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Diagnosis and Management of Hypertension – Adult – Ambulatory

Diagnosis and Management of Hypertension – Adult – Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Cardiovascular


1
Diagnosis and Management of
Hypertension – Adult – Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................ 3
SCOPE ................................................................................................................. 4
METHODOLOGY .................................................................................................. 4
INTRODUCTION .................................................................................................. 5
RECOMMENDATIONS ......................................................................................... 5
Blood Pressure Screening ................................................................................... 5
Establishing the Diagnosis ................................................................................... 5
Treatment and Management .............................................................................. 7
Blood Pressure Classifications .......................................................................... 7
Treatment Goals .............................................................................................. 8
Monitoring and Laboratory Testing ................................................................. 9
Treatment Modalities- Lifestyle Modifications and Pharmacotherapy .......... 10
Table 5 – Lifestyle Modifications .................................................................... 10
Table 8 - Antihypertensive Doses and Adjustment Schedules ........................ 16
UW HEALTH IMPLEMENTATION ........................................................................ 17
APPENDIX A. EVIDENCE GRADING SCHEME(S) ................................................... 19
APPENDIX B. HOME BLOOD PRESSURE MONITORING ....................................... 21
REFERENCES ...................................................................................................... 22
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2


Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org

Coordinating Team Members:
Heather Johnson, MD, MS- Medicine- Cardiology
Jim Stein, MD- Medicine- Cardiology
Patrick McBride, MD- Medicine- Cardiology
Mukesh Singh, MD- Cardiology (SwedishAmerican)
Michael Thom, MD- Internal Medicine
Nancy Fuller, MD- Internal Medicine
Joel Buchanan, MD- Internal Medicine
Jeff Huebner, MD- Family Medicine/Population Health
Doug Smith, MD- Family Medicine
Pam Olson, MD- Family Medicine
Stephanie Gorham, MD- Family Medicine (SwedishAmerican)
Chris Danford, MD- Family Medicine Resident
Donald Wiebe, MD- Laboratory
Cindy Gaston, PharmD- Drug Policy Program
Sara Shull, PharmD- Drug Policy Program
Kristina Yokes, PharmD- Pharmacy- Ambulatory Clinics
Karen Kopacek, R. Ph- UW-Madison School of Pharmacy
Vonda Shaw- Cardiac Rehabilitation
Tami Schiltz- Clinical Nutrition
Diane Wendland, MD- Family Medicine (Unity Point Health- Meriter)
Heidi Vierstra- Unity Point Health- Meriter
Elaine Rosenblatt, MSN, FNP-BC- Unity Health Insurance
Heidi Wolf- Unity Health Insurance
Carl Nelson, PharmD- Unity Health Insurance
Erica Guetzlaff, PharmD- Group Health Cooperative

Review Individuals/Bodies:
Micah Chan, MD, MPH, FACP, FNKF, FASDIN- Medicine- Nephrology
Maryl Johnson, MD- Medicine- Cardiology
Vanessa Rein, MD- Medicine- Endocrinology
David Feldstein, MD- Internal Medicine
Jennifer Passini, MD- Medicine- Hospitalists
Elizabeth Chapman, MD- Medicine- Geriatrics
Holly Hanson, NP- Medicine- Hospitalists

Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 04/28/16)


Release Date: May 2016 | Next Review Date: April 2018





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3


Executive Summary
Guideline Overview
A UW Health multi-disciplinary group has developed this clinical practice guideline to assist in
identifying, diagnosing, treating, and monitoring adults 18 years and older with hypertension. In
preparation for the clinical practice update, the guideline workgroup reviewed the 2014
Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report, a
report from the panel members appointed to the Eighth Joint National Committee (JNC 8).
Additional trials and hypertension data not incorporated by the JNC 8 panel were also reviewed.

After comprehensive evaluation of the above mentioned sources, the guideline workgroup
expressed criticism for the methodology under which JNC 8 was developed and its
inconsistency with previous reports. The guideline workgroup agreed that this guideline would
be based primarily on the 2013 Clinical Practice Guidelines for the Management of
Hypertension in the Community: A Statement by the American Society of Hypertension and the
International Society of Hypertension. This document currently reflects the clinical practice
consensus of this committee and is supplemented by other individual articles or sources.

Key Revisions (2016 Focused Periodic Review)
1. Endorsed U.S. Preventive Services Task Force (USPSTF) blood pressure screening
recommendations, with modifications to best fit UW Health.
2. Revised blood pressure treatment goals based on recent publications (e.g., SPRINT).
3. Removed recommendations for BUN, fasting glucose, and annual lipid testing.
4. Removed recommendation for Mediterranean diet as primary dietary intervention for
patients with hypertension.

Key Practice Recommendations
1. This guideline and the USPSTF recommend obtaining blood pressure measurements
outside of the clinical setting to confirm a new diagnosis of hypertension before starting
treatment. Additional out-of-clinic readings are also recommended in patients suspected of
KDYLQJ�³ZKLWH�FRDW´�RU�³PDVNHG´�K\SHUWHQVLRQ��
2. Patients with a new diagnosis of hypertension should have an evaluation for possible
secondary causes of hypertension, especially obstructive sleep apnea.
3. Lifestyle modifications are the cornerstone of treatment for every patient (See Table 5 -
Lifestyle Modifications). Educate all patients to limit their sodium intake to 1,500 to 2,400
mg/day.
4. An ACE-inhibitor (or angiotensin receptor blocker) and/or a long-acting dihydropyridine
calcium channel blocker may be a more effective initial medication regimen than a thiazide
or thiazide-type diuretic.
5. Chlorthalidone (12.5 to 25 mg daily) is the recommended thiazide-type diuretic, rather than
hydrochlorothiazide (HCTZ).

Companion Documents
1. 2016 Diabetes Guideline: Key Practice Recommendations
2. Referral Criteria for Workplace HTN Screening
3. Standard Rooming Criteria ± Pediatric/Adult ± Ambulatory Guideline
4. Preventive Health Care ± Pediatric/Adult ± Ambulatory Guideline
5. Alcohol Assessment and Intervention ± Pediatric/Adult ± Ambulatory Guideline
6. Standards of Medical Care in Diabetes ± Pediatric/Adult ± Inpatient/Ambulatory Guideline
7. Tobacco Cessation ± Pediatric/Adult ± Inpatient/Ambulatory Guideline
8. Secondary Prevention of Atherosclerotic Cardiovascular Disease ± Adult ± Inpatient/Ambulatory
Guideline
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4


Scope
Disease/Condition(s): Hypertension

Clinical Specialty: Internal Medicine, Family Medicine, Obstetrics/Gynecology, Cardiovascular
Medicine, Nephrology, Neurology, Pharmacy, Laboratory

Intended Users: Physicians, Advanced Practice Providers, Nurses, RN Care Coordinators,
Pharmacists

Objective(s): To provide recommendations that reduce the incidence of stroke, myocardial
infarction, congestive heart failure, and kidney failure by identifying and treating hypertension.

Target Population: Adults age 18 years or older

Interventions and Practices Considered:
ξ Lifestyle modifications (e.g., weight management, physical activity, diet modifications)
ξ Pharmacological treatment

Major Outcomes Considered:
ξ Blood pressure reduction at or below goal

Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.


