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Hypertension - 2016 Summary Document

Hypertension - 2016 Summary Document - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Cardiovascular, Related


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 Overweight or obesity (BMI ≥ 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
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
(≥ 140/90 mm Hg in a clinic setting), as multiple measurements over time have better predictive value for the
diagnosis of hypertension than a single measurement. The USPSTF recommends obtaining 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
“white coat” or “masked” hypertension. (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
ξA 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)
ξWork 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 ≥15%, age ≥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)
**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 Hospitals 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 Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2016CCKM@uwhealth.org