• Kaiser Permanente Care Management Institute. Hypertension guidelines. Oakland (CA): Kaiser Permanente Care Management Institute; 2005 Jun. 83 p. [104 references]

This is the current release of the guideline.

Recommendations are identified as either "evidence-based (A to D and I)" or "consensus." For definitions of the levels of recommendations see the end of the "Major Recommendations" field.

Definition of Hypertension

The Care Management Institute (CMI) Hypertension Guidelines Project Management Team used the definition of hypertension to be a blood pressure at or above 140/90 mm Hg. The guidelines pertain to uncomplicated hypertension which is defined as hypertension in nonpregnant adults who do not have diabetes, heart failure, renal insufficiency, or known coronary heart disease.

Treatment of Hypertension

When to Begin Pharmacotherapy for Hypertension

In addition to lifestyle interventions:

If an individual has blood pressure of 140 to 159 mm Hg systolic OR 90 to 99 mm Hg diastolic (Stage 1), and does not have target organ damage or diabetes mellitus, then:

• If there is documentation of elevated blood pressure (>140 mm Hg systolic OR >90 mm Hg diastolic) for two or more months prior to the current measurement, then initiate pharmacotherapy.
• If this is the first elevated measurement, wait approximately two months. After two months, if blood pressure is >140 mm Hg systolic OR >90 mm Hg diastolic, then initiate pharmacotherapy.

If an individual has blood pressure of 160 to 179 mm Hg systolic OR 100 to 109 mm Hg diastolic (Stage 2), and does not have target organ damage or diabetes mellitus, then:

• If there is documentation of elevated blood pressure (>140 mm Hg systolic OR >90 mm Hg diastolic) for one or more months prior to the current measurement, then initiate pharmacotherapy.
• If this is the first elevated measurement, wait approximately one month. After one month, if blood pressure is >140 mm Hg systolic OR >90 mm Hg diastolic, then initiate pharmacotherapy.

If an individual has blood pressure >180 mm Hg systolic OR >110 mm Hg diastolic, then initiate pharmacotherapy.

Methodology – Consensus-based (Guideline Quality Committee [GQC]-sponsored)

Appropriate Office-Based Target Blood Pressure for Hypertension

When treating an individual with hypertension, the target office blood pressure is <139/<89 mm Hg.

Methodology – Consensus-based (GQC-sponsored)

Home Blood Pressure Monitoring for Diagnosis and Management

Diagnosis of hypertension should be established in the medical office.

Home self-measurement of blood pressure is recommended to:

• Identify a low-risk subpopulation of individuals with "white coat hypertension," without target organ disease or diabetes, for whom medication may not necessary. These individuals have home blood pressure levels <130/80 mm Hg but have office blood pressure levels >140/>90 mm Hg.
• Attain control in patients with uncontrolled hypertension (>135/85 mm Hg by home monitoring) according to drug treatment algorithms, and by using telephone/e-mail/fax or other electronic patient communications in conjunction with standard provider-based clinic visits.
• Monitor controlled hypertension over time.

Methodology – Consensus-based (GQC-sponsored)

First-Line Treatment of Hypertension

Thiazide diuretics are recommended as first-line agents for initial therapy in people with hypertension.

Methodology – Evidence-based (GQC-sponsored), Grade A

Initial Combination Treatment of Hypertension

Combination therapy consisting of a thiazide diuretic plus an angiotensin converting enzyme inhibitor (ACEI) (or a thiazide diuretic plus other medication if the patient is ACEI-intolerant) is an option for initial therapy for Stage 1 hypertension (systolic blood pressure 140 to 159 mm Hg OR diastolic blood pressure 90 to 99 mm Hg).

Combination therapy of a thiazide diuretic plus an ACEI (or a thiazide diuretic plus other medication if ACEI-intolerant) is recommended for Stage 2 hypertension (systolic blood pressure >160 mm Hg OR diastolic blood pressure >100 mm Hg).

Methodology – Consensus-based (GQC-sponsored)

Step-Care Therapy for Hypertension

Because most people with hypertension will need more than one drug to control their hypertension effectively:

• For two drugs:
  If blood pressure is not controlled on a thiazide-type diuretic alone, then a thiazide-type diuretic + ACE inhibitor is recommended.
• For three drugs:
  If blood pressure is not controlled on a thiazide-type diuretic + ACE inhibitor, then a thiazide-type diuretic + ACE inhibitor + beta-blocker is recommended.
• For four drugs:
  If blood pressure is not controlled on a thiazide-type diuretic + ACE inhibitor + beta-blocker, then a thiazide-type diuretic + ACE inhibitor + beta-blocker + dihydropyridine calcium channel blocker is recommended.

