• Michigan Quality Improvement Consortium. Medical management of adults with hypertension. Southfield (MI): Michigan Quality Improvement Consortium; 2007 Aug. 1 p.

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement Consortium. Medical management of adults with hypertension. Southfield (MI): Michigan Quality Improvement Consortium; 2005 Aug. 1 p.

The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.

Initial Assessment

• The objectives of the initial evaluation are to assess lifestyle, cardiovascular risk factors, and concomitant disorders, reveal identifiable causes of hypertension, and check for target organ damage and cardiovascular disease.
• Physical examination: 2 or more blood pressure (BP) measurements using regularly calibrated equipment with the appropriate sized cuff and separated by at least 2 minutes, verification in contralateral arm, funduscopic exam, neck exam (bruits), heart and lung exam, abdominal exam for bruits or aortic aneurysm, and extremity pulses [A]
• Laboratory tests prior to initiating therapy: potassium, creatinine, glucose, hematocrit, calcium, urinalysis, lipid panel, and electrocardiogram (EKG) [D]

Patient Education and Nonpharmacologic Interventions

• Lifestyle modification: weight reduction (body mass index [BMI] goal <25), reduction of dietary sodium to less than 2.4 g/day, DASH diet [A] (i.e., diet high in fruits and vegetables, reduced saturated and total fat), aerobic physical activity >30 minutes most days of the week, tobacco avoidance, increased dietary potassium and calcium, moderation of alcohol consumption¹ [A]
• Use of self BP monitoring. Home measurement device should be checked regularly for accuracy. Mean self measured BP >135/85 is generally considered to be hypertensive

¹Moderate alcohol consumption is defined as up to two drinks per day for men, one drink per day for women and older people.

Goals of Therapy

• Adjust therapy to achieve target BP <140/90 (<130/80 for patients with diabetes or kidney disease)

Pharmacologic Interventions

• Prehypertension (120-139/80-89): none unless compelling indication (e.g., diabetes, renal failure, congestive heart failure [CHF], post-myocardial infarction [MI], stroke, arteriosclerotic cardiovascular disease)
• Hypertension, Stage 1 (140-159/90-99): thiazide-type diuretics alone or in combination with angiotensin-converting enzyme inhibitor (ACEI), beta blocker, or calcium channel blocker (extended/sustained release or long acting)². Angiotensin receptor blocker (ARB) if ACEI not tolerated
• Hypertension, Stage 2 (>160/>100): two-drug combination (thiazide-type diuretic plus ACEI, beta blocker, or calcium channel blocker [extended/sustained release or long acting]²; use ARB if ACEI not tolerated)
• ACEI (ARB if ACEI not tolerated) are recommended in patients with diabetes or heart failure [A].
• Beta-blockers are recommended in patients with ischemic heart disease or heart failure.
• 3 or more drugs may be necessary for some patients to achieve goal BP.

²Avoid use of short-acting nonsustained release calcium channel blockers [A].

Monitoring and Adjustment of Therapy [D]

• Prehypertension without medication: annual BP check with lifestyle modification counseling
• Hypertension, Stage 1: initiate therapy and recheck at monthly intervals until goal is reached.
• Hypertension, Stage 2: initiate therapy and recheck weekly or more often if indicated. Symptomatic Stage 2 may require hospital monitoring and treatment.
• Modify antihypertensive therapy as needed if adverse effects become intolerable
• Once BP controlled with medication: recheck every 3 to 6 months.
• Serum potassium and creatinine should be monitored at least 1 to 2 times/year for patients on medication.

Definitions:

Levels of Evidence for the Most Significant Recommendations

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational studies
4. Opinion of expert panel

None provided

• Michigan Quality Improvement Consortium. Medical management of adults with hypertension. Southfield (MI): Michigan Quality Improvement Consortium; 2007 Aug. 1 p.

2003 Aug (revised 2007 Aug)

Michigan Quality Improvement Consortium - Professional Association

Michigan Quality Improvement Consortium

Michigan Quality Improvement Consortium Medical Director's Committee

Physician representatives from participating Michigan Quality Improvement Consortium health plans, Michigan State Medical Society, Michigan Osteopathic Association, Michigan Association of Health Plans, Michigan Department of Community Health, and Michigan Peer Review Organization

Standard disclosure is requested from all individuals participating in the Michigan Quality Improvement Consortium (MQIC) guideline development process, including those parties who are solicited for guideline feedback (e.g. health plans, medical specialty societies). Additionally, members of the MQIC Medical Directors' Committee are asked to disclose all commercial relationships.

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement Consortium. Medical management of adults with hypertension. Southfield (MI): Michigan Quality Improvement Consortium; 2005 Aug. 1 p.

None available

None available

This NGC summary was completed by ECRI on April 14, 2004. The information was verified by the guideline developer on July 27, 2004. This NGC summary was updated by ECRI on November 28, 2005. The updated information was verified by the guideline developer on December 19, 2005. This NGC summary was updated by ECRI Institute on March 4, 2008. The updated information was verified by the guideline developer on March 12, 2008.

This NGC summary is based on the original guideline, which may be reproduced with the citation developed by the Michigan Quality Improvement Consortium.