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5


Introduction
Hypertension is the most common condition seen in primary care and leads to myocardial
infarction, stroke, renal failure, and death if not detected early and treated appropriately.1,2
Patients want to be assured that blood pressure (BP) treatment will reduce their disease
burden; clinicians want guidance on hypertension management using the best scientific
evidence. This guideline takes a rigorous, evidence-based approach to recommend treatment
thresholds, goals, and use of medications in the management of hypertension in adults.
Evidence was drawn from randomized controlled trials and national guidelines for determining
efficacy and effectiveness.
Recommendations
BLOOD PRESSURE SCREENING
Factors which increase risk for high blood pressure include:2-5
ξ High-normal blood pressure/pre-hypertension (130-139/85-89 mmHg)
ξ Overweight or obesity �%0,�• 25 kg/m2 or > 23 kg/m2 in Asian Americans)
ξ Diabetes mellitus or impaired fasting glucose
ξ Tobacco use
ξ African American ancestry
ξ Family history of hypertension
ξ Secondary causes of hypertension (see Table 2)

The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood
pressure in adults aged 18 years or older.5 (USPSTF Grade A) Annual blood pressure screening
is recommended for adults aged •�40 years old and for all adults with an increased risk for high
blood pressure (see risk factors above).5 (UW Health Moderate quality evidence, strong
recommendation) Patients aged 18-39 years with normal blood pressure (< 130/85 mmHg), and
no other cardiovascular disease risk factors, should be rescreened every 3-5 years.5 (USPSTF
Grade A) Blood pressure measurements should be obtained using proper technique with manual
and/or validated automated devices.5,6
ESTABLISHING THE DIAGNOSIS
Patient Evaluation
Assess lifestyle and identify other cardiovascular disease (CVD) risk factors using personal
history, physical examination and selective testing.1,2 Evaluate for the presence of target organ
damage, CVD risk factors (Table 1), and potential secondary causes of hypertension (Table 2).1

Table 1 – Cardiovascular Disease Risk Factors and Target Organ Damage1,4
CARDIOVASCULAR DISEASE RISK FACTORS TARGET ORGAN DAMAGE
ξ Tobacco use
ξ Dyslipidemia
ξ Overweight (BMI
>25 kg/m2 or > 23
kg/m2 in Asian
Americans)
ξ Diabetes mellitus#
ξ Age (> 45 years for men; > 55
years for women)
ξ Physical inactivity
ξ Family history of early
vascular disease or
hypertension (women < 65
years; men < 55 years)
ξ Heart disease (left ventricular hypertrophy,
angina, prior MI, prior CABG, heart failure)
ξ Chronic kidney disease (CKD)
ξ CVA or TIA
ξ Peripheral arterial disease
ξ Retinopathy
BMI- body mass index; MI- myocardial infarction; CABG- coronary artery bypass graft; CVA- cerebrovascular accident ; TIA- transient ischemic attack
#Fasting glucose, oral glucose tolerance test (OGTT), or HgbA1C are appropriate tests to screen for diabetes mellitus.3
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6


Table 2 – Secondary Causes of Hypertension1,2
ξ Obstructive sleep apnea (OSA)
ξ CKD
ξ Thyroid or parathyroid disease
ξ Medications (stimulants, estrogen,
corticosteroids, erythropoietin alfa,
mineralocorticosteroids, cyclosporine,
tacrolimus, NSAIDS, herbals, OTC cold
medication, bupropion, triptans, SNRIs)
ξ Cushing syndrome
ξ Primary aldosteronism
ξ Pheochromocytoma
ξ Coarctation of the aorta
ξ Illicit stimulants (amphetamines,
methamphetamines, and cocaine)
ξ Alcohol abuse
ξ Renovascular disease/Renal artery
stenosis
NSAID- Non-steroidal antiinflammatory drug; OTC- over the counter; SNRI- serotonin- norepinephrine reuptake inhibitor

Blood Pressure Measurement and Diagnosis of Hypertension
1. Blood pressure measurements obtained using proper technique with manual and/or
validated automated devices are acceptable, however automated devices are preferable.6
(UW Health Moderate quality evidence, weak/conditional recommendation)

2. It is important to consider all blood pressure measurements in the clinical context of the
patient to avoid over- or under-diagnosis of hypertension (e.g., elevated measurement
expected during acute injury such as a broken wrist or low blood pressure in the setting of
dehydration).

3. The diagnosis of hypertension should be based on the presence of two or more elevated
EORRG�SUHVVXUHV�UHDGLQJV��•��������PP+J�LQ�D�FOLQLF�VHWWLQJ�, because multiple
measurements over time have better positive predictive value for the diagnosis of
hypertension than a single measurement.2,5 The USPSTF recommends obtaining blood
pressure measurements outside of the clinical setting to confirm a new diagnosis of
hypertension before starting treatment.5 (USPSTF Grade A) Measurements outside the clinic,
although optimal, may not always be possible due to patient barriers (including compliance).
(UW Health Moderate quality evidence, weak/conditional recommendation) Additional out-of-clinic
readings are also UHFRPPHQGHG�LQ�SDWLHQWV�VXVSHFWHG�RI�KDYLQJ�³ZKLWH�FRDW´�RU�³PDVNHG´�
hypertension.1,7-9 (UW Health Moderate quality evidence, strong recommendation)

Out-of-clinic blood pressure readings may be obtained via ambulatory blood pressure
monitoring (ABPM) or extended home blood pressure monitoring (HBPM).5,8,9 (USPSTF
Grade A) The USPSTF found convincing evidence that ABPM is the best method for
diagnosing hypertension, and considers it to be the reference standard for confirming the
diagnosis.5 24-hour ABPM is offered by the UW Preventive Cardiology Clinic (608-263-
7420). Alternatively, good quality evidence suggests that confirmation of hypertension with
HBPM may be acceptable.5

During extended HBPM, patients should initially monitor their home blood pressure 1-2
times per day at various times of the day, at least 5 times per week, over a 1-2 week
period.9 (UW Health Low quality evidence, weak/conditional recommendation) Patients should be
encouraged to bring their home blood pressure readings to their follow-up visit.

All patients should be advised to use a home blood pressure cuff. The home blood pressure
monitor should be automated, digital and have an upper arm cuff (not wrist or fingertip).6
(UW Health Moderate quality evidence, strong recommendation) Mobile health technologies
including smartphone apps should not be used.10 (UW Health Low quality evidence, strong
recommendation) (See Appendix B for equipment information)
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TREATMENT AND MANAGEMENT
Physicians are strongly encouraged to discuss the benefits and risks of treatment with their
patients. As the relationship between blood pressure and risk of CVD events is continuous and
independent of other risk factors, the benefits of blood pressure treatment are highest at higher
levels and diminish at lower blood pressures.1,11,12

Potential harms of hypertension treatment depend on the specific antihypertensive agent and
other patient-related factors (e.g., age, polypharmacy, left ventricular function, kidney function,
and co-morbidities) but may include hypotension, syncope, electrolyte abnormalities, and acute
kidney injury or acute renal failure.11,13 In the Systolic Blood Pressure Intervention Trial
(SPRINT), approximately 4.7% of patients assigned to the intensive treatment goal (systolic
blood pressure < 120 mmHg) compared to 2.5% of those with a standard goal (systolic blood
pressure < 140 mmHg) had serious adverse events that were possibly or definitely related to
the intervention. Syncope and hypotension (outside of the clinic) were more common in the
intensive-treatment group than in the standard treatment group; however the absolute difference
between groups was < 1% and there were no between-group differences for injurious falls.
Rates of acute kidney injury or acute renal failure were 1.8% higher (absolute difference) with
intensive treatment.13

Blood Pressure Classifications
Blood pressure is strongly related to CVD morbidity and mortality. Compared to patients with
normal blood pressure, there is a doubling of CVD risk in patients with pre-hypertension.1
Systolic hypertension is more predictive of events than diastolic blood pressure, especially in
patients over 40 years old.1

Table 3 outlines the blood pressure classifications at diagnosis.6 Classification is based on the
mean of two or more properly measured seated blood pressure readings on each of two or
more office visits, optimally confirmed with patient measurements as described above.