Methodology – Consensus-based (GQC-sponsored)

Supplementary Treatment of Uncomplicated Hypertension with Behavior Change Measures

• A moderately low-sodium, low-fat diet with a high intake of fruits and vegetables (Dietary Approaches to Stop Hypertension [DASH] diet) is recommended to supplement pharmacotherapy for patients with hypertension.
• Weight reduction is recommended for patients with a body mass index (BMI) >25 kg/m² on antihypertensive medications.
• It is recommended that hypertension patients who consume alcohol have no more than one alcoholic drink (for women) or two alcoholic drinks (for men) daily.
• Physical activity (at least 30 minutes of walking or equivalent at least three times per week) is recommended for patients with hypertension who are on medications.

Methodology – Consensus-based (GQC-sponsored)

Concomitant Therapy

Use of Aspirin in Hypertensive Patients Receiving Antihypertensive Medications

For individuals aged 50 to 80 years, whose hypertension is controlled by antihypertensive medications, low-dose aspirin (81 mg) is recommended as an adjunct therapy to further reduce risks of long-term cardiovascular outcomes (excluding mortality). When recommending aspirin, consider potential side effects, especially gastrointestinal bleeding.

Methodology – Evidence-based (GQC-sponsored), Grade A

Use of Statins in Hypertensive Patients Taking Antihypertensive Medications

There is insufficient evidence to recommend the use of statins in hypertensive patients in the absence of other significant risk factors. Patients with hypertension should be treated for hyperlipidemia according to their total cardiovascular risk profile.

Methodology – Evidence-based (GQC-sponsored), Grade A

Definitions:

Recommendations are classified as either "evidence-based (A-D, I)" or "consensus."

• Evidence-based: sufficient number of high-quality studies from which to draw a conclusion, and the recommended practice is consistent with the findings of the evidence. A recommendation can also be considered "evidence-based" if there is insufficient evidence and no practice is recommended.
• Consensus: insufficient evidence and a practice is recommended based on the consensus or expert opinion of the Guideline Quality Committee (GQC).

Label and Language of Recommendations*

^[a] All statements specify the population for which the recommendation is intended.

*Recommendations should be labeled and given an evidence grade. The evidence grade should appear in the rationale. Evidence is graded with respect to the degree it supports the specific clinical recommendation. For example, there may be good evidence that Drugs 1 and 2 are effective for Condition A, but no evidence that Drug 1 is more effective than Drug 2. If the recommendation is to use either Drug 1 or 2, the evidence is good. If the recommendation is to use Drug 1 in preference to Drug 2, the evidence is insufficient.

A clinical algorithm titled "Management of Adult Hypertension" is available in the pocket guide for this guideline. See the "Availability of Companion Documents" field for ordering information.

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

The recommendations contained in these guidelines are based on the current evidence from randomized, controlled trials and meta-analyses of those studies. In cases when high-quality evidence is lacking, recommendations are made on the basis of consensus reached after literature review.

• Kaiser Permanente Care Management Institute. Hypertension guidelines. Oakland (CA): Kaiser Permanente Care Management Institute; 2005 Jun. 83 p. [104 references]

Not applicable: The guideline was not adapted from another source.

2005 Jun

Kaiser Permanente Care Management Institute - Managed Care Organization

Kaiser Permanente Care Management Institute

Hypertension Project Management Team

Hypertension Guidelines Workgroup

Hypertension Project Management Team Members: Marc Jaffe, MD, Clinical Lead, KP Northern California; Laura Finkler, Project Manager, Care Management Institute; Joel Handler, MD, Clinical Consultant, KP Southern California; Tabitha Pousson, Staff Assistant, Care Management Institute

Hypertension Guidelines Workgroup Members: Marc Jaffe, MD, Clinical Lead, KP Northern California; Gary M Besinque, PharmD, Formulary Pharmacist, KP California; Patricia E Casey, MSN, RN, Director, Regional CV Program, KP Mid-Atlantic States; Laura Finkler, Project Manager, Care Management Institute; Beverly Green, MD, Associate Director of Preventive Care, Group Health Cooperative; Jeff Goforth, PharmD, Pharmacist, KP Georgia; Joel Handler, MD, Internist, KP Southern California; Steven Hong, MD, Internist, KP Hawaii; Jennifer Jeans, MD, Internist, KP Colorado; Mateo Ledezma, MD, Nephrologist, KP Southern California; Terry Moler, PharmD, Internist, KP Colorado; David E Page, MD, Internist, KP Mid-Atlantic States; Marguerite V Patton, RN, MSN, Implementation Specialist, KP Ohio; Verleen Smith, RN, Prevention Specialist, KP Colorado; Micah L Thorp, MD, Nephrologist, KP Northwest; Joseph D Young, MD, Internist, KP Northern California; Joel L Whittaker, MPH, Consultant, Clinical Practice Guidelines Unit, KP Southern California

All members of the Workgroup signed a Financial Conflict of Interest Disclosure Form stating that neither they nor their family had a financial interest in any company that makes or sells an agent recommended in the guideline.

This is the current release of the guideline.

Electronic copies: None available

Print copies: Available from the Kaiser Permanente Care Management Institute, One Kaiser Plaza, 16L, Oakland, CA 94612

None available

This NGC summary was completed by ECRI on October 31, 2006. The information was verified by the guideline developer on November 28, 2006.