service person in extreme weather conditions).

MOST COMPELLING INDICATIONS SHOULD INCLUDE A THIAZIDE-TYPE DIURETIC

Preferred Agents in Patients with Comorbidities

Other Special Populations

* For patients with diabetes mellitus, please refer to the VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus.

**For patients with kidney disease.

ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; NCCB = nondihydropyridine calcium channel blocker; CKD = chronic kidney disease; LADHP = long-acting dihydropyridine calcium cannel blocker

14. Is BP Control Adequate and Therapy Tolerable?

    Objective

    Assess adequacy of HTN control and adverse effects to treatment.

    Recommendations

    The primary objective in hypertension treatment is to decrease blood pressure to less than 140/90 mm Hg, or to lower goals in selected patient populations.

    1. Patients should be seen within 1 month after the initiation of therapy to determine adequacy of HTN control, degree of patient adherence, and presence of adverse effects. (Allied health professional may be useful to conduct these follow-up visits.)
    2. Earlier follow-up may be necessary for patients:
       1. Requiring blood tests
       2. At increased risk for adverse outcomes from HTN due to very high BP or target organ damage
       3. At risk for postural hypotension
    3. Assessment of blood pressure control should be based on measurement of BP in the clinic setting. Out of office measurements may provide useful clinical information.
    4. Once the patient's BP is controlled, follow-up at 3 to 6 month intervals (depending on patient status) is generally appropriate.
    5. Older persons, persons with diabetes, those with neurological disease and patients with postural symptoms should be evaluated for postural hypotension.
    6. Target level for blood pressure is included in the following table.

Target Values For HTN Control (ADOPTED FROM JNC7)

SHEP = Systolic Hypertension in the Elderly; Syst-Eur = Systolic Hypertension in Europe; HDFP = Hypertension Detection and Follow-up Program; HOT = Hypertension Optimal Treatment; UKPDS = United Kingdom Prospective Diabetes Study; IDNT = Irbesartan in Diabetic Nephropathy Trial; RENAAL = Reduction of Endpoints in NIDDM with the Angiotensin II Receptor Antagonist Losartan; MDRD = Modification of Diet in Renal Disease; AASK = African American Study Of Kidney Disease And Hypertension

The VA/DOD Hypertension Guideline recommends a minimal target threshold that is based on level I evidence derived from randomized clinical trials. For persons with diabetes this is 140/80 mm Hg, and for persons without diabetes 140/90 mm Hg. The VA/DOD Hypertension Guideline also acknowledges that there are data from multiple observational studies, including pooled data from randomized clinical trials (level II evidence) demonstrating that lower blood pressure levels are associated with risk reduction for adverse outcomes; the relationship is linear without a threshold. Consequently, clinicians are encouraged to set target values for each patient based upon their individual circumstances, including tolerance of medications.

QE = Quality of Evidence; R = Recommendation (see Appendix E in the original guideline document)

15. Continue Current Treatment; Reinforce Lifestyle Modification; Follow up at Next Regular Visit

    Objective

    Follow patients who attain the desired target BP.

    Recommendations

    1. Once the patient's BP is stabilized, follow-up at 3- to 6-month intervals (depending on patient status) is generally appropriate.
    2. Decrease or cessation of antihypertensive drug therapy is possible in patients who are willing to do so and whose BP is very well controlled. Cessation may be considered in patients well controlled on monotherapy. These patients should be closely followed-up.

QE = Quality of Evidence; R = Recommendation (see Appendix E in original guideline document)

16. Self Monitoring

    Objective

    Assess and promote blood pressure control.

    Recommendations

    1. Home blood pressures may be used as a supplement to, but should not wholly substitute for, obtaining clinic blood pressures to assess or promote blood pressure control.
    2. If home blood pressure monitoring is used, a minimum of two measurements per day for at least two days should be obtained and then averaged in order to provide a reliable estimate of home blood pressure.*
    3. In order to improve accuracy and interpretation of home blood pressure measurements, the use of a device with a memory function is recommended rather than relying on the patient's recall or diary.
    4. Home blood pressure monitoring may assist in detecting a white coat effect or poorer control at home than in the office.

