FINAL DRAFT-HTN 4/1/08

SUBJECTIVE

Patient presents for evaluation of confirmed hypertension

CLASSIFICATION OF BLOOD PRESSURE (BP)*
CATEGORY / SBP mmHg / DBP mmHg
Normal / < 120 / and / < 80
Prehypertension / 120 – 139 / or / 80 - 89
Hypertension, Stage1 / 140 – 159 / or / 90 – 99
Hypertension, Stage 2 / 160 / or / 100
* See Blood Pressure Measurement Techniques (reverse side)
Key: SBP = systolic blood pressure DBP = diastolic blood pressure

*** For those with high pressures (systolic greater than 180 mm Hg or diastolic greater than 110 mm Hg) evaluate and treat immediately or within one week, depending on clinical situation and complications.

Confirm Elevated Blood Pressure:

Confirmation is based on the initial visit, plus two follow up visits with at least two blood pressure readings at each visit.

At least once a BP must be checked in both arms. At least once the BP must be taken in the upper arm above the antecubital space.

  • Medications and Compliance Reviewed

Medications that contribute to elevated BP

-NSAIDS

-decongestants

-diet aids

-herbals

  • Past history reviewed/Problem list

Pertinent conditions (CAD, angina, previous MI, DM, CHF, PVD, prior hx HTN, previous HTN rx, lipid disorders (including metabolic syndrome), LVH, Retinopathy, Renal disease (GFR<60 and microalbuminuria)

  • Lifestyle factors

Smoking, high sodium intake, high fat diet, physical inactivity, excessive alcohol, overweight (BMI>30)

  • Family history

Cardiovascular

Dyslipidemia

Diabetes

Family history of premature cardiovascular disease (men younger than 55 or

women younger than 65).

ROS

  • Constitutional (wt gain or loss), fatigue
  • Visual (blurred vision, other)
  • Neurological (headache, dizziness, weakness, loss of feeling, other)
  • Respiratory (dyspnea at rest or activity, snoring, apneic spells)
  • Cardiac (Chest pain with or without exertion, palpitations, irregular pulse,

orthopnea, claudication, edema)

  • Neuropsych (depression, insomnia, psychosocial stress, anxiety)

PHYSICAL EXAM

  • Vitals
  • Waist circumference
  • General (grooming, orientation, distress, obesity, other)
  • Head
  • Fundoscopic (hemorrhages, exudates, AV crossing changes, disc normal or edematous, arteriolar narrowing general or focal, cataracts, eye doctor visit)
  • Neck (JVD, thyromegaly, carotid bruits, other)
  • Lungs (auscultation, percussion, respiratory effort, rales, wheezing, rhonchi, other)
  • Heart (rhythm, murmurs, PMI, gallop, click, other)
  • Abdomen (soft, tenderness, organomegaly, abnormal pulsation, bruits, enlarged

kidneys, mass, other)

  • Neurological (localized weakness, facial droop, gait)
  • Extremities ( edema, pulses, symmetry, radial-femoral delay)
  • Psych (orientation, mood, affect)

LAB

FBS

  • HCT
  • Na
  • K
  • Creatinine (GFR)
  • Ca
  • Lipids
  • 12 lead EKG

Additional tests may be ordered at the discretion of the provider based on clinical findings. These may include, but are not limited to, CBC, CXR, uric acid, and urine microalbumin.

ASSESSMENT

Primary hypertension without target organ disease or with target organ disease (LVH, CAD, CABG, CHF, PVD, angina, renal disease, retinopathy, stroke, TIA, dementia)

ASSESS FOR IDENTIFIABLE CAUSES OF HYPERTENSION
  • Sleep apnea
/
  • Cushing’s syndrome or steroid therapy

  • Drug induced/related
/
  • Pheochromocytoma

  • Chronic kidney disease
/
  • Coarctation of aorta

  • Primary aldosteronism
/
  • Thyroid/parathyroid disease

  • Renovascular disease

Risk Factors for Major Cardiovascular Disease:

