Kaiser Permanente Colorado Region
Adult Hypertension Practice Guideline
Date: Nov 2000Reviewed: November 2002
Review Date: July 2004
Responsible Party: Simone Ince MD, Internal Medicine
Jonathan Gordon MD, Family Practice
Caroline Kicklighter PharmD, Clinical Pharmacy
Peggy Green RD, Prevention Department
Verleen Smith RN, Prevention Department
Nancy Larson RN, Prevention Department
Approval: November 2002
These practice guidelines are informational only and are not intended to substitute for the reasonable
exercise of independent clinical judgment by providers in any particular set of circumstances for each patient encounter. This guideline is meant to be flexible and to be used as a resource for integration with sound exercise of clinical judgment. The recommendations here can be used as a starting point to create an approach to care that is unique to the needs of an individual patient. The implementation of this guideline is not intended to conflict with any agreed upon health plan benefits nor is it intended to prevent access to care that the practitioner believes is warranted based on clinical judgment.
Rational for Guideline:
This guideline summarizes our approach to treating hypertension in Colorado KP enrollees. Authoritative guidelines exist for the treatment of hypertension (JNC VI 1997). Although there is consensus in many areas regarding the treatment of hypertension, other areas remain contentious and debated. This guideline emphasizes efforts that are supported by currently available randomized controlled trial evidence of benefit and demonstrated cost-effectiveness. It is likely that the specific approach to treating hypertension will evolve as new evidence is published.
Target Population: All men and women 18 years of age and older with elevated blood pressure.
Method for measuring compliance: HEDIS measure for hypertension control.
Guideline:
Hypertension is defined as systolic blood pressure (SBP) of greater than 140 mm Hg, diastolic blood pressure (DBP) of greater than 90 mm Hg, or taking antihypertensive medication. The objective of identifying and treating high blood pressure is to reduce the risk of cardiovascular disease and associated morbidity and mortality. The positive relationship between SBP and DBP and cardiovascular risk is well recognized. This relationship is significant for those with and without known coronary heart disease. To that end, it is useful to provide a classification of adult blood pressure for the purpose of identifying high-risk individuals and to provide guidelines for follow-up and treatment.
Cardiovascular Risk Stratification:
The risk of cardiovascular disease in patients with hypertension is determined not only by the level of blood pressure but also by the presence or absence of target organ damage or other risk factors such as smoking or diabetes. These factors independently modify the risk for subsequent cardiovascular disease. Their presence or absence is determined during routine evaluation of patients with hypertension. Based on this assessment and the level of blood pressure, the patient’s risk group can be determined. This empiric classification stratifies patients with hypertension into risk groups for therapeutic decisions.
Self-Measurement of Blood Pressure:
Measurement of blood pressure outside of the medical office may provide valuable information for the initial evaluation of patients with hypertension and for monitoring the response to treatment. Self-measurement has four general advantages: (1) distinguishing sustained hypertension from “white-coat” hypertension; (2) Assessing response to anithypertensive medication; (3) improving patient adherence to treatment; (4) potentially reducing costs. Patient’s blood pressure tends to be higher when measured in the medical office compared to outside of the office. There is no universally agreed upon upper limit of normal home blood pressure, but the readings of 135/85 mm Hg or greater should be considered elevated.
Although the mercury sphygmomanometer is still the most accurate device for clinical use, it is not practical for home use. Either validated electronic devices or aneroid sphygmomanometers that have proven to be accurate according to standard testing are recommended for use along with appropriate sized cuffs.
Routine use of ambulatory blood pressure monitoring to diagnose "white coat hypertension" defined as persistently elevated blood pressures in a doctor's office with normal blood pressures at home or at work, is rarely necessary and has not been recommended by the JNCVI.
Nonpharmacologic Treatment:
Recent controlled trials have confirmed that changes in diet and lifestyle do lower blood pressure and may also reduce cardiovascular risk. They may lower blood pressure as much as drug monotherapy, reduce the need for drug therapy, enhance antihypertensive effects of drugs, reduce the need for multiple drug regimens; and favorably impact overall cardiovascular risk.
Lifestyle Modifications:
Lifestyle modifications offer the potential for preventing hypertension and have been shown to be effective in lowering blood pressure and can reduce other cardiovascular risk factors at little cost and with minimal risk. Weight reduction of as little as 10 pounds reduces blood pressure in a large proportion of overweight persons with hypertension. Excessive alcohol intake is an important risk factor for high blood pressure, can cause resistance to antihypertensive therapy, and is a risk factor for stroke.
Physical Activity:
Regular aerobic physical activity can enhance weight loss and functional health status and reduce the risk for cardiovascular disease and all-cause mortality. Benefits of physical activity on blood pressure can be seen when the individual does 30 minutes of sustained low-moderate intensity exercise done most days of the week. Activities such as walking, stair climbing, bicycling, and rowing are examples of appropriate exercise. Accumulating 30 minutes of low-moderate intensity exercise (i.e. even in 5-10 minute increments) by the end of the day is another way to begin to reap the benefits of lowering blood pressure.
