The recommendations for the diagnosis and management of hypertension (HTN) in the primary care setting are organized into 2 major algorithms. Each algorithm, the objectives and recommendations or annotations that accompany it, and the evidence supporting the recommendations are presented below. The quality of evidence (QE) grading (I-III); overall quality (Good, Fair, Poor); and final grade of recommendations (R) (A-D, I) are provided for specific statements. These grades, along with "net effect of the interventions" are defined at the end of the "Major Recommendations" field.
- Screening for Elevated Blood Pressure
- Management of Elevated Blood Pressure
- Any Adult in the Health Care System
Recommendation
- Screen adults for elevated blood pressure (BP)
- Obtain Blood Pressure
Recommendation
- Blood pressure should be measured with a technique using a properly calibrated and validated instrument:
- Patient should be seated quietly for 5 minutes with back supported, feet on the floor, and arm bared, unrestricted
by clothing, and supported at heart level. Measurement of BP in the standing position may be indicated for patients at
risk for postural hypotension or at the discretion of the clinician.
- Smoking, exercise, or caffeine ingestion should not have occurred within 30 minutes prior to the BP
measurement.
- The appropriate blood pressure cuff size should be chosen for the patient. The cuff should be wrapped snugly
around the arm with the bladder centered over the brachial artery. The bladder should encircle at least 80% of the
arm.
For Auscultatory Measurements Only:
- Palpated radial pulse obliteration pressure should be used to estimate the systolic BP (SBP). The cuff should then
be inflated 20 to 30 mm Hg above this level for the auscultatory determinations.
- Position the stethoscope over the brachial artery and rapidly inflate the cuff. Deflate the cuff at a rate of 2 to
3 mm Hg per second, listening for Phase 1 and Phase 5 Korotkoff sounds. The first appearance of sound (Phase 1) is
used to record the SBP. Phase 5, at the disappearance of sound, is the diastolic BP (DBP) in adults. Listen 10 to 20
mm Hg below Phase 5 for any further sound then deflate the cuff completely.
- The BP should be recorded in even numbers with the patient's position, arm used, and cuff size documented.
- BP readings should be repeated in the same arm and averaged, if different. Two minutes should elapse before
repeating the BP measurement. If the readings differ by more than 5 mm Hg, additional measurements should be
obtained.
- Measurements can be taken with a mercury sphygmomanometer, but a recently calibrated aneroid manometer or a
validated electronic device is an acceptable alternative.
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
Use the standardized technique to measure blood pressure. |
Systolic Hypertension in the Elderly Program (SHEP) Cooperative Research Group, 1991
"Major outcomes," 2002
|
I |
Good |
A |
QE = Quality of Evidence; R = Recommendation (see Appendix E in the original guideline document)
- Is SBP >120 or DBP >80 mm Hg?
Objective
Identify patients with abnormal elevated blood pressure.
Recommendation
- Screen adults for elevated blood pressure, defined as a systolic blood pressure 120 mm Hg and above or a diastolic
blood pressure 80 mm Hg and above.
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
Blood pressure measurement can identify adults at increased risk for cardiovascular disease due to
high blood pressure. |
Sheridan, Pignone, & Donahue, 2003 |
I |
Good |
A |
2 |
The treatment of high blood pressure substantially decreases the incidence of cardiovascular disease
and causes few major harms. |
Sheridan, Pignone, & Donahue, 2003 |
I |
Good |
A |
3 |
SBP>120 mm Hg or DBP > 80 mm Hg is higher than optimal in terms of vascular risks. |
Lewington et al., 2002 |
I |
Fair to Good |
B |
QE = Quality of Evidence; R = Recommendation (see Appendix E in original guideline document)
- Annually Screen For Blood Pressure
Objective
Screen for future elevation of blood pressure.
Recommendations
- Blood pressure screening should occur periodically.
- Blood pressure screening is recommended annually for adults 50 years of age and older and/or for those who have
prehypertension and/or other cardiovascular risk factors.
- Blood pressure screening is recommended at indeterminate intervals, preferably annually. This may occur at the
time of routine preventive care or routine health assessments.