  • Hypertension
  • Age (older than 55 for men, 65 for women)
  • Diabetes mellitus
  • Elevated LDL cholesterol
  • Low HDL cholesterol (men <40 mg/dL, women <50mg/dL)
  • Estimated GFR less than 60 mL/min
  • Microalbuminuria
  • Family history of premature cardiovascular disease (men younger than 55 or

women younger than 65)

  • Obesity (body mass index greater than or equal to 30 kg/m2, waist

circumference greater than 40 inches for men and greater than 35 inches for women)

  • Physical inactivity
  • Tobacco usage, particularly cigarettes

Consider a Diagnosis of Secondary HTN:

  • Patients with an abrupt onset of symptomatic HTN
  • Stage 2 hypertension
  • Hypertensive crisis
  • Sudden loss of BP control after many years of stability on drug therapy
  • Drug resistant HTN
  • Individuals with no family history of HTN
  • Acute increase in plasma creatinine that is unexplained or after an initial treatment with an ACE or an ARB
  • Lateralizing abdominal bruit
  • Recurrent flash pulmonary edema

Secondary Etiology / Clinical Scenario / Tests / Comments
Renal artery stenosis / FMD – young females
Older patients with vascular disease / Duplex Doppler US or
MRA or
CT angiogram / All are options and debated. MRA most often used at Theda for screening. If pt has RI Nephrogenic Systemic Fibrosis, although rare, now a real issue as it is life threatening. Contrast induced nephropathy also issue with CT angio.
Primary renal disease / Abnormal GFR / GFR
UA / Renal US can show asymmetry and Polycystic Kidney Disease.
Pheochromocytoma / Headache (90%), palpitations, sweating/pallor, paroxysm of HTN or persistent HTN (50/50) / 24 urine fractionated metanepharines or
Plasma fractionated metanepharines / Options are debated.
Primary aldosteronism / Hypokalemia, adrenal incidentaloma / Plasma aldosterone concentration (PAC) to plasma renin activity (PRA) = PAC/PRA / Different sources will sight different cutoffs to change sensitivity and specificity. In general, <20 normal
Cushing’s Disease / “moon”facies, central obesity, stria, ecchymosis / 1mg Overnight Dexamethasone Suppression Test
24 hour urine cortisol / Options are debated.
Obstructive Sleep Apnea / Snoring +/- apneic spells, daytime somnelence / Overnight Sleep Study
Coarctation of the Aorta / Absent or lagging LE pulses / CT angiogram
Thyroid disorder / Both hypo and hyper / TSH / TSH sufficient for screening test.
Hyperparathyroidism / Hypercalcemia – stones, groans, and psychic overtones / PTH

Calculated 10 year CHD risk

Goal BP

  • < 140/90
  • Goal BP for those pts with diabetes, CKD, and heart failure: <130/80

Goal blood pressures measured out of the office setting should be:

  • <135/85 (no comorbidities)
  • <125/75 ( those with comorbidities) Review this with the patient.

Goal blood pressures for those patients with chronic kidney disease:

  • <130/80
  • <120/75 if urinary protein excretion > 1-2g/day

Consider 24 hour ambulatory blood pressure monitoring (ABPM) in the assessment of white coat or office effect patients who lack evidence of target organ damage, and who have normal out-of-office BP readings. Other clinical situations in which ABPM may be helpful include the assessment of drug resistance, hypotensive symptoms, episodic hypertension and suspected autonomic dysfunction.

PLAN

Lifestyle modifications should be:

  • The cornerstone of the initial therapy for hypertension
  • Reviewed and re-emphasized at least annually

Lifestyle Modifications to Prevent and Manage Hypertension

Modification / Recommendation / Approximate SBP reduction
(range)
Weight reduction / Maintain normal body weight
(body mass index 18.5-24.9
kg/m2). / 5-20 mm Hg/10 kg
Adopt DASH** eating plan / Consume a diet rich in fruits,
vegetables and low-fat dairy
products, with a reduced content of saturated and total fat. / 8-14 mm Hg
Dietary sodium reduction / Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). / 2-8 mm Hg
Physical activity / Engage in regular aerobic
physical activity such as brisk
walking (at least 30-45 minutes per day, most days of the week). / 4-9 mm Hg
Moderation of alcohol
consumption / Limit consumption to no more
than two drinks (e.g., 24 oz.
beer, 10 oz. wine, or 3 oz. 80
proof whiskey) per day in most men and to no more than one drink per day in women and lighter-weight persons. / 2-4 mm Hg