Table 3 – Blood Pressure Classifications and Management1,2,6
OFFICE BLOOD
PRESSURE
SYSTOLIC/DIASTOLIC
(mmHg)
LIFESTYLE
MODIFICATION
Normal < 120 / < 80 Encourage
Pre-hypertension 120-139 / 80-89 Yes
Stage 1 140-159 / 90-99 Yes
Stage 2 > 160 / > 100 Yes


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8


Treatment Goals
To prevent the complications of hypertension, set clear treatment goals based on the individual
SDWLHQW¶V�ULVN and values and preferences established through a shared-decision making
conversation; the systolic and diastolic blood pressure should be at goal:
1. For uncomplicated hypertension, including patients with chronic kidney disease (CKD)
without proteinuria, the goal is an office blood pressure <140/90 mmHg (home blood
pressure < 135/85 mmHg).1,2,14 (UW Health Moderate quality evidence, strong recommendation)

2. Patients with diabetes mellitus should be treated to a goal of < 140/90 mmHg.3 (ADA Grade
A) Lower targets, such as < 130/80 mmHg, may be appropriate for certain individuals such
as younger patients, those with albuminuria, and/or those with hypertension and one or
more additional atherosclerotic CVD risk factors, if they can be achieved without undue
treatment burden.3 (ADA Grade C) Younger patients are defined as < 40 years of age. (UW
Health Very low quality evidence, weak/conditional recommendation)

3. A lower office systolic blood pressure target of < 130 mmHg may also be considered in
individuals with left ventricular V\VWROLF�G\VIXQFWLRQ��/9()�” 40%), congestive heart failure
(with preserved or reduced ejection fraction), and CKD with proteinuria defined as urine
SURWHLQ�FUHDWLQLQH�UDWLR�• ���• 1 gram protein/24 houUV��RU�XULQH�SURWHLQ�&U�UDWLR�• 0.22 if
African-$PHULFDQ��• 300mg/24 hours).11,12,14-18 (UW Health Moderate quality evidence,
weak/conditional recommendation)

4. For patients > 50 years old with a systolic blood pressure > 130-180 mmHg and a history of
CVD or with increased CVD risk* a target systolic blood pressure closer towards 120 mmHg
is indicated, unless they have one of the following11-13 (UW Health High quality evidence,
weak/conditional recommendation):
ξ high antihypertensive medication burden** or intolerance to current regimen
ξ 1 minute standing SBP <110 mmHg
ξ history of CVA
ξ diabetes mellitus (see recommendation above for patients with diabetes mellitus)
ξ organ transplant
ξ pregnancy
ξ < 3 years expected survival
ξ reside in a skilled nursing facility
ξ difficulty with medication adherence including alcohol abuse, psychiatric disease,
history of non-compliance.

*Increased CVD risk is defined as one of the following: peripheral artery disease, abdominal
aortic aneurysm (AAA) > 5 cm with or without repair, 10-\HDU�)UDPLQJKDP�5LVN�6FRUH�•
�����DJH�• 75 years, left ventricular hypertrophy, ankle-brachial index ” 0.9, increased
coronary artery calcification (score > 400 Agatston units), abnormal stress test (with or
without imaging), 50% or greater coronary or carotid artery stenosis, CKD without
proteinuria (eGFR 20-59 ml/min/1.73 m2)

**Excessive number of baseline antihypertensive medications is defined as • 4 medications
and SBP <150 mmHg OR •���medications and SBP is 150-180 mmHg. These patients are
less likely to benefit from an intensive target (SBP ~120 mmHg) due to the large burden of
medications likely needed to achieve goal.


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9


Table 4 –Blood Pressure Treatment Goals
BLOOD PRESSURE GOALS POPULATION
HOME < 135/85 mmHg Uncomplicated hypertension, including diabetes mellitus or CKD
without proteinuria OFFICE < 140/90 mmHg
Additional Considerations
ξ A lower office systolic goal of < 130 mmHg may be considered in patients with LVEF <
40%, congestive heart failure, diabetes mellitus (< 40 years of age, albuminuria, and/or
those with one or more additional atherosclerotic CVD risk factor), and CKD with
proteinuria (urine protein/Cr ratio > 1 or > 0.22 in African-Americans)
ξ Work towards a systolic goal of 120 mmHg in patients > 50 years old with SBP > 130-
180 mmHg and history of CVD or with increased CVD risk* unless contraindicated**
*Increased CVD risk (one of the following): peripheral artery disease, AAA > 5 cm, 10-year Framingham Risk Score
•�����DJH�•���\HDUV��OHIW�YHQWULFXODU�K\SHUWURSK\��DQNOH-EUDFKLDO�LQGH[�” 0.9, increased coronary artery calcification
(score > 400 Agatston units), abnormal stress test (with or without imaging), 50% or greater coronary or carotid artery
stenosis, CKD without proteinuria (eGFR 20-59 ml/min/1.73 m2)

**Contraindications: High antihypertensive medication burden or intolerance to current regimen; one minute standing
SBP <110 mmHg; history of stroke; diabetes mellitus; organ transplant; pregnancy; < 3 years expected survival;
residing in a skilled nursing facility; difficulty with medication adherence including alcohol abuse, psychiatric disease,
history of non-compliance.
Monitoring and Laboratory Testing
1. Following diagnosis, blood pressure should be measured at each health care encounter.
(UW Health Low quality evidence, strong recommendation) Blood pressure control should be
assessed periodically at a clinic visit with a RN, APP or MD, however active telephone recall
has also demonstrated benefit in patients with low appointment adherence.1,19 (UW Health
Low quality evidence, strong recommendation)

Patients who are not at goal (and not undergoing medication adjustments) should be seen in
the clinic for assessment by a RN, APP, or MD at least every 3 months, whereas patients at
goal may be seen annually. (UW Health Very low quality evidence, weak/conditional
recommendation) All patients may be seen more frequently if deemed necessary per the
results of prior clinical assessments or need for medication adjustments.

2. Treatment decisions, including medication adjustments, should be based on office blood
pressure measurements that are considered within the full clinical context of each individual
patient. Ongoing home blood pressure monitoring (in addition to clinic measurements) is
recommended, as needed, to provide additional information for assessing treatment
response or for changes in clinical status.20(UW Health Moderate quality evidence, strong
recommendation) The home blRRG�SUHVVXUH�JRDO�LV�” 135/85 mmHg.6 (UW Health Moderate
quality evidence, strong recommendation)

Patients should be encouraged to bring their home blood pressure cuff to clinic as an
educational opportunity (e.g., to avoid improper use, evaluate appropriate size, etc.) and to
consider comparing office and home monitoring equipment (e.g., large discrepancies in
measurement). (UW Health Very low quality evidence, weak/conditional recommendation)