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
Blood pressure screening should occur periodically. |
Sheridan, Pignone, & Donahue, 2003 |
II-1 |
Fair |
B |
2 |
Blood pressure screening annually for adults older than 50 and/or for adults with prehypertension
and/or other cardiovascular risk factors |
Franklin et al., 1997 |
II-3 |
Fair |
B |
3 |
Annual screening for healthy adults |
Experts Consensus |
III |
Poor |
I |
QE = Quality of Evidence; R = Recommendation (see Appendix E in original guideline document)
- Address Other Cardiovascular Risk Factors
Objective
Evaluate and address all modifiable cardiovascular risk factors.
Recommendations
- Screening lipid profile should be done per the VHA/DoD Clinical Practice Guideline for the Management of Dyslipidemia
- Screening for diabetes mellitus should be done per the VA/DoD Clinical Practice Guideline for the Management of Diabetes
Mellitus
- 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
- 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.
- 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).
- SBP >140 or DBP >90 or DBP >80 with DM?
Recommendation
- 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.
- Initiate Lifestyle Modification
Objective
Provide dietary and lifestyle changes to help treat HTN and assist in reducing risk factors for cardiovascular
disease.
Recommendations
- 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)
- Individual LSM are effective; however, addressing multiple modifications may have a greater effect on reducing
blood pressure. (B)
- Successful implementation will require multiple visits and close follow-up. (B)
- Education may take place in either individual or group settings involving allied health professionals.
(B)
- Clinician empathy increases patient trust, motivation, and adherence to therapy.
- Physicians should consider their patients' cultural beliefs and individual attitudes in formulating
therapy.
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
Initiate LSM for prehypertension |
Staessen et al., 2004
Obarzanek et al., 2003
|
I |
Good |
A |
2 |
Addressing multiple modification |
Appel et al., 2003
Miller, 2002
Staessen et al., 2004
|
I |
Fair |
B |
3 |
Reduce sodium intake |
Appel et al., 2003
Hooper et al, 2003
Jurgens & Graudal, 2004 |
I |
Fair |
B |
4 |
Limit alcohol consumption |
Xin et al., 2001 |
I |
Fair |
B |
5 |
Reduce/maintain body weight (body mass index [BMI]<25) |
Neter et al., 2003
Mulrow et al., 2004
|
I |
Fair |
B |
6 |
Daily exercise |
Whelton et al., 2002
Kelley, Kelley, & Tran, 2001
|
I |
Fair |
B |
7 |
Dietary approaches rich in fruits, vegetables, and low-fat dairy products, with overall reduced
saturated and total fat content |
Stamler, 1997
Cappuccio et al., 1995
Appel et al., 2002 |
I |
Fair |
B |
8 |
Dietary Approaches to Stop Hypertension (DASH) Diet |
Obarzanek et al., 2003 |
I |
Fair |
B |
QE = Quality of Evidence; R = Recommendation (see Appendix E in original guideline document)
- Obtain History
Objective
Elicit historical features that may influence clinical decision-making.
Recommendations
The patient's medical history pertinent to hypertension should include:
- Duration, levels, and nature of BP elevation
- History or symptoms to rule out coronary heart disease (CHD), heart failure, cerebrovascular disease, peripheral
vascular disease, renal disease, DM, dyslipidemia, and gout
- Survey for baseline symptoms of sexual dysfunction, depression, cough, and angioedema
- Family history of hypertension, premature CHD, cerebrovascular accident (CVA), DM, dyslipidemia, or renal
disease
- Other symptoms suggesting other causes of elevated BP
- Results and adverse effects of any previous antihypertensive therapy
- History of recent change in weight, physical activity, tobacco use
- Dietary assessment, including intake of sodium, saturated fat, and caffeine
- 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
- History of alcohol and illicit drug use (especially cocaine and other stimulants)
- 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:
- Tobacco use
- Dyslipidemia
- Diabetes Mellitus
- Obesity (body mass index [BMI] > 30)
- Physical inactivity
- Microalbuminuria or estimated glomerular filtration rate (GFR) <60 mL/min
- Age (>55 years for men, >65 years for women)