**DASH indicates Dietary Approaches to Stop Hypertension.

  • Medications

COMPELLING INDICATIONS FOR INDIVIDUAL DRUG CLASSES
COMPELLING INDICATION / INITIAL THERAPY OPTIONS
  • Heart failure
/ THIAZ, BB, ACEI, ARB, ALDO ANT
  • Post myocardial infarction
/ BB, ACEI, ALDO ANT
  • High CVD risk
/ THIAZ, BB, ACEI, CCB
  • Diabetes
/ THIAZ, BB, ACEI, ARB, CCB
  • Chronic kidney disease
/ ACEI, ARB
  • Recurrent stroke prevention
/ THIAZ, ACEI
Key: THIAZ = thiazide diuretic, ACEI = angiotensin converting enzyme inhibitor, ARB = angiotensin receptor blocker, BB = beta blocker, CCB = calcium channel blocker, ALDO ANT = aldosterone antagonist

Primary HTN Medications:

  • A Thiazide type diuretic should be considered as initial therapy with uncomplicated HTN.
  • In patients for whom diuretics are contraindicated or poorly tolerated, use of a beta-blocker, ACE inhibitor, ARB or calcium antagonist is appropriate.
  • Outcome data does not support B blockers for first line therapy for patients >60 years of age.
  • In order to decrease cost, consider three strategies: split tablet dosing, 3 month supply by mail order and generic medications.

HTN with Diabetes:

  • Regimen should include either an ACE inhibitor or an ARB. If one class is not tolerated the other should be substituted.
  • If needed to achieve BP targets:

GFR  50ml/min- a thiazide diuretic should be added

GFR < 50ml/min- a loop diuretic should be added

  • Multiple drug therapy (two or more agents at maximal doses) is generally required to achieve blood pressure targets.

FOLLOW UP

  • Once a hypertensive drug therapy is initiated, most patients should return for follow up and medication adjustments at least monthly until BP goal is reached.
  • Option if not at goal:

-Increase dose of initial drug.

-Substitute agent from another class

-Add a second drug from another class

  • BP at goal:

-Follow up office visit in 3-6 months

-Follow up visits to assess for target organ disease, new risk factors, comorbidities and need for lab tests.

-Serum potassium and creatinine should be monitored at least annually. Additional labs as indicated with change in condition or medication regimen.

PATIENT EDUCATION

Website / Title/Description / Organization
/ Web site with excellent resources for patient education and general heart health resources. Understanding and Controlling Your High Blood Pressure and Exercise and Your Heart. / American Heart Association (AHA)
/ Web site with excellent resources for patient education. Includes an online catalogue of materials.
-Facts about Heart Disease and Women: Preventing and Controlling High Blood Pressure (brochure #97-3655)
-Facts about Lowering Blood Pressure (brochure #5232)
-Facts about the DASH Diet (booklet #03-4082)
-Your Guide to Lowering Blood
Pressure (booklet #03-5232) / National Heart, Lung & Blood Institute (NHLBI)
/ Web site with excellent resources for patient education resources, particularly using search terms “hypertension,” “blood pressure” and “home monitoring.” / Mayo Health Oasis

/ Comprehensive health resources for consumers, physicians, nurses, and educators. Includes news, chat forums, health quizzes and consumer product updates.

REFERENCES

Institute for Clinical Systems Improvement Health Care Guideline, Hypertension Diagnosis and Treatment, Eleventh Edition /October 2006.

JNC 7, The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, U.S. Department Of Health And Human Services, May 2003.

Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, Adult Treatment Panel III, September 2002.

Institute for Clinical Systems Improvement Health Care Management of Type 2 Diabetes Mellitus, Eleventh Edition/ November 2006.

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