3. Check creatinine and potassium levels 1-2 weeks after medication initiation, at each dose
change, and every 12 months thereafter in patients on diuretics, ACE-Is, ARBs, or
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10
spironolactone.1-3,21 (UW Health Low quality evidence, strong recommendation) More frequent
monitoring may be needed if symptoms suggest renal or electrolyte disorders.
4. Check serum sodium after diuretic (including spironolactone) initiation, at each dose
change, and as needed to evaluate for hyponatremia. (UW Health Low quality evidence, strong
recommendation)
5. Additional laboratory monitoring (e.g., BUN, fasting lipid panel, fasting glucose) can be
considered for individual patients, but are no longer recommended based on a diagnosis of
hypertension alone.
Treatment Modalities- Lifestyle Modifications and Pharmacotherapy
Lifestyle Modifications
1. All patients should be encouraged to make lifestyle modifications, as these are the
cornerstone of treatment (Table 5).2,22 (UW Health High quality evidence, strong recommendation)
Lifestyle modifications can be as effective as pharmacological monotherapy and may
mitigate the need for drug or multi-drug treatment. They may also reduce the number and
dose of antihypertensive medications and can be as or more effective than drug
monotherapy. Lifestyle changes should be reinforced at every patient encounter, even after
medication initiation.
2. In patients with Stage 1 hypertension, without other CVD risk factors or target organ
damage, six months of monitored lifestyle modifications may be considered prior to initiating
an antihypertensive medication.2 (UW Health Moderate quality evidence, weak/conditional
recommendation)
3. Providers should consider referrals to registered dieticians and exercise experts to help
patients initiate lifestyle changes. (UW Health Very low quality evidence, weak/conditional
recommendation) Of the choices for dietary interventions, the DASH-Sodium diet is most
effective at lowering blood pressure.22 (UW Health High quality evidence, strong recommendation)
Table 5 – Lifestyle Modifications
LIFESTYLE ELEMENT
(Range of
Approximate SBP
Pressure Reduction)
RECOMMENDATIONS
COMMENTS
Patient handout: Lowering Blood Pressure with Lifestyle
Change
https://content.healthdecision.org/handouts/lower-bp
Weight
(5-20 mmHg/10kg
weight loss)
Weight loss in
patients who are
overweight or obese.
Weight loss can lower BP, increase the efficacy of
antihypertensive medications, and improve CVD risk factors
such as diabetes mellitus and dyslipidemia. As little as a 10
pound loss may improve BP. For every one pound of weight
loss, BP may decrease by 1-2 mmHg.
Alcohol
(2-4 mmHg)
Reduce or eliminate
alcohol.
Alcohol is a risk factor for hypertension, contributes excess
calories, can reduce efficacy of antihypertensive medications,
and increases the risk of stroke. Men should have no more
than 2, and women no more than 1, alcoholic drink(s) daily.
Examples of one drink are 12 oz. of beer, 4 oz. of wine, or 1
oz. of spirits.
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11
LIFESTYLE ELEMENT
(Range of
Approximate SBP
Pressure Reduction)
RECOMMENDATIONS
COMMENTS
Patient handout: Lowering Blood Pressure with Lifestyle
Change
https://content.healthdecision.org/handouts/lower-bp
Physical Activity
(4-9 mmHg)
30-45 minutes of
moderately intense
physical activity most
days of the week with
a minimum of 150
minutes per week.
Exercise contributes to weight loss and reduces the risks of
CVD and overall mortality. Patients at high risk should have
an exercise stress test prior to starting a new program.
Medically supervised exercise programs should be advised if
BP response to exercise is a concern (call UW Preventive
Cardiology Program 263-7420 for information about
monitored exercise sessions).
Patient handout: Making Exercise Part of Your Life
https://content.healthdecision.org/handouts/exercise-life
DASH (DASH-
Sodium) diet
(2-8 mmHg)
Limit to 1500-2400
mg/day.
African-Americans, patients > 65 years old, and patients with
diabetes mellitus are especially sensitive to changes in
sodium intake. Processed foods (canned soups and
vegetables, frozen and boxed dinners, chips, luncheon
meats, etc.) and foods eaten out are responsible for 50-75%
of the sodium in the American diet.
Patient handout: Dietary Approaches to Stop
Hypertension (DASH) Diet
https://content.healthdecision.org/handouts/dash-diet
Potassium,
Magnesium, and
Calcium
Recommendations
for good health:
Potassium ± 4700
mg/day
Diets high in potassium are especially effective for reducing
blood pressure in African- Americans.
POTASSIUM mg
Cooked beans, 1 c. 700-1000
Baked potato, 1 med. 850
Squash, sweet potato, 1 c. 900
Cooked spinach, 1 c. 850
Banana, 1 med. 600
Canned tomato, 1 c. 600
Orange juice, melon 1 c. 500
Most salt substitutes contain potassium. Although useful for
some patients, salt substitutes and high potassium diets
should not be used in patients with stage 4 or 5 CKD.
They should be used with caution in patients on ACE-Is,
ARBs, or aldosterone antagonists.
Tobacco and
second-hand
smoke
Smoking cessation
and avoidance of
second-hand smoke.
Tobacco and its by-products increase CVD risk and may
make antihypertensive medications less effective. Each
cigarette causes an increase in blood pressure. The CVD
benefits of smoking cessation are evident in one year.
For hypertension specialty consultants, contact the UW Health Advanced Hypertension Program at 608-263-1530
(http://www.uwhealth.org/hypertension/advanced-hypertension-clinic/41039). For additional nutrition information, contact the UW
Preventive Cardiology Program (608-263-7420), UWMF Health & Nutrition Education Department (608-287-2770), or UW Health
Outpatient Nutrition (608- 890-5500). Consult local facilities and providers for additional resources in your area.
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12
Pharmacotherapy
1. The choice of medication should be influenced by patient age, ethnicity/race, and other
clinical characteristics such as comorbidities or pregnancy status (Figure 1, Table 6 and
Table 7).2 (UW Health Moderate quality evidence, weak/conditional recommendation)
2. Most patients with hypertension require 2-3 drugs to get to their target blood pressure goal.1
Consider starting two medications for patients with blood pressure measurements > 20/10
mmHg above goal.1(UW Health Moderate quality evidence, weak/conditional recommendation)
Patients on pharmacotherapy should be monitored for possible side effects of medication to
help assure patient compliance (see Monitoring and Laboratory Testing section).
Figure 1 - Initiation and Titration of Antihypertensive Medication
Office blood pressure > 140/90 mmHg in
adults aged 18 years or older
(Recommended to confirm diagnosis with readings
outside of the clinic)
Start Lifestyle Modifications
(e.g., weight loss, physical activity, DASH-sodium diet, smoking cessation)
Stage 1 Drug Therapy
(140-159/90-99 mmHg)
(Consider a delay in uncomplicated Stage 1 patients*)
All Patients
Stage 2 Drug Therapy
(> 160/100 mmHg)
Special Cases
ξ Kidney disease
ξ Diabetes
ξ Coronary disease
ξ Stroke history
ξ Heart failure
See Tables 6 and 7
Black Patients
Non-Black
Patients
Age < 60
years?
ACE-I or ARB
Yes
CCB or Thiazide
No
ACE-I or ARB
If needed, add...
CCB + Thiazide + ACE-I (or ARB)
If needed...
CCB or Thiazide
If needed, add...
CCB or Thiazide
ACE-I or ARB
OR
combine CCB + Thiazide
If needed, add...
If needed...
Start with 2 drugs
CCB or Thiazide
+
ACE-I or ARB
If needed...
Add other drugs (e.g., spironolactone; centrally acting agents; β-blockers)
If needed, add...
Refer to Hypertension Specialist
If needed...
If needed...
*Six months of monitored lifestyle modifications may be considered in patients with Stage 1 hypertension, without other
cardiovascular risk factors or target organ damage, prior to initiating antihypertensive medications. | CCB: calcium channel blocker;
ACE-I: angiotensin-converting enzyme inhibitors; ARB: angiotensin receptor blocker
Figure adapted from the 2014 American Society of Hypertension and the International Society of Hypertension Guideline.2
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Table 6 - Treatment of Hypertension With and Without Compelling Indications2,5,23,24
Patient Type First Drug
Add Second Drug if
Needed to Achieve a BP
< 140/90 mmHg
If Third Drug is Needed
to Achieve a BP < 140/90
mmHg
A. When hypertension is the only or main condition
Black patients (African
ancestry): All ages CCB
a
or thiazide diuretic
ARBb or ACE inhibitor
(If unavailable can add
alternative first drug
choice)
Combination of CCB +
ACE inhibitor or ARB +
thiazide diuretic
White and other non-black
patients: < 60 years ARB
b
or ACE inhibitor CCBa or thiazide diuretic
Combination of CCB +
ACE inhibitor or ARB +
thiazide diuretic
White and other non-black
patients: > 60 years
CCBa or thiazide diuretic
(Although ACE inhibitors or
ARBs are also usually
effective)
ARBb or ACE inhibitor (for
CCB or thiazide if ACE
inhibitor or ARB used first)
Combination of CCB +
ACE inhibitor or ARB +
thiazide diuretic
B. When hypertension is associated with other conditions
Hypertension and diabetes
mellitus
ARB or ACE inhibitor
Note: In black patients, it is
acceptable to start with a
CCB or thiazide
CCB or thiazide diuretic
Note: In black patients, if
starting with a CCB or
thiazide, add an ARB or
ACE inhibitor
The alternative second
drug (thiazide or CCB)
Hypertension and chronic
kidney disease
ARB or ACE inhibitor
Note: In black patients,
good evidence for renal
protective effects of ACE
inhibitors
CCB or thiazide diureticc The alternative second
drug (thiazide or CCB)
Hypertension and clinical
coronary artery diseased
Ǻ-blocker plus ARB or
ACE inhibitor CCB or thiazide
The alternative second
drug (thiazide or CCB)
Hypertension and stroke
historye
ACE inhibitor or ARB Thiazide diuretic or CCB The alternative second
drug (CCB or thiazide)
Hypertension and heart failure
Patients with symptomatic heart failure should usually receive an ARB or ACE inhibitor
� ȕ-blocker + diuretic + spironolactone regardless of blood pressure. A dihydropyridine
CCB can be added if needed for BP control
Abbreviations: ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; BP = blood pressure; CCB =
calcium channel blocker; eGFR = estimated glomerular filtration rate
a CCBs are generally preferred, but thiazides may cost less.
b ARBs can be considered because ACE inhibitors can cause cough and angioedema, although ACE inhibitors may cost
less.
c
If eGFR < 40 mL/min, a loop diuretic (e.g., furosemide or torsemide) may be needed.
d 1RWH��,I�KLVWRU\�RI�P\RFDUGLDO�LQIDUFWLRQ��D�ȕ-blocker and ARB/or ACE inhibitor are indicated regardless of blood
pressure.
e Note: If using a diuretic, there is good evidence for indapamide (if available).
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14