- Family history of cardiovascular disease for women younger than 65 or men younger than 55
- 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:
- Fundoscopy
- Arteriovenous (AV) nicking or arterial narrowing
- Hemorrhages
- Exudates
- Papilledema
- Neck
- Carotid bruits and pulses
- Jugular venous distention
- Thyromegaly
- Heart
- Normal rate and regular rhythm
- Apical impulse
- Precordial heave
- Clicks, murmurs, third or fourth heart sounds
- Lungs
- Crackles
- Wheezes or rhonchi
- Abdomen
- Masses (e.g., aortic aneurysm, polycystic kidneys)
- Bruits
- Extremities
- Peripheral arterial pulses
- Femoral bruits
- Edema
- Central and peripheral nervous systems
- Signs of prior cerebrovascular accident (CVA)
- Signs or symptoms of dementia
Target organ damage associated with clinical cardiovascular diseases includes:
- Heart diseases
- Left ventricular hypertrophy
- Angina or prior myocardial infarction
- Prior coronary revascularization
- Heart failure
- Stroke or transient ischemic attack
- Chronic kidney disease (nephropathy)
- Peripheral arterial disease
- Retinopathy
- 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
- Urinalysis (UA)
- Blood chemistry (potassium, sodium, blood urea nitrogen [BUN], creatinine, fasting glucose)
- Fasting lipid profile (total cholesterol [TC], high-density lipoprotein cholesterol [HDL-C], low-density
lipoprotein cholesterol [LDL-C], triglycerides [TG])
- 12-lead electrocardiography
Optional Laboratory Tests*
- Hematocrit, complete blood cell count
- Glomerular filtration rate (GFR) estimated by Modification of Diet in Renal Disease Study Group (MDRD)
equation**
- Blood calcium
- Urinary protein excretion (24-hour urine collection or spot urine for protein/creatinine ratio)
- Uric acid
- Glycosylated hemoglobin (HbA1c)
- Thyroid-stimulating hormone (thyrotropin) (TSH)
- 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).
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
Routine tests: Urinalysis, Blood Chemistry, Fasting Lipid Profile, ECG |
Chobanian et al., 2003 |
III |
Poor |
I |
QE = Quality of Evidence; R = Recommendation (see Appendix E in original guideline document)
- 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
Disease |
Features |
Recommended Test/Referral |
Cushing's syndrome and other glucocorticoid excess states including chronic steroid therapy |
Amenorrhea
Increased dorsal fat
Diabetes mellitus
Edema
Hirsutism
Moon facies
Purple striae
Truncal obesity
|
History
24- hour urine for free cortisol
Dexamethasone suppression test
|
Hyperparathyroidism |
Hypercalcemia
Polyuria/polydipsia
Renal stones
|
Serum calcium and parathyroid hormone (PTH) level |
Hyperthyroidism |
Anxiety
Brisk reflexes
Hyperdefecation
Heat intolerance
Tachycardia
Tremor
Weight loss
Wide pulse pressure |
Thyroid Stimulating Hormone (TSH)
Free T4 |
Pheochromocytoma |
Labile BP
Orthostatic hypotension
Paroxysms (headaches, palpitations, sweating, pallor)
Tachycardia
|
Plasma metanephrines or 24-hour urine for metanephrines and/or catecholamines
Consider referral to specialist
|
Primary hyperaldosteronism |
K+ <3.5 mEq/L in patients not on diuretic therapy; or
K+ <3 mEq/L in patients on diuretic therapy
Muscle cramps
Polyuria
Weakness
|
Plasma aldosterone and plasma renin activity
24 hour urinary aldosterone level on a high sodium diet
|
Kidney disease |
Abnormal urine sediment
Elevated serum creatinine
Hematuria on two occasions or structural renal abnormality (e.g., abdominal or flank masses)
Proteinuria
|
Urinalysis; estimation of urinary protein excretion and creatinine clearance by using a single random
urine test; renal ultrasound may also be considered (See annotation H in original guideline document.)
Consider referral to nephrology
|
Renovascular disease |
Abdominal bruits over the renal arteries
Abrupt onset of severe HTN
Diastolic BP >115 mm Hg
Initial onset age >50 years old
Worsening BP control when previously stable
Evidence of atherosclerotic vascular disease
|
There are a variety of screening tests for renovascular HTN, depending on equipment and expertise in
institutions. Magnetic resonance angiography, renal artery Doppler, and post-captopril renograms are used.
However, there is no single best test for renovascular HTN, and consultation with experts in your institution is
recommended.