    * Note: Patients enrolled in a formal Care Coordination\Telehealth (CC-TH) should follow the instructions of the CC-TH program.

QE = Quality of Evidence; R = Recommendation (see Appendix E in original guideline document)

17. Adjust Therapy

    Objective

    Modify drug therapy to help achieve BP control.

    Recommendations

    If the blood pressure continues to be elevated, clinicians may consider choosing one of the strategies that have proven effective in the treatment of HTN.

    1. Increase the dose of the original medication.
       • Titrating the dose usually means doubling the dose. Be aware of the dose response that is not always linear although adverse effects may increase with higher doses.
    2. Add another agent
       • If a thiazide-type diuretic is not chosen as the initial drug, it should be used as the second agent, unless contraindicated or not tolerated, especially because it frequently enhances the effects of the initial agent and has the best cardiovascular outcome data. (IA)
       • When using combination therapy select those agents that have been shown to reduce morbidity and mortality. (A)
       • When using combination therapy select agents from different classes and provide benefit for comorbid condition or compelling indications if they exist. (C)
       • Combination therapy includes a potential for drug-drug interactions, but these are uncommon.
    3. Consider care management by pharmacist in the follow-up and adjustment of medication to improve blood pressure goal. (B)
    4. Involving other allied health professionals in follow-up may as well improve blood pressure control. (C)

QE = Quality of Evidence; R = Recommendation (see Appendix E in the original guideline document)

18. Reassess Adherence

    Objective

    Identify causes of inadequate response to therapy following dose or stepwise titration.

    Recommendation

    Adherence to an antihypertensive medication regimen can be improved by a multi pronged approach including:

    • Address barriers for obtaining the medications (administrative, economic, etc.).
    • Simplify medication regimens incorporating patient's preference.
    • Coordinate with other health care team members to improve monitoring of adherence with prescriptions of pharmacological and lifestyle modification.
    • Educate patients and patients' families about their disease/treatment regimens.
    • Encourage greater patient responsibility/autonomy in monitoring their blood pressure and adjusting their prescriptions.

    Causes of Inadequate Response to Therapy are shown in Table 11 of the original guideline document.

    The primary care provider should employ measures that assist in improving patient adherence to treatment. Many of these measures are designed to engage the patient in his or her wellness. The table below titled "Strategies to Improve Patient Adherence to Antihypertensive Therapy" lists several suggestions to improve the patient's adherence to therapy.

Strategies to Improve Patient Adherence to Antihypertensive Therapy

19. Consider Consultation

    Objective

    Determine appropriate point in time to consider consultation to improve hypertension management.

    Recommendation

    From a clinical perspective, referral to, or consultation with hypertension specialists or those with particular expertise in the relevant clinical area should be considered if there is:

    1. Failure to achieve target blood pressure goals when on appropriate doses of three medications, one of which should typically be a thiazide-type diuretic and assuming that other remedial causes of inadequate response have been identified and addressed
    2. Suspected secondary cause for hypertension

Hypertension and Comorbid Conditions (From Appendix C in the original guideline document)

C1 Patients with Diabetes with SBP >140 or DBP >80 mm Hg

Recommendations

1. Patients with diabetes with hypertension (systolic BP >140 or diastolic BP >-90 mm Hg) should:
   • Begin anti-hypertensive therapy with a diuretic or an angiotensin converting enzyme inhibitor (ACEI)
   • If ACEI induced side-effects occur, consider switching to an angiotensin receptor blocker (ARB)
   • Use other preferred agents (beta blockers, long acting calcium channel blockers) as necessary, depending on other comorbid conditions or compelling indications to achieve a blood pressure <140/80 mm Hg.
2. Patients with diabetes with initial SBP <140 mm Hg and DBP between 80 and 89 mm Hg (within the "pre-hypertensive" category identified by JNC 7) may benefit from lowering diastolic blood pressure to < 80 mm Hg. (A)
3. Individuals with diabetes whose blood pressures is <140/80 mm Hg who have clinical cardiovascular disease may benefit from ACEI therapy even without a reduction in blood pressure. (A)
4. In patients with diabetes with renal insufficiency (i.e., serum creatinine >1.5 mg/dL) and proteinuria (i.e., >1 g/24h) there are some data suggesting that further BP lowering (<125/75 mm Hg) may slow progression of renal disease. Lower BP should be achieved, if feasible and practical, depending on the tolerance of medications and side effects of BP lowering. (B)