Table 7 – Compelling Indicators: Heart Failure and Chronic Kidney Disease2

HEART FAILURE

ξ ACE-I (or ARB) is indicated in nearly all
patients with LV systolic dysfunction.

ξ ACE-I (or ARB) should be titrated to target
heart failure doses, even if blood pressure
is low, as long as the patient does not
become symptomatic or develop impaired
renal perfusion.

ξ Beta Blockers (carvedilol and metoprolol
succinate) in nearly all patients with LV
systolic dysfunction Titrate to target heart
failure doses.

ξ Consider spironolactone after the patient is
placed on the maximum doses of ACE-I
and beta-blocker, especially if Class III or
IV heart failure or LV ejection fraction is <
40%.

ξ Diuretics (usually loop) are often required
for fluid management.

CHRONIC KIDNEY DISEASE (CKD)

Stages of CKD
Stage Description GFR
(mL/min/1.73m²)
1 Kidney damage with normal GFR >90
��������.LGQH\�GDPDJH�ZLWK�PLOG�Ļ�*)5�������������-89
��������0RGHUDWH�Ļ�*)5��������������������������������������-59
��������6HYHUH�Ļ�*)5�����������������������������������������-29
5 Kidney failure <15 (or dialysis)

CKD is defined as either kidney damage or GFR <60 mL/min/1.73
m² for 3 months. Kidney damage is defined as pathologic
abnormalities or markers for damage, including abnormalities in
blood or urine tests or imaging studies.

ξ ACE-,�DQG�$5%¶V�FDQ�VORZ�SURJUHVVLRQ�RI�NLGQH\�GLVHDVH�23
ξ A limited increase in serum creatinine of as much as 30%
above baseline with ACE-I or ARB is acceptable and not a
reason to withhold treatment, unless hyperkalemia develops.
ξ In CKD stages 4 and 5 (estimated glomerular filtration rate <30
mL/min/per 1.73 m²) higher doses of loop diuretics may be
needed in combination with other drug classes.

Diuretics24-26
1. Typically thiazide-type diuretics are used instead of loop diuretics unless the patient has
fluid retention that does not respond (such as patients with LV systolic dysfunction or
advanced kidney disease).
2. Diuretics should be considered part of all triple medication regimens, though do not need to
be the first or second line medications, as previously recommended. They are especially
useful in patients with edema, who are overweight, or in the elderly.
3. Chlorthalidone (12.5-25 mg daily) is the recommended thiazide-type diuretic rather than
hydrochlorothiazide (HCTZ).27,28 It is longer acting and a more potent antihypertensive;
however more careful monitoring for electrolyte and renal disturbances is needed.
4. Diuretics are synergistic with other classes of antihypertensive medications.
5. Low doses of thiazide-type diuretics should be used unless the patient has heart failure or
chronic kidney disease and GFR <30-40 mg/min, then use a loop diuretic (furosemide).
6. $�GLXUHWLF�PXVW�EH�DGGHG�SULRU�WR�GLDJQRVLQJ�D�SDWLHQW�ZLWK�³UHVLVWDQW�K\SHUWHQVLRQ´��
5HVLVWDQW�K\SHUWHQVLRQ�LV�XQFRQWUROOHG�EORRG�SUHVVXUH�RQ�•��GUXJV��RI�ZKLFK�RQH�LV�D�
diuretic, or controlled on 4 drugs including a diuretic. Secondary causes should be strongly
considered in these patients, with the most likely being OSA, hyperaldosteronism, or chronic
kidney disease.
7. High dose diuretics can worsen insulin resistance and dyslipidemia in susceptible
individuals, such as those with diabetes mellitus or the metabolic syndrome.

ACE-I AND ARB2,23-26,29,30
1. Use long-acting agents for once per day dosing. Losartan is the weakest ARB and is best
dosed twice daily.
2. Angiotensin antagonists can be effective as first-line antihypertensive agents (or in
combination with diuretics) especially if the potassium level is low or low-normal.
3. $5%¶V�DUH�DOWHUQDWLYHV�IRU�SDWLHQWV�ZLWK�$&(-I associated cough or angioedema.
4. In patients with chronic kidney disease, use ACE-I or ARB.
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15


5. After initiating an ACE-I or ARB, an acceptable rise in serum creatinine is up to 30% without
stopping the medication. Repeat the creatinine in 2-4 weeks to confirm that it has stabilized
or decreased.
6. Contraindicated in pregnant patients. Women of child-bearing potential should be counseled
about risks of pregnancy.
7. Avoid combining ACE-Is with ARBV��WKLV�FRPELQDWLRQ�FDQ�LQFUHDVH�D�SDWLHQW¶V�risk for
adverse renal events.

CALCIUM CHANNEL BLOCKERS25,26,29-31
1. Amlodipine, long-acting nifedipine, and felodipine are very effective at lowering blood
pressure. Diltiazem and verapamil can effectively lower blood pressure at high doses, but
may cause bradycardia and constipation. Calcium channel blockers may cause lower
extremity edema.
2. Do not use short-acting nifedipine.

ALDOSTERONE ANTAGONISTS
1. Low dose spironolactone (12.5-25 mg daily) can be very effective as a 3rd or 4th line agent,
especially in overweight patients and patients with hypokalemia. Lab monitoring is required
after starting spironolactone to evaluate for hyperkalemia.

BETA-BLOCKERS25,32
1. No longer recommended as a first-, second- or third-line antihypertensive agents unless
there is a compelling indication (e.g., coronary artery disease, LV systolic dysfunction, atrial
fibrillation rate control, etc.).
2. Combined alpha-beta-blockers (i.e., carvedilol, labetalol) are much more effective and less
likely to cause metabolic disturbances than high dose pure beta-blockers (like atenolol and
metoprolol).
3. Can worsen insulin resistance and dyslipidemia in susceptible individuals, such as those
with diabetes mellitus or the metabolic syndrome.
4. Beta-blockers should be used cautiously in patients with type I diabetes mellitus because of
the potential to mask hypoglycemia.