Intravenous pyelogram is relatively contraindicated in diabetes and no longer recommended as screening test for
renovascular disease.
|
Sleep apnea |
Daytime somnolence
Fatigue
Obesity
Snoring or observed apneic episodes |
Referral for sleep study |
Aortic Coarctation |
Weak or delayed femoral pulses |
Computerized tomography angiography |
Drug or substance induced |
Nonsteroidal anti-inflammatory drugs (NSAIDs), including Cox-2 Inhibitors
Sympathomimetics (e.g., decongestants, anorectics)
Oral contraceptives
Adrenal steroids
Erythropoietin
Cyclosporine, tacrolimus
Cocaine, amphetamines
Excessive alcohol use
Licorice
Selected dietary supplements (e.g., ma huang, ephedra, bitter orange)
|
History
Urine toxicology as indicated
|
- 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)
- 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).
- To reach target blood pressure, it is likely that a large proportion of patients will require combination therapy
with more than one agent.
- Drug therapy should be initiated in conjunction with LSM.
- Initial combination therapy with two drugs--particularly low-dose combinations--is more effective in achieving
target level BP.
- 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)
- 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.
- 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.
- In addition to lifestyle modifications, drug therapy should be considered in patients with prehypertension and
DM.
- Additional compelling indications should be considered in determining non-pharmacologic, as well as pharmacologic
treatment.
Management of Elevated Blood Pressure for Adults
BP Classification |
SBP |
DBP |
LSM |
Initial Drug Therapy |
Prehypertension |
120-139 |
80-89 |
Yes |
Consider for those with DM when BP 140/80 or greater |
Stage 1 Hypertension |
140-159 |
90-99 |
Yes |
Thiazide-type diuretic unless contraindicated or not tolerated (Consider angiotensin-converting enzyme inhibitors [ACEIs], angiotensin receptor blockers [ARBs], beta blocker [BB], calcium channel blocker [CCBs])
For compelling indication see Table "Preferred Agents in Patients with Comorbidities" below. |
Stage 2 Hypertension |
>160 |
>100 |
Yes |
Drug therapy with 2 drugs for most patients. This should include a thiazide-type diuretic unless contraindicated or not tolerated (Consider ACEIs, ARBs, BB, CCB)
For compelling indication see Table "Preferred Agents in Patients with Comorbidities" below. |
- Drug Treatment
Objective
Determine the most appropriate drug therapy regimen based on available evidence and patient comorbidities.
Recommendations
- Thiazide-type diuretics are recommended as first line therapy for drug treatment of hypertension
either as monotherapy or in combination with other agents. (A)
- The following may be used as alternative or supplementary therapy:
- ACEIs (A)
- ARBs (A)
- Beta-blockers (A)
- Long-acting calcium channel blockers (A)
Other Supplemental Agents
- Reserpine can be used as supplemental therapy when other agents do not provide clinical adequate
response. (A)
- 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:
- Centrally acting drugs (e.g., clonidine, methyldopa) (B)
- Vasodilators (e.g., hydralazine, minoxidil) (B)
- Aldosterone antagonists (e.g., spironolactone, eplerenone) (B)
- Combined alpha-beta blockers (B)
- Alpha blockers (B)
Avoid use of:
- Alpha-blockers should be avoided as monotherapy (D), may be used as supplemental
therapy. (B)
- 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
Condition |
Preferred Agents |
Alternate Agents |
Other Agents |
Comments |
HTN - without compelling indications |
Thiazide-type diuretic |
ACEI
ARB
Beta-blocker CCB
|
Aldosterone antagonist
Alpha-blocker Clonidine Reserpine Vasodilator |
- Immediate-release nifedipine should not be used.
- An ARB may be considered in a patient who is intolerant to an ACEI.
- Alpha-blockers are useful in treating symptomatic BPH, but are not recommended as monotherapy for treating
HTN.
|
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
|
Preferred Agents |
Additional/Alternative |
Other Agents |
DM* |
Thiazide-type diuretic and/or
ACEI |
ARB
CCB
Beta-blocker
|
|
Systolic HF |
ACEI
Beta-blocker |
ARB
Hydralazine-Nitrate
Aldosterone antagonist |
Diuretic (for treatment of volume overload)
LADHP |
CKD** |
ACEI
ARB
Diuretic (thiazide or loop, based on kidney function) |
Beta-blocker
NCCB
LADHP
|
|
Post Stroke |
Thiazide-type diuretic
and
ACEI
|
|
|
Post-MI |
Beta-blocker
ACEI
|
NCCB
Thiazide-type diuretic |
LADHP |
Other Special Populations
|
Preferred Agents |
Alternate Agents |
Comments |
African Americans |
Thiazide-type diuretic
ACEI |
|
Differences in efficacy are not as apparent when diuretics are added to ACEIs and beta -blockers |
High ambient temp and/or extreme conditions |
ACEI
ARB
|
CCB
Low dose Thiazide-type diuretic
|
For patent already deployed consider CCB |
* 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
- 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.
