Many of the major recommendations are presented in an algorithm:
Risk Stratification and Treatment*
- Risk Group A (No risk factors; No TOD/CCD**)
Blood Pressure High-Normal (130-139/85-89) -- Lifestyle modifications
Blood Pressure Stage 1 (140-159/90-99) -- Lifestyle modification (up to 12 mos.)
Blood Pressure Stage 2 & 3 (>160/>100) -- Drug therapy
- Risk Group B (At least 1 risk factor, not including diabetes; No TOD/CCD)
Blood Pressure High-Normal (130-139/85-89) -- Lifestyle modifications
Blood Pressure Stage 1 (140-159/90-99) -- Lifestyle modification (up to 6 mos.)***
Blood Pressure Stage 2 & 3 (>160/>100) -- Drug therapy
- Risk Group C (TOD/CCD and/or diabetes, with or without other risk factors)
Blood Pressure High-Normal (130-139/85-89) -- Drug therapy****
Blood Pressure Stage 1 (140-159/90-99) -- Drug therapy
Blood Pressure Stage 2 & 3 (>160/>100) -- Drug therapy
*Lifestyle modification should be adjunctive therapy for all patients recommended for pharmacologic therapy.
**TOD/CCD indicates target organ disease/clinical cardiovascular disease.
***For patients with multiple risk factors, clinicians should consider drugs as initial therapy plus lifestyle modifications.
****For those with heart failure, renal insufficiency, or diabetes.
Comorbidity Factors
Patient Comorbidity or Demographics Which Represent Indications for Drug Therapy Modification
- Isolated systolic hypertension -- Start with diuretic (hydrochlorothiazide [HCTZ] 25 mg daily [QD]).
- Angina pectoris -- Start with beta blocker (Atenolol, Metoprolol), then calcium channel antagonist (CCA) (Verapamil, Diltiazem).
- Congestive heart failure (CHF) or ejection fraction <40% -- Start with angiotensin-converting enzyme (ACE) inhibitor (should be used even if on diuretic already).
- Diabetes mellitus -- Start with ACE inhibitor (Enalapril). Maintain blood pressure (BP) <130/80.
- Renal insufficiency -- (Serum creatinine [Scr] >2.5 mg/dL) -- Start with a loop diuretic (furosemide), beta-blocker or CCA (Verapamil and Diltiazem preferred); ACE inhibitor use is a relative contraindication in ACE inhibitor naive patient. Maintain blood pressure <130/85.
- Post myocardial infarction -- Start with non-intrinsic sympathomimetic activity (non-ISA) beta blocker (Metoprolol).
- Peripheral vascular disease -- Start with CCA (Verapamil, Diltiazem)
- Benign prostatic hypertrophy -- Start with alpha blocker (Doxazosin)
- Dyslipidemia -- Alpha agonist (Clonidine), alpha blocker (Doxazosin), ACE inhibitor or CCA
- Vascular headaches -- Start with beta-blocker (Atenolol, Metoprolol) or CCA (Verapamil, Diltiazem).
- Asthma or chronic obstructive pulmonary disease (COPD) -- Start with diuretic; beta-blocker is relative contraindication.
- Hyperuricemia or gout -- Start with beta-blocker; diuretic is relative contraindication.
Hypertension Disease Management Guidelines
Detection and Confirmation
The following procedures are recommended for the detection and confirmation of hypertension:
- Patients should be seated in a chair with their backs supported and their arms bared and supported at heart level. Patients should have refrained from smoking or ingesting caffeine during the 30 minutes prior to the reading.
- Blood pressure (BP) measurement should begin after the patient has been at rest for at least 5 minutes.
- Appropriate cuff size must be used to ensure accurate readings. The bladder within the cuff should encircle at least 80% of the arm. A large adult cuff should be kept in all clinics.
- Measurement of blood pressure with a mercury sphygmomanometer is the preferred method. However, a recently calibrated aneroid manometer or a validated electronic device can be used.
- Systolic blood pressure (SBP) and diastolic blood pressure (DBP) should be recorded.
- Two or more readings separated by 2 minutes should be obtained and averaged for proper confirmation. If these two readings differ by more than 5 mm Hg, additional readings should be obtained two weeks apart.
The Following Recommendations for Follow-up are Based on Initial Blood Pressure Readings
Initial blood pressure (mm Hg)* and Recommended Follow-up Schedule**
- Systolic <130; Diastolic<85 -- Recheck in two years
- Systolic 130-139; Diastolic 85-89 -- Recheck in 1 year**
- Systolic 140-159; Diastolic 90-99 -- Confirm within 2 months**
- Systolic 160-179; Diastolic 100-109 -- Evaluate or refer to source of care within 1 month
- Systolic >180; Diastolic >110 -- Evaluate or refer to source of care immediately or within 1 week depending upon clinical situation
*If systolic and diastolic categories are different, follow up should be for the shorter time (e.g. 160/86 mm Hg should be evaluated or referred within one month).
**Modify the scheduling for follow up according to reliable information about past blood pressure measurements, other cardiovascular risk factors, or target organ disease.
***Provide advice about lifestyle modifications.
Medical History
- Known duration and levels of elevated blood pressure
- Patient history or symptoms of coronary heart disease (CHD), heart failure, cerebrovascular disease, peripheral vascular disease, renal disease, diabetes mellitus, dyslipidemia, gout, or sexual dysfunction
- Family history of high blood pressure, premature coronary heart disease, stroke, diabetes, dyslipidemia, or renal disease
- Symptoms suggestive of hypertension (headache, nose bleeds, dizziness, abnormal physical exam)
- History of recent changes in weight, leisure time physical activity, and smoking or tobacco use
- Dietary assessment including intake of sodium, alcohol, saturated fat, and caffeine
- History of all prescribed and over-the-counter (OTC) medication, herbal remedies, and illicit drugs
- Results and adverse effects of past antihypertensive therapy
- Psychosocial and environmental factors that may influence hypertensive control
Physical Exam
- Two or more blood pressure readings separated by 2 minutes with the patient supine or seated
- Verification in the contralateral arm (if values are different, the higher value should be used)
- Measurement of weight, height, and waist circumference
- Fundoscopic examination for hypertensive retinopathy (i.e., arteriolar narrowing, focal arteriolar constrictions, arteriovenous crossing changes, hemorrhages and exudates, disc edema)
- Examination of the neck for carotid bruits, distended veins, or enlarged thyroid gland
- Examinations of the heart for abnormalities in the rate and rhythm, increased size, precordial heave, clicks, murmurs, and third and fourth heart sounds
- Examination of the lungs for rales and evidence for bronchospasm
- Examination of the abdomen for bruits, enlarged kidney, masses, and abnormal aortic pulsation
- Examination of the extremities for diminished or absent peripheral arterial pulsations, bruits, and edema
- Neurological assessment
Routine Laboratory Test
Routine laboratory test recommended prior to initiating therapy and annually to determine end organ damage and other risk factors include:
- Urinalysis (UA)
- Complete blood count (CBC)
- Chemistry panel (e.g., Chem 20)
- Fasting lipid profile (cardiac risk panel)
- Electrocardiogram (EKG)
Secondary Causes of Hypertension
- Renal disease
- Coarctation of the aorta
- Primary aldosteronism
- Cushing’s syndrome
- Pheochromocytoma
- Pregnancy
- Drug-induced
Life Style Modification
- Lose weight if over weight
- Increase aerobic activity (30-45 minutes most days of the week)
- Reduce sodium intake
- Maintain adequate intake of dietary potassium
- Maintain adequate intake of dietary calcium and magnesium for general health
- Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health
- Limit alcohol intake