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16


Table 8 - Antihypertensive Doses and Adjustment Schedules
Medication Starting Dose (mg)
Minimum Interval Between Dose
Adjustments
Usual Dose
(mg)
Max Dose
(mg)
Doses
per Day
Angiotensin-converting enzyme inhibitors (ACE-I)
Benazepril 5-10
Increase every 1-2 weeks
10-40 40 1
Enalapril 2.5-5 5-10 40 1-2
Lisinopril 5-10 10-40 40 1
Captopril 12.5-25 25-50 50 2-3
Quinapril 5-20 10-80 80 1
Fosinopril 10 10-40 80 1
Perindopril 2-4 4-8 16 1
Trandolapril 1-2 2-4 8 1
Ramipril 2.5 5-10 20 1
Consider lower starting dose when receiving concomitant diuretics or in volume depleted state
Angiotensin II receptor blockers (ARB)
Losartan 25-50
Increase every 1-4 weeks
50-100 100 2
Valsartan 80-160 80-320 320 1
Candesartan 8 8-32 32 1
Irbesartan 75-150 150-300 300 1
Olmesartan 10-20 20-40 40 1
Telmisartan 20-40 40-80 80 1
Azilsartan medoxomil 40 80 80 1
Consider lower starting dose when receiving concomitant diuretics or in volume depleted state
Calcium channel blockers (CCB) – Dihydropyridine
Amlodipine 2.5-5 Increase in 2.5 mg increments
every 1-2 weeks
5-10 10 1
Nifedipine ER 30-60 Increase every 1-2 weeks 30-90 120 1
Felodipine 2.5-5 Increase in 5 mg increments every 1-2 weeks 5-10 10 1
Calcium channel blockers (CCB) – Non-dihydropyridine
Diltiazem ER 120-180 Increase every 2 weeks 120-360 360 1
Verapamil IR: 120-240
SR: 120-180
ER: 180hctz
Increase every 1-2 weeks
IR: 80-320
SR: 120-360
ER: 120-360
IR: 320
SR: 360
ER: 360
IR: 1
SR: 1-2
ER: 1
Thiazide diuretics
Chlorthalidone 12.5-25
Increase after a suitable trial
12.5-25 25 1
Hydrochlorothiazide 12.5-25 12.5-25 25 1
Indapamide 1.25 Double dose every 4 weeks 1.25-2.5 5 1
Loop diuretics
Furosemide 20
Increase as tolerated
20-80 80 2
Bumetanide 0.5 0.5-2 5 2
Torsemide 5 2.5-10 10 1
Beta-blockers (BB)
Atenolol 25
Increase every 1-2 weeks
25-100 100 1
Metoprolol tartrate 50 50-100 200 2
Metoprolol succinate 25-50 50-100 200 1
Nadolol 40 40-120 320 1
Propranolol IR: 80
LA: 80
IR: 80-320
LA: 80-320
IR: 320
LA: 320
IR: 2
LA: 1
Bisoprolol 2.5-5 5-10 20 1
Carvedilol 12.5 12.5-50 50 2
Labetalol 100 Increase by 200 mg every 2-3 days 200-400 400 2
Aldosterone blocker
Spironolactone 25 12.5-25 25 1
Eplerenone 50 50-100 100 1-2
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17


UW Health Implementation
Potential Benefits:
ξ Reduction in CVD morbidity and mortality with proper blood pressure control

Potential Harms:
ξ ACE-Is and ARBs are contraindicated in patients who are pregnant
ξ Medication-specific side-effects such as lab abnormalities, syncope, hypotension
ξ Sleep disturbances or discomfort using out-of-office blood pressure monitoring devices

Pertinent UW Health Policies & Procedures
1. UWMF Policy 102.097- Allied Health Blood Pressure Visit

Patient Resources
1. Health Facts For You #379- Heart Health: The DASH Diet
2. Health Facts For You #4462- High Blood Pressure
3. Health Facts For You #7761- Hypertension Medicines- ACE Inhibitors
4. Health Facts For You #7762- Hypertension Medicines- ARBs (Angiotensin Receptor Blockers)
5. Health Facts For You #7765- Hypertension Medicines- Beta-Blockers
6. Health Facts For You #7764- Hypertension Medicines- Calcium Channel Blockers
7. Health Facts For You #7763- Hypertension Medicines- Diuretics
8. Health Facts For You #7684- Taking Your Blood Pressure at Home
9. Health Facts For You #523- Heart Health: Resources for Heart- Healthy Living
10. Health Facts For You #6246- The Benefits of Exercise
11. Health Facts For You #5117- Potassium Sparing Diuretics
12. Health Facts For You #4678- Loop Diuretics (oral)
13. Health Facts For You #5041- Thiazide Diuretics (oral)
14. Health Facts For You #5817- Your Risk of Heart and Vascular Disease
15. Healthwise- Blood Pressure Test: Home
16. Healthwise- Blood Pressure: Elevated
17. Healthwise- Diet: DASH
18. Healthwise- Hypertension
19. Healthwise- Hypertension: General Info
20. Healthwise- Hypertension: Acute
21. Health Information- Angiotensin II Receptor Blockers (ARBs) for High Blood Pressure
22. Health Information- Angiotensin-Converting Enzyme (ACE) Inhibitors for High Blood Pressure
23. Health Information- Antihypertensive Medications, Deciding About
24. Health Information- Automated Ambulatory Blood Pressure Monitoring
25. Health Information- Beta-Blockers for High Blood Pressure
26. Health Information- Blood Pressure Screening
27. Health Information- Blood Pressure Monitoring at Home
28. Health Information- Blood Pressure Numbers: When to Get Help
29. Health Information- Calcium Channel Blockers for High Blood Pressure
30. Health Information- DASH Diet Sample Menu
31. Health Information- Direct Renin Inhibitors for High Blood Pressure
32. Health Information- Diuretics for High Blood Pressure
33. Health Information- High Blood Pressure: Should I Take Medicine?
34. Health Information- High Blood Pressure in African Americans
35. Health Information- High Blood Pressure Treatment Guidelines
36. Health Information- Home Blood Pressure Test
37. Health Information- Hypertension (High Blood Pressure)
38. Health Information- Hypertension: Checking your blood pressure at home
39. Health Information- Hypertension: Taking medicines properly
40. Health Information- Hypertension: Using the DASH diet
41. Health Information- Other Medicines for High Blood Pressure
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18


42. Health Information- Prehypertension
43. Health Information- Secondary High Blood Pressure
44. The DASH Diet (https://content.healthdecision.org/handouts/dash-diet)
45. Lowering Blood Pressure with Lifestyle Change (https://content.healthdecision.org/handouts/lower-bp)
46. Making Exercise Part of Your Life (https://content.healthdecision.org/handouts/exercise-life)

Guideline Metrics
WCHQ (2015)
1. CKD Screening- % of patients age 18-85 years with either diabetes or hypertension (excluding those
with CKD and ESRD) who had an eGFR test during the last year.
2. Blood Pressure Control in CKD Stages I, II, III- % age 18-85 years with a diagnosis of CKD in stage I,
II, or III (excluding those with CKD in stages IV or V or with ESRD) whose most recent blood pressure
reading within the last year is controlled to a rate of < 140/90 mmgHg.
3. Blood Pressure Control in CKD Stages IV, V- % age 18-85 years with a diagnosis of CKD in stage IV
or V (excluding ESRD) whose most recent blood pressure reading within the last year is controlled to
a rate of < 140/90 mmHg.
4. Blood Pressure Control in Diabetes- % age 18-75 years whose most recent blood pressure reading
within the last year is controlled to a rate of < 140/90 mmHg.
5. Blood Pressure Control in IVD- % age 18-75 years with a diagnosis of IVD whose most recent blood
pressure reading within the last year is controlled to a rate of < 140/90 mmHg.
6. High Blood Pressure- % age 18-85 years who have a diagnosis of essential hypertension and whose
blood pressure was adequately controlled based on JNC 8 goals: < 140/90 mmHg for patients less
than 60 years of age or patients of any age with a diagnosis of diabetes and/or chronic kidney
disease; < 150/90 for patients 60 years of age and older without diabetes or chronic kidney disease.