- 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.)
- Earlier follow-up may be necessary for patients:
- Requiring blood tests
- At increased risk for adverse outcomes from HTN due to very high BP or target organ damage
- At risk for postural hypotension
- 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.
- Once the patient's BP is controlled, follow-up at 3 to 6 month intervals (depending on patient status) is
generally appropriate.
- Older persons, persons with diabetes, those with neurological disease and patients with postural symptoms should
be evaluated for postural hypotension.
- Target level for blood pressure is included in the following table.
Target Values For HTN Control (ADOPTED FROM JNC7)
Condition |
Target (SBP/DBP mm Hg) |
Level of Evidence (QE, R) |
Resource* |
Hypertension |
<140/90 |
<150/90 (I,A)
<140/90 (II,B)
|
SBP: SHEP, Syst-Eur
DPB: HDFP, HOT |
Diabetes |
<140/80 |
(I, A) |
UKPDS, HOT |
DM + Nephropathy |
<140/80 |
(I, A) |
IDNT, RENAAL, MDRD |
Chronic Kidney Disease |
<140/90 |
<140/90 (I, A)
<130/80 (III, C) |
AASK |
Proteinuria >1g/day |
<125/75 |
(III, C) |
Post analyses MDRD |
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.
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
Treat for HTN if SBP >150 mm Hg |
Lewington et al., 2002
SHEP Cooperative Research Group, 1991
Staessen et al., 1997 |
II-2
I
I |
Good
Good
Good |
A |
2 |
Treat for HTN if SBP >140 mm Hg |
Lewington, et al., 2002
Chobanian et al., 2003 |
II-2
III |
Good
Poor |
B |
3 |
Treat for HTN if DBP >90 mm Hg |
Lewington et al., 2002 |
II-2 |
Good |
A |
4 |
Confirm SBP >140 mm Hg or DBP >90 mm Hg on 2 or more visits, unless there are
other clinical reasons for beginning therapy immediately (e.g., if target organ damage) |
Sheridan, Pignone, & Donahue, 2003 |
III |
Fair |
C |
5 |
Confirm and/or begin treatment within 1 month if SBP >160 mm Hg or DBP >100 mm
Hg |
SHEP Cooperative Research Group, 1991 |
III |
Fair |
C |
6 |
Classify SBP 120 to 139 mm Hg or DBP 80 to 89 mm Hg as "prehypertension" |
Chobanian et al., 2003
Lewington, et al., 2002 |
II-2 |
Good |
B |
QE = Quality of Evidence; R = Recommendation (see Appendix E in the original guideline document)
- Continue Current Treatment; Reinforce Lifestyle Modification; Follow up at Next Regular Visit
Objective
Follow patients who attain the desired target BP.
Recommendations
- Once the patient's BP is stabilized, follow-up at 3- to 6-month intervals (depending on patient status) is
generally appropriate.
- 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.
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
Follow-up visits may occur every three to six months |
Birtwhistle et al., 2004 |
IIa |
Good |
B |
2 |
Decrease or cessation of antihypertensive drug therapy |
Nelson et al., 2003 |
I |
Fair |
B |
QE = Quality of Evidence; R = Recommendation (see Appendix E in original guideline document)
- Self Monitoring
Objective
Assess and promote blood pressure control.
Recommendations
- 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.
- 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.*
- 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.
- 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.
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
Home blood pressure may be used as an alternative to clinic blood pressure in improving blood
pressure control |
Ebrahim, 1998
Boulware et al., 2001 |
I |
Good |
B |
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 |
Stergiou et al., "Self-monitoring," 1998 |
I |
Good |
B |
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 |
Bachmann et al., 2002 |
I |
Good |
B |
4 |
The use of home blood pressures may be used as a reliable alternative to 24-hour ambulatory blood
pressure monitoring in the detection of the white coat effect |
Stergiou et al., "White coat," 1998 |
I |
Good |
B |
QE = Quality of Evidence; R = Recommendation (see Appendix E in original guideline document)
- 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.
- 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.
- 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.
