Hypertension Guidelines Overview

Diagnosis of Hypertension

  • New Guidelines (2017):
    • Diagnosis threshold lowered to 130/80 mm Hg from 140/90 mm Hg.
    • Affects a significant number of patients.
    • Importance of measuring blood pressure (BP) in two positions and documenting clearly.
    • Patients should maintain BP logs at home.

Blood Pressure Criteria

  • Normal BP: < 120 mm Hg systolic and < 80 mm Hg diastolic
  • Elevated BP: 120 to 129 mm Hg systolic and < 80 mm Hg diastolic
  • Stage 1 Hypertension: 130 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic
  • Stage 2 Hypertension: 140 mm Hg or more systolic or 90 mm Hg or more diastolic
    • Summary Table:
      | Stage | Systolic | Diastolic |
      |------------------|------------------|-------------|
      | Elevated BP | 120-129 | < 80 | | Stage 1 | 130-139 | 80-89 | | Stage 2 | 140 or higher | > 90 |

Confirming the Diagnosis

  • Ensure proper diagnosis confirmation:
    • Measure BP in two positions.
    • Encourage at-home BP monitoring.
    • Patients should keep a written log (recommended at least once a week).
    • Consider laboratory tests including: CBC, CMP, TSH, FLP, EKG/ECHO, magnesium, and possibly HgbA1C.
    • Utilize a 24-hour ambulatory BP monitor if necessary.
    • Rule out white coat hypertension.
    • Special considerations for patients with BP > 160/90 or with symptoms or high-risk for complications.

Lifestyle Modifications for Hypertension

  • Dietary Approaches to Stop Hypertension (DASH Diet):
    • Focus on low salt, lean protein, low-fat dairy, whole grains, fruits, and vegetables.
    • Literature suggests potential BP reduction of 11/3 mm Hg with the DASH diet.
  • Physical Activity:
    • Encourage gentle exercise such as walking, yoga, mindfulness, and tai chi.
  • Weight Management & Conditions:
    • Weight loss and treatment for obstructive sleep apnea (OSA) are important.

When to Initiate Medication

  • Antihypertensive therapy indicated for:
    • BP exceeding 130/80 mm Hg.
    • Estimated 10-year risk for cardiovascular disease is 10% or more (assessed using ASCVD Risk Estimator Plus from the American College of Cardiology).

Choosing Antihypertensive Medication

  • First-line options include:
    • Diuretics.
    • Calcium Channel Blockers.
    • ACE Inhibitors.
    • Angiotensin II Receptor Blockers (ARBs).
  • Considerations for selection:
    • Evaluate patient conditions such as edema or dyspnea to choose diuretics.
    • Race/ethnicity considerations; African American patients may respond better to diuretics or calcium channel blockers.

Managing Uncontrolled Hypertension

  • If BP goals are not achieved:
    • Consider adding a second agent or combination medications.
    • Re-evaluate the patient and possibly perform further tests (e.g., MRI of the brain; CT of renal arteries).
    • It may take multiple medications; identify underlying issues (compliance, literacy, financial barriers, potential side effects).

Pediatric Hypertension

  • Based on the Task Force on Blood Pressure Control in Children:
    • Conduct lab tests including urinalysis, EKG/Echo (for left ventricular hypertrophy), and consider renal ultrasound.
    • The DASH diet is effective and recommended for children.
    • In children with diabetes, use ARBs or ACE inhibitors.
    • Calcium channel blockers or beta blockers for migraine headaches in children.

Special Populations

  • Diabetics:
    • Any first-line agent is applicable; use ACE or ARB if albuminuria is present.
  • Chronic Kidney Disease (CKD):
    • Caution with ACE/ARBs; discontinue if patient experiences hyperkalemia, hypotension, or reaches Stage V CKD.
  • Congestive Heart Failure:
    • Treatment goal: BP < 130/80 mm Hg.

Follow-Up Strategies

  • Ensure patients are monitoring their BP at home and keeping logs.
  • Address lifestyle factors: diet and physical exercise.
  • Emphasize 3 key points during consultations.
  • Importance of clear written communication (typing and printing preferred).
  • Focus on health literacy; repeat lab tests (e.g., BMP or CMP) in one month and review results with patients during follow-up visits.
  • Involve the patient in healthcare decision-making processes.