ACO-MSSP (2016)
1. %of patients age 18-85 years who had a diagnosis of hypertension and whose blood pressure was
adequately controlled (< 140/90 mmHg) during the measurement period.

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing Newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the guideline
recommendations (such as the following) will be reviewed for consistency and modified as
appropriate.

Delegation Protocols
Hypertension Lab Ordering ± Adult [78]; Antihypertensive Medication Titration [99]
Prescription Renewal Delegation Protocol- UW Health Primary Care Clinics

eConsults
UWOP ECONSULT TO CARDIOLOGY- HYPERTENSION [5626]

Order Sets & Smart Sets
Advanced Hypertension [5068]; Blood Pressure (Allied Health Visit) [5055]; HTN [5094];
Kidney- Hypertension Clinic [3285]

Reporting Workbench Report
Multi-condition Report

Smart Texts
Home BP Monitoring [34557]; Goal BP [34550]; Buy Home BP Cuff [34555]; BP Check [34546]



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19


Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
LQWHQGHG�WR�UHSODFH�D�FOLQLFLDQ¶V�MXGJPHQW�RU�WR�HVWDEOLVK�D�SURWRFRO�IRU�DOO�SDWLHQWV��,W�LV�
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

Appendix A. Evidence Grading Scheme(s)

Grading of Recommendations Assessment, Development and Evaluation (GRADE)

Figure 1. GRADE Methodology adapted by UW Health

GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and
circumstances are unlikely to affect the decision.
Weak/Conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.



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20


U.S. Preventive Services Task Force (USPSTF)

USPSTF Grades for Recommendations
Grade Definition
A The USPSTF recommends the service. There is high certainty that the net benefit is
substantial.
B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
C
The USPSTF recommends selectively offering or providing this service to individual
patients based on professional judgment and patient preferences. There is at least
moderate certainty that the net benefit is small.
D The USPSTF recommends against the service. There is moderate or high certainty that
the service has no net benefit or that the harms outweigh the benefits.
I Statement
The USPSTF concludes that the current evidence is insufficient to assess the balance of
benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and
the balance of benefits and harms cannot be determined.

American Diabetes Association (ADA)

ADA Grading Scheme
Level of
Evidence Description
A
Clear evidence from well-conducted, generalizable RCTs that are adequately powered,
including:
ξ Evidence from a well-conducted multicenter trial
ξ Evidence from a meta-analysis that incorporated quality ratings in the analysis

Compelling non-H[SHULPHQWDO�HYLGHQFH��L�H���³DOO�RU QRQH´�UXOH�GHYHORSHG�E\�WKH�&HQWHU�IRU�
Evidence-Based Medicine at the University of Oxford

Supportive evidence from well-conducted RCTs that are adequately powered, including:
ξ Evidence from a well-conducted trial at one or more institutions
ξ Evidence from a meta-analysis that incorporated quality ratings in the analysis
B
Supportive evidence from well-conducted cohort studies
ξ Evidence from a well-conducted prospective cohort study or registry
ξ Evidence from a well-conducted meta-analysis of cohort studies

Supportive evidence from a well-conducted case-control study
C
Supportive evidence from poorly controlled or uncontrolled studies
ξ Evidence from randomized clinical trials with one or more major of three or more
minor methodological flaws that could invalidate the results
ξ Evidence from observational studies with high potential for bias (such as case series
with comparison with historical controls)
ξ Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation
E Expert consensus or clinical experience

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21


Appendix B. Home Blood Pressure Monitoring

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22


References
1. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure:
the JNC 7 report. JAMA. May 2003;289(19):2560-2572.
2. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the
management of hypertension in the community: a statement by the American Society of
Hypertension and the International Society of Hypertension. J Clin Hypertens
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3. Association AD. Professional Practice Committee for the Standards of Medical Care in
Diabetes-2016. Diabetes Care. Jan 2016;39 Suppl 1:S107-108.
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6. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure
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9. Shimbo D, Abdalla M, Falzon L, Townsend RR, Muntner P. Role of Ambulatory and
Home Blood Pressure Monitoring in Clinical Practice: A Narrative Review. Ann Intern
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10. Plante TB, Urrea B, MacFarlane ZT, et al. Validation of the Instant Blood Pressure
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11. Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on
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13. Wright JT, Williamson JD, Whelton PK, et al. A Randomized Trial of Intensive versus
Standard Blood-Pressure Control. N Engl J Med. Nov 2015;373(22):2103-2116.
14. Appel LJ, Wright JT, Greene T, et al. Intensive blood-pressure control in hypertensive
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15. Lee DS, Vasan RS. Goals and guidelines for treating hypertension in a patient with heart
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Heart Association Task Force on Practice Guidelines. Circulation. Jun 2014;129(25
Suppl 2):S76-99.
23. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and
cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J
Med. Sep 2001;345(12):861-869.
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among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet. Sep
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Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

2016 Hypertension Guideline: Key Practice Recommendations

Blood Pressure Screening
When to
Screen
Adults > 18 years old without known hypertension (HTN)
should be screened for high blood pressure. (USPSTF Grade A)
Risk factors:
ξ High-normal blood pressure/pre-
hypertension (130-139/85-89 mm Hg)
ξ KǀĞƌǁĞŝŐŚƚ�Žƌ�ŽďĞƐŝƚLJ�;�D/�ш�Ϯϱ�ŬŐͬŵ2 or
> 23 kg/m2 in Asian-Americans)
ξ Diabetes mellitus or impaired fasting glucose
ξ Tobacco use
ξ African American ancestry
ξ Family history of hypertension
ξ Secondary causes of hypertension
Screening
Interval
Adults > 40 years old and all those at increased risk for high
blood pressure should be rescreened annually.
Patients aged 18-39 years with normal blood pressure
(< 130/85 mm Hg), and no other cardiovascular disease
(CVD) risk factors, should be rescreened every 3-5 years.
Establishing the Diagnosis
1. It is important to consider all blood pressure measurements in the clinical context of the patient (e.g., elevated
measurement expected during acute injury such as a broken wrist or hypotension during dehydration).