- Consider care management by pharmacist in the follow-up and adjustment of medication to improve blood pressure
goal. (B)
- Involving other allied health professionals in follow-up may as well improve blood pressure control.
(C)
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
Add second agent |
Materson, Reda, & Williams, 1996
"Major outcomes," 2002 |
I |
Good |
A |
2 |
Thiazide-type diuretic should be used as one of the agents in combination therapy |
"Major outcomes," 2002
Chobanian et al., 2003 |
I |
Good |
A |
3 |
When using combination therapy, select agents from different classes |
Group Consensus |
III |
Poor |
C |
4 |
Involving other allied health professionals in follow-up |
Group Consensus |
III |
Poor |
C |
5 |
Consider care management by pharmacist in the follow-up |
|
I |
Fair |
B |
QE = Quality of Evidence; R = Recommendation (see Appendix E in the original guideline document)
- 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
- Be aware of signs of patient non-adherence to therapy (e.g., missed appointments, missed refills).
|
- Establish the goal of therapy early: to reduce BP to non-hypertensive levels with minimal or no adverse
effects.
|
- Educate patients about the disease and involve them and their families in its treatment. Have them measure blood
pressure at home.
|
- Maintain contact with patients.
|
- Integrate pill taking into routine activities of daily living.
|
- Prescribe medications that require no more than twice daily dosing if possible.
|
- Ask about adverse effects and adjust therapy to prevent, minimize, or ameliorate side effects.
|
- Enlist the support of pharmacist in adjusting medication with regular follow-up.
|
- Consider group visits for education
|
- 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:
- 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
- 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
- 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.
- 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)
- 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)
- 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)
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
GENERAL RECOMMENDATIONS |
1 |
Treatment of HTN in patients with diabetes to retard progression of macrovascular complications and
DM |
Hansson et al., 1998
"Major outcomes," 2002 |
I |
Good |
A |
2 |
Target BP of <140/80 mm Hg for patients with diabetes with HTN, due to high-risk for
cardiovascular disease |
Group Consensus |
III |
Poor |
C |
3 |
Consideration of lower BP targets (<125/75 mm Hg) to slow the progression of renal disease for
patients with diabetes with elevated serum creatinine and/or urinary protein excretion above 1 g/day |
|
II-2 |
Fair |
B |
GENERAL THERAPEUTIC RECOMMENDATIONS |
4 |
Antihypertensive therapy with thiazide diuretic or ACEI for patients with diabetes with BP >140/80
mm Hg. Switch to ARB if ACEI-induced side-effects occur, then use other agents to achieve BP target <140/80 mm
Hg |
Hansson et al, 1998
Yusuf et al., 2000 |
I |
Good |
A |
SPECIFIC THERAPEUTIC RECOMMENDATIONS |
5 |
ACEI for normotensive patients with type 1 DM and proteinuria and for patients with type 2 DM and
microalbuminuria or a high-risk for cardiovascular disease |
Yusuf et al, 2000 |
I |
Good |
A |
6 |
Consideration of ACEI for normotensive patients with type 1 DM |
|
I |
Fair |
B |
7 |
Treatment with ARBs for patients with type 2 DM and nephropathy, microalbuminuria, or HTN and left
ventricular hypertrophy |
|
I |
Good |
A |
8 |
Combination ACEI and NCCB to provide renal protection in patients with inadequate response to an
ACE-I alone |
|
II-2 |
Fair |
B |
9 |
Diuretics to enhance the BP lowering effects of other antihypertensive agents. |
|
I |
Good |
A |
THERAPEUTIC CAUTIONS |
10 |
Use caution in prescribing long-acting DHCCBs without an ACEI or ARB because of the risk of less
renal protection and/or adverse cardiovascular outcomes. |
|
I |
Good |
A |
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
- 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.
- In African Americans with hypertensive kidney disease, ACEI may be a first line therapy for treating HTN.
- 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).
- 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.
- 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.
- Avoid potential nephrotoxic medications such as non-steroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitor,
aminoglycosides, intravenous (IV) contrast, and excessive diuretic use.
- 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.
