Mount Carmel Health Partners Clinical Guidelines Hypertension

Diagnosis Treatment ( for adults 18 years or older) Hypertension is generally diagnosed on the basis of a persistently high blood pressure. Usually this requires three separate sphygmomanometer measurements at least one week apart. Ini al assessment should include a complete history and physical exam. If the eleva on is extreme, however, or if symptoms of organ damage are present, then the diagnosis may be given and treatment should start immediately. Timely achievement of blood pressure targets within 6 weeks with aggressive follow-up monitoring and medica on adjustment is an important factor in minimizing the risk of adverse cardiovascular outcomes. • Normal: SBP less than 140mm Hg and DBP less than 90mm HG Secondary Causes of Hypertension • Primary renal disease • Primary aldosteronism • Pheochromocytoma • Cushing’s syndrome • Sleep apnea syndrome • Coarcta on of the aorta • Hypothyroidism and Hyperthyroidism • Primary Hyperparathyroidism • S mulants (e.g., cocaine, methylphenidate) /Alcohol Induced Treatment should begin by making therapeu c lifestyle changes including weight reduc on, diet modiﬁca on by reducing animal products and sodium while increasing intake of plant products, reduce alcohol consump on, cessa on of tobacco use, and increased physical ac vity. • Review pa ent self-check results and reinforce lifestyle modiﬁca on. • Assess adherence to drug therapy. • Review lab results: lipid panel, blood glucose, urine, albumin/ crea nine ra o. Recommenda ons Resistant Hypertension is the failure to reach the goal blood pressure in pa ents adhering to full doses of an appropriate three- drug regimen that includes a diure c. Causes (non-pharmacological) improper blood pressure measurement excess sodium intake • iden ﬁable causes of hypertension • excess alcohol intake • poor adherence to lifestyle and dietary recommenda on • poor adherence to blood pressure medica ons • “white coat” resistance Causes (pharmacological) • inadequate doses • inadequate diure c therapy • interfering substances • chronic use of NSAIDs • over the counter medica ons • cor costeroids • sympathomime cs • Combined oral contracep ves • herbal supplement • • Evalua on • Conduct a complete history and physical. • Assess risk factors, comorbidi es, and iden ﬁable causes of hypertension such as kidney disease, sleep apnea, and renovascular disease. • Obtain tests: urinalysis, blood glucose, hematocrit, lipid panel, serum potassium, crea nine, calcium, and EKG. • Addi onal studies for pa ents with resistant or diﬃcult to treat hypertension: • Repeat measurement of home and ambulatory blood pressure • Echocardiography • Consider tests for causes of secondary hypertension. • Consider referral to Mount Carmel Hypertension Center, especially if there is a failure of three an hypertension medica ons including a diure c. 1. In the general popula on age 60 years or older, ini ate pharmacolgic treatment to lower BP to a goal of SBP lower than 150mm Hg and DBP lower than 90mm Hg. Corollary Recommenda on: In the general popula on age 60 years or older, if pharmacologic treatment for high BP results in lower achieved SBP (for example <140mm Hg) and treatment is not associated with adverse eﬀects on health or quality of life, treatment does not need to be adjusted. 2. In the general popula on younger than 60 years, ini ate pharmacologic treatment to lower BP to a goal DBP of lower than 90mm Hg. 3. In the general popula on younger than 60 years, ini ate pharmacologic treatment to lower BP to a goal SBP of lower than 140mm Hg. 4. In the popula on age 18 or older with CKD, ini ate pharmacologic treatment to lower BP to goal SBP of lower than 140 mm Hg and goal DBP lower than 90mm Hg. 5. In the popula on age 18 years or older with diabetes, ini ate pharmacologic treatment to lower BP to a goal SBP of lower than 140mm Hg and goal DBP lower than 90mm Hg. 6. In the general nonblack popula on, including those with diabetes, ini al an hypertensive treatment should include a thiazide-type diure c, calcium channel blocker (CCB), angiotensin-conver ng enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). 7. In the general black popula on, including those with diabetes, ini al an hypertensive treatment should include a thiazide-type diure c or CCB. 8. In the popula on age 18 or older with CKD and hypertension, ini al (or add-on) an hypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD pa ents with hypertension regardless of race or diabetes status. 9. The main objec ve of hypertension treatment is to aOain and maintain a goal BP. If the goal BP is not reached within a month of treatment, increase the dose of the ini al drug or add a second drug from one of the classes in #6 above (thiazide-type diure c, CCB, ACEI, or ARB). The clinician should con nue to assess the BP and adjust the treatment regimen un l the goal BP is reached. If the goal BP cannot be reached with 2 drugs, add and trate a third drug from the list provided. Do not use an ACEI and an ARB together in the same pa ent. If goal BP cannot be reached using the drugs in #6 above because of a contraindica on or the need to use more than 3 drugs to reach the goal BP, an hypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for pa ents in whom the goal BP cannot be aOained using the above strategy or for the management of complicated pa ents from whom addi onal clinical consulta on is needed. Hypertension - 2

Mount Carmel Health Partners Clinical Guidelines Hypertension | Page 2