2. The diagnosis of hypertension should be based on the presence of two or more elevated blood pressures readings
;ш�ϭϰϬͬϵϬ�ŵŵ�,Ő�ŝŶ�Ă�ĐůŝŶŝĐ�ƐĞƚƚŝŶŐͿ͕�ĂƐ�ŵƵůƚŝƉůĞ�ŵĞĂƐƵƌĞŵĞŶƚƐ�ŽǀĞƌ�ƚŝŵĞ�ŚĂǀĞ�ďĞƚƚĞƌ�ƉƌĞĚŝĐƚŝǀĞ�ǀĂůƵĞ�ĨŽƌ�the
diagnosis of hypertension than a single measurement. The USPSTF recommends obt aining blood pressure
measurements outside of the clinical setting to confirm a new diagnosis of hypertension before starting
treatment. (USPSTF Grade A) Additional out-of-clinic readings are also recommended in patients suspected of having
͞ǁŚŝƚĞ�ĐŽĂƚ͟�Žƌ�͞ŵĂƐŬĞĚ͟�ŚLJƉĞƌƚĞŶƐŝŽŶ. (UW Health Moderate quality evidence, strong recommendation)

3. Out-of-clinic blood pressure readings may be obtained via ambulatory blood pressure monitoring (ABPM) or
extended home blood pressure monitoring (HBPM). (USPSTF Grade A)
ξ 24-hour ABPM is offered by the UW Preventive Cardiology Clinic (608 -263-7420).
ξ During HBPM, patients should initially monitor their home blood pressure 1-2 times per day at various times of
the day, at least 5 times per week, over a 1-2 week period. (UW Health Low quality evidence, weak/conditional
recommendation) Encourage patients to bring their home blood pressure readings to their next follow-up visit.
ξ All patients should be advised to use a home blood pressure cuff. The home blood pressure monitor should be
automated, digital and have an upper arm cuff (not wrist or fingertip). (UW Health Moderate evidence, strong
recommendation) Mobile health technologies including smartphone apps should NOT be used. (UW Health Low quality
evidence, strong recommendation)
Target Blood Pressure Goals
BLOOD PRESSURE GOALS (mmHg) POPULATION
HOME < 135/85
Uncomplicated HTN, including diabetes mellitus or CKD without proteinuria OFFICE < 140/90
Additional Considerations
ξ A lower office systolic goal of < 130 mmHg may be considered in patients with LVEF < 40%, congestive heart failure, diabetes
mellitus (< 40 years of age, albuminuria, and/or those with one or more additional atherosclerotic CVD risk factor), and CKD with
proteinuria (urine protein/Cr ratio > 1 or > 0.22 in African-Americans)
ξ Work towards a systolic goal of 120 mmHg in patients > 50 years old with SBP > 130-180 mmHg and history of CVD or with
increased CVD risk* unless contraindicated**
*Increased CVD risk (one of the following): peripheral artery disease, AAA > 5 cm, 10-LJĞĂƌ�&ƌĂŵŝŶŐŚĂŵ�ZŝƐŬ�^ĐŽƌĞ�шϭϱй͕�ĂŐĞ�шϳϱ�LJĞĂƌƐ͕�ůĞĨƚ�
ventricular hypertrophy, ankle-ďƌĂĐŚŝĂů�ŝŶĚĞdž�ч 0.9, increased coronary artery calcification (score > 400 Agatston units), abnormal stress test (with
or without imaging), 50% or greater coronary or carotid artery stenosis, CKD without proteinuria ( eGFR 20-59 ml/min/1.73 m2)

**Contraindications: High antihypertensive medication burden or intolerance to current regimen; one minute standing SBP <110 mmHg; history of
stroke; diabetes mellitus; organ transplant; pregnancy; < 3 years expected survival; residing in a skilled nursing facility; difficulty with medication
adherence including alcohol abuse, psychiatric disease, history of non-compliance.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

2016 Hypertension Guideline: Key Practice Recommendations

Monitoring and Lab Testing
1. Check creatinine and potassium levels 1-2 weeks after medication initiation, at each dose change, and every 12
months thereafter in patients on diuretics, ACE-Is, ARBs, or spironolactone. (UW Health Low quality evidence, strong
recommendation)
2. Check serum sodium after diuretic (including spironolactone) initiation, at each dose change, and as needed to
evaluate for hyponatremia. (UW Health Low quality evidence, strong recommendation)
3. Patients who are not at goal (and not undergoing medication adjustments) should be seen in the clinic for
assessment by a RN, APP, or MD at least every 3 months, whereas patients at goal may be seen annually. (UW Health
Very low quality evidence, weak/conditional recommendation) All patients may be seen more frequently if deemed necessary
per the results of prior clinical assessments or need for medication adjustments.
4. Treatment decisions, including medication adjustments, should be based on office blood pressure measurements
that are considered within the full clinical context of each individual patient. Ongoing home blood pressure
monitoring (in addition to clinic measurements) is recommended, as needed, to provide additional information for
assessing treatment response or for changes in clinical status. (UW Health Moderate quality evidence, strong recommendation)
5. Patients should be encouraged to bring their home blood pressure cuff to clinic as an educational opportunity (e.g.,
to avoid improper use, evaluate appropriate size, etc.) and to consider comparing office and home monitoring
equipment (e.g., large discrepancies in measurement). (UW Health Very low quality evidence, weak/conditional recommendation)

Figure 1. Initiation and Titration of Antihypertensive Medications
Office blood pressure > 140/90 mmHg in
adults aged 18 years or older
(Recommended to confirm diagnosis with readings
outside of the clinic)
Start Lifestyle Modifications
(e.g., weight loss, physical activity, DASH-sodium diet, smoking cessation)
Stage 1 Drug Therapy
(140-159/90-99 mmHg)
(Consider a delay in uncomplicated Stage 1 patients*)
All Patients
Stage 2 Drug Therapy
(> 160/100 mmHg)
Special Cases
ξ Kidney disease
ξ Diabetes
ξ Coronary disease
ξ Stroke history
ξ Heart failure
See Tables 6 and 7
Black Patients
Non-Black
Patients
Age < 60
years?
ACE-I or ARB
Yes
CCB or Thiazide
No
ACE-I or ARB
If needed, add...
CCB + Thiazide + ACE-I (or ARB)
If needed...
CCB or Thiazide
If needed, add...
CCB or Thiazide
ACE-I or ARB
OR
combine CCB + Thiazide
If needed, add...
If needed...
Start with 2 drugs
CCB or Thiazide
+
ACE-I or ARB
If needed...
Add other drugs (e.g., spironolactone; centrally acting agents; β-blockers)
If needed, add...
Refer to Hypertension Specialist
If needed...
If needed...

*Six months of monitored lifestyle
modifications may be considered in
patients with Stage 1 hypertension,
without other cardiovascular risk
factors or target organ damage,
prior to initiating antihypertensive
medications.
CCB: calcium channel blocker; ACE-I:
angiotensin-converting enzyme inhibitors;
ARB: angiotensin receptor blocker
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org

UW Health Referral Criteria for Workplace Hypertension (HTN) Screening
These general referral criteria are intended to provide guidance to clinical staff (e.g., RN) screening for
hypertension (HTN) in workplace sites affiliated with UW Health clinics. They are general criteria that do
not take into account underlying patient conditions or co-morbidities (e.g., presence of diabetes or
kidney disease, etc.). In all cases, clinical staff conducting screening will use professional judgement and
refer patients to their primary care physician (PCP) if/when concerns regarding blood pressure or other
patient conditions warrant additional follow-up.
In particular, emergency medical services should be contacted for patients experiencing symptoms of
hypoperfusion (e.g., lightheadedness, dizziness, nausea, clammy skin, blurry vision, loss of
consciousness) or hypertension (e.g., hypertensive crisis, such as severe headaches, severe anxiety,
shortness of breath, nosebleeds).
Range Action
< 130/80 mmHg with symptoms of hypoperfusion Call 911
< 130/80 mmHg without symptoms of hypoperfusion No action
130-139 / 80-89 mmHg and no blood pressure-related
symptoms
Encourage lifestyle modification per UW Health
HTN guideline and continue care with PCP
140-159 / 90-109 mmHg and no blood pressure-
related symptoms Refer to PCP to be seen within next 6 weeks
160-179 / 110-119 mmHg with no blood pressure-
related symptoms Refer to PCP to be seen within the next week
180-209 / 110-119 mmHg with no blood pressure-
related symptoms Refer to PCP to be seen within the 3 days
ш 210/120 mmHg without blood pressure-related
symptoms Call PCP
ш 210/120 mmHg with blood pressure-related
symptoms Call 911
Additional References:
- Refer to UW Health Preventive Care Guideline for information on blood pressure screening.
- Refer to UW Health Hypertension Guideline for information about blood pressure monitoring and
treatment, including lifestyle modifications that can be recommended.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org