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
ACEI for treating HTN in African Americans patients |
Wright et al., 2002 |
I |
Good |
A |
2 |
ACEI more effective in patients with HTN and kidney disease |
The GISEN Group, 1997
Jafar et al., 2001 |
I |
Good |
A |
3 |
ACEI and ARB may offer more renoprotection than with either class of medication alone in patient
with nondiabetic kidney disease |
Nakao et al., 2003 |
I |
Good |
A |
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
- A diuretic should be used in the treatment of patients with signs of fluid overload.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
Diuretic in patients with signs of fluid overload |
Hunt et al., 2001 |
III |
Fair |
B |
2 |
ACEI for all patients unless contraindicated/not tolerated |
"Comparative effects of therapy," 1988
SOLVD Investigators, 1991
Cohn et al., 1991
CONSENSUS Trial Study Group, 1987
Garg & Yusef, 1995
Hunt et al., 2001 |
I
I
I
I
II-2
III
|
Good |
A |
3 |
Beta-adrenergic blocker in conjunction with an ACEI in all stable patients unless contraindicated/not
tolerated |
"Effect of metoprolol," 1999
The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II), 1999
Leizorovicz et al., 2002
Shibata, Flather, & Wang, 2001
Hunt et al., 2001 |
I
I
II-2
II-2
III
|
Good |
A |
4 |
ARB should be alternative to an ACEI in patients on a diuretic, beta-adrenergic blocker, and usually
digoxin and are unable to tolerate an ACEI |
Cohn & Tagnoni, 2001
Granger et al., 2003
McMurray et al., 2003
Pfeffer et al., 2003
Hunt et al., 2001 |
I
I
I
I
III
|
Good |
A |
5 |
HYD/ISDN as alternative to an ACEI in patients on a diuretic, beta-adrenergic blocker, and usually
digoxin and are unable to tolerate an ACEI |
Cohn et al., 1986
Cohn et al., 1991
|
I
I
|
Fair |
B |
6 |
Digoxin in patients with symptoms despite an ACEI, beta-adrenergic blocker, and diuretic |
Digitalis Investigation Group, 1997
"Comparative effects of therapy," 1988
Jaeschke, Oxman, & Guyatt, 1990
|
I
I
II-2
|
Good |
A |
7 |
Aldosterone antagonist in patients with severe HF unless contraindicated/not tolerated |
Pitt et al., 1999 |
I |
Good |
A |
QE = Quality of Evidence; R = Recommendation (see Appendix E in the original guideline document)
C4 Stroke Prevention
Recommendations
- When an ACEI is used as principal therapy after stroke, a thiazide (or similar) diuretic should be used to assure
maximal effect. (A)
- 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)
- Alternatives (in alphabetical order) include ACEI/ARB, beta-blockers, dihydropyridine (long-acting) or diltiazem
calcium channel blockers. (Primary prevention I, A Secondary prevention B)
- 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).
|
Recommendations |
Sources |
QE |
Overall Quality |
R |
1 |
In post-stroke patient using ACEI as principal therapy, a thiazide (or similar) diuretic should be
used to assure maximal effect |
"Randomised trial," 2001 |
I |
Good |
A |
2 |
Diuretics as a principal agent for risk reduction after stroke or TIA
- Primary prevention
- Secondary prevention
|
"Major outcomes," 2002
Turnbull, 2003
Psaty, Lumley, & Furberg, 2003
Collins & MacMahon,1994
"Randomised trial," 2001
PATS Collaborating Group, 1995
|
I
III
|
Good
Poor
|
A
C
|
3 |
Alternatives to diuretics (in alphabetical order)
ACEI/ARB, beta-blockers, dihydropyridine (long-acting) or diltiazem calcium channel blockers
|
Yusuf et al., 2000
Staessen et al., 1997
Dahlof et al., 2002
Psaty, Lumley, & Furberg, 2003
"Major outcomes," 2002
Hansson et al., "Randomised," 1999
Hansson et al., "Effect," 1999
"Randomised trial," 2001
|
III |
Poor |
C |
4 |
ACEI may provide additional benefit to existing antihypertensive therapies or for primary stroke
prevention
In post-stroke patients with pre-hypertension, the addition of an ACEI for secondary prevention may be considered but
should be with a diuretic |
Yusuf et al., 2000
"Randomised trial," 2001 |
I
I
|
Good
Good
|
A
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.
- 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.
- 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
|
Net Benefit of the Intervention |
Overall Quality of Evidence |
Substantial |
Moderate |
Small |
Zero or Negative |
Good |
A |
B |
C |
D |
Fair |
B |
B |
C |
D |
Poor |
I |
I |
I |
I |