QE = Quality of Evidence; R = Recommendation (see Appendix E in the original guideline document)

C2 Kidney Disease

Objective

To provide recommendations on pharmacologic therapy for renal preservation in patients with kidney disease, regardless of blood pressure level

Recommendations

1. ACEI may be preferred agent for patients with HTN and kidney disease (reduced kidney function with proteinuria). ARB may be substituted for patients with ACEI-induced cough.
2. In African Americans with hypertensive kidney disease, ACEI may be a first line therapy for treating HTN.
3. A diuretic should be used when a second blood pressure medication is needed or if hyperkalemia occurs. Thiazide diuretic may be used if estimated GFR >30 cc/min/1.73m², but loop diuretics are usually needed for lower kidney function. Potassium-sparing diuretics should be avoided in patients with chronic kidney disease (CKD).
4. A stable increase of serum creatinine as much as 35% above baseline after ACEI or ARB initiation may be tolerated, as long as hyperkalemia does not occur. ACEI or ARB should be discontinued, or other potentially reversible causes of kidney failure investigated if progressive and rapid rise of serum creatinine continues. Since CKD is associated with progressive rise in creatinine over years, ACEI or ARB should not be discontinued for this situation, since these medications are renoprotective.
5. When treating HTN in patients with non-diabetic kidney disease, use of combined therapy with ACEI and ARB may offer more renoprotection than with either class of medication alone.
6. Avoid potential nephrotoxic medications such as non-steroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitor, aminoglycosides, intravenous (IV) contrast, and excessive diuretic use.
7. Monitor kidney function over time by estimating GFR or Clcr. Consider consulting with a nephrologist if a non-diabetic patient has nephrotic range proteinuria, or kidney function is < 30 cc/min/1.73m².

QE = Quality of Evidence; R = Recommendation (see Appendix E in the original guideline document)

Chronic Heart Failure (HF)

Objective

To provide recommendations on pharmacologic therapy for patients with HTN and concomitant chronic heart failure (HF) due to systolic dysfunction

The recommendations in this annotation refer to patients with Stage C heart failure (HF) (e.g., patients with past or current HF symptoms and evidence of structural heart damage).

Many of the classes of medications used to treat patients with hypertension have also been shown to provide benefit in patients with chronic HF. If the patient continues to have an elevated blood pressure despite optimal treatment for HF based on the following recommendations, additional antihypertensive medications should be initiated (except for NCCBs or nifedipine) to achieve blood pressure goal.

Recommendations

1. A diuretic should be used in the treatment of patients with signs of fluid overload.
2. All patients should be treated with an ACEI unless contraindicated or not tolerated. These agents improve HF symptoms, functional status, and quality of life, while decreasing frequency of hospitalization and mortality.
3. A beta-adrenergic blocker should be used in conjunction with an ACEI in all patients who are considered stable (i.e., minimal or no signs of fluid overload or volume depletion and not in an intensive care unit), unless contraindicated or not tolerated. These agents have been shown to reduce mortality and decrease the symptoms of HF.
4. An ARB should be considered as an alternative to an ACEI in patients who are on a diuretic, beta-adrenergic blocker, and usually digoxin and are unable to tolerate an ACEI due to cough or possibly, angioedema.
5. The combination of hydralazine and isosorbide dinitrate (HYD/ISDN) may be considered as an alternative to an ACEI in patients who are on a diuretic, beta-adrenergic blocker, and usually digoxin and are unable to tolerate an ACEI due to hypotension, renal insufficiency, or possibly, angioedema.
6. Digoxin (although not effective for the treatment of HTN) should be used in patients whose symptoms persist despite treatment with an ACEI, a beta-adrenergic blocker, and a diuretic. Digoxin reduces symptoms associated with HF and decreases the risk for hospitalizations due to HF but does not improve mortality.
7. Low dose spironolactone (an aldosterone antagonist) should be considered in patients with recent New York Heart Association (NYHA) Class IV HF and current Class III or IV symptoms and left ventricular ejection fraction (LVEF) <35%, provided the patient has preserved renal function and normal potassium levels. This therapy improves symptoms (as assessed by change in New York Heart Association (NYHA) functional class), decreases hospitalizations for worsening HF, and decreases mortality.

QE = Quality of Evidence; R = Recommendation (see Appendix E in the original guideline document)

C4 Stroke Prevention

Recommendations

1. When an ACEI is used as principal therapy after stroke, a thiazide (or similar) diuretic should be used to assure maximal effect. (A)
2. Diuretics remain a principal agent for risk reduction after stroke or transient ischemic attack (TIA) based on data on primary prevention studies and extrapolation from the PROGRESS trial on secondary prevention. (Primary prevention of stroke A; Secondary prevention B)
3. Alternatives (in alphabetical order) include ACEI/ARB, beta-blockers, dihydropyridine (long-acting) or diltiazem calcium channel blockers. (Primary prevention I, A Secondary prevention B)
4. In post-stroke patients with pre-hypertension, the addition of an ACEI may be considered but should be with a diuretic, as noted above (level of evidence for secondary prevention A). An ACEI may provide additional benefit to existing antihypertensive therapies or for patients who are not hypertensive for primary stroke protection (Primary prevention A).

QE = Quality of Evidence; R = Recommendation (see Appendix E in the original guideline document)

C5 High Ambient Temperature and/or Extreme Conditions

These recommendations are based on consensus opinion that considers the available literature, experience in the field, and physiology.

1. Patients who are likely to be deployed should preferably be started on ACEI/ARB or CCB. Diuretics, if needed, should be used in low doses. This stipulation also applies to those who do extreme physical activity and are prone to dehydration. Patients should be stable on their medications prior to deployment. Clinicians should discuss how deployment might effect blood pressure control and describe potential complications of treatment with their patients as part of pre-deployment processing. If possible, the patient should be monitored for signs and symptoms of dehydration and adequate blood pressure control for the first 7 to 10 days of deployment while they are becoming acclimatized.
2. For patients who are diagnosed with and/or started on treatment for hypertension during a deployment, dihydropyridine CCBs are the preferred agents in the desert environment since they are available in once a day formulations, do not limit heart rate, and do not require electrolytes to be checked after initiation.

Definitions:

Strength of Evidence

I: Evidence obtained from at least one properly done randomized controlled trial

II-1: Evidence obtained from well designed controlled trails without randomization

II-2: Evidence obtained from well designed cohort or case-control analytic study

II-3: Evidence obtained from multiple time series; dramatic results of uncontrolled experiments

III: Opinion of respected authorities, case reports, and expert committees

Overall Quality

Good: High grade evidence (I or II-1) directly linked to health outcome

Fair: High grade evidence (I or II-1) linked to intermediate outcome; or grade evidence (II-2 or II-3) directly linked to health outcome

Poor: Level III evidence or no linkage of evidence to health outcome

Net Effect of Intervention

Substantial:

• More than a small relative impact on a frequent condition with a substantial burden of suffering, or
• A large impact on an infrequent condition with a significant impact on the individual patient level

Moderate:

• A small relative impact on a frequent condition with a substantial burden of suffering, or
• A moderate impact on an infrequent condition with a significant impact on the individual patient level

Small:

• A negligible relative impact on a frequent condition with a substantial burden of suffering, or
• A small impact on an infrequent condition with a significant impact on the individual patient level

Zero or Negative:

• Negative impact on patients, or
• No relative impact on either a frequent condition with a substantial burden of suffering, or
• An infrequent condition with a significant impact on the individual patient level

Recommendation Grade

• Screening for Elevated Blood Pressure
• Management of Elevated Blood Pressure

References open in a new window

Explicit indicators to measure implementation system wide are a part of the Veterans Health Administration's performance measurement system and are described in the Technical Manual available from the Department of Veterans Affairs (VA) Web site.

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

Electronic copies: Available from the Department of Veterans Affairs Web site.

Print copies: Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

Electronic copies: Available from the Department of Veterans Affairs (VA) Web site.

Print copies: Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

The following is also available:

• Putting clinical practice guidelines to work [online tutorial]. Available from the Department of Veterans Affairs Web site.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.