Diet:
Sodium is linked to levels of blood pressure. Individual response of blood pressure to variation in sodium intake differs widely; as groups, African Americans, older people, and patients with hypertension or diabetes are more sensitive to changes in dietary sodium chloride than are others in the general population. High dietary potassium intake may protect against the development of hypertension and improve blood pressure control in patients with hypertension. Inadequate potassium intake may increase blood pressure. Therefore, an adequate intake of potassium preferably from food sources such as fresh fruits and vegetables should be maintained. In most epidemiological studies, low dietary calcium intake is associated with an increased prevalence of hypertension. An increased calcium intake may lower blood pressure in some patients with hypertension but overall effect is minimal. Although it is important to maintain an adequate intake of calcium for general health, there is currently no rationale for recommending calcium supplements to lower blood pressure. Although evidence suggests an association between lower dietary magnesium intake and higher blood pressure, no convincing data currently justify recommending an increased magnesium intake in an effort to lower blood pressure.
There are two significant studies that have been published in recent years related to hypertension. The Dietary Approaches to Stopping Hypertension (DASH) trial, published in 1999, studied the effects of a diet that is rich in fruits, vegetables, and low-fat dairy products (with reduced saturated fat and total fat) on blood pressure. This study, which allowed 2400 mg of Na per day, demonstrated a lowering of systolic blood pressure by 5.5 mm HG and diastolic blood pressure by 3.0 mm HG more than blood pressure in those trial participants on a control diet (typical American diet). A second study, the DASH-Sodium trial published in January 2001, demonstrates an additional lowering of systolic and diastolic blood pressure with reduced sodium intake. The DASH-Sodium trial, studied blood pressure results at three different levels of sodium intake, the highest level of sodium restriction being 1500 mg per day. This study demonstrated a mean systolic blood pressure that was up to 11.5 mm HG lower (in the subgroup with lowest sodium intake) in participants with hypertension as compared to participants with Hypertension on the control high sodium diet. The combined effects on blood pressure of both low sodium intake and the DASH diet were greater than the effects of either intervention alone and were substantial. These two studies show that individuals who follow the DASH diet with sodium restriction can achieve reductions in blood pressure through diet that are equal to drug monotherapy.
Caffeine: No direct relationship between caffeine intake and elevated blood pressure has been found in most epidemiological surveys.
Dyslipidemia:
Dyslipidemia is a major independent risk factor for coronary artery disease; therefore, dietary therapy and, if necessary, drug therapy for dyslipidemia are an important adjunct to antihypertensive treatment. Diets varying in total fat and proportions of saturated to unsaturated fats have had little, if any, effect on blood pressure. Large amounts of omega-3 fatty acids may lower blood pressure however, patients experience abdominal discomfort. One study found no significant effect in preventing hypertension.
Stress Management:
The role of stress management techniques in treating patients with elevated blood pressure is uncertain.
Tobacco Usage:
Cigarette smoking is a powerful risk factor for cardiovascular disease, and avoidance of tobacco in any form is essential. A significant rise in blood pressure accompanies the smoking of each cigarette.
Implementation of lifestyle modifications should not delay the start of an effective antihypertensive drug regimen in those at higher risk.
Hypertension Treatment Guideline
Definition:
Hypertension is present when the systolic blood pressure is greater than 140 mm Hg or the
diastolic blood pressure is greater than 90 mm Hg based on two or more office blood pressure
readings. Home blood pressure readings greater than 135/85 mm Hg indicate hypertension. Blood
pressure targets may be lower for certain individuals.
No Risk Factors / Patientswith
Diabetes / Isolated Systolic Hypertension / Renal Insufficiency
>1 gram of protein
in urine / Impaired LV
Function
Target BP Goal / 140/90 mm Hg / 130/80 mm Hg / 140/90
mm Hg* / 125/75
mm HG / <130/80 or as low as tolerated by the patient
- An interim BP target may be <160/90 mm Hg for initial systolic > than 180 mm Hg.
Measurement:
Blood pressure is measured after sitting quietly for five minutes, on a bare arm with an
appropriately sized arm cuff. Home blood pressure monitors using a finger or wrist device are
unreliable and their use should be discouraged.
Diagnosis:
Hypertension should be treated when two or more readings at separate visits are greater than
140/90 mm Hg. Lifestyle modifications should be initiated in all individuals with elevated blood
pressure. The minimum baseline evaluation for those with hypertension includes a physical exam
and measurement of potassium, creatinine, fasting lipid profile, fasting glucose, and UA.
Lifestyle Modifications:
Lifestyle modifications focusing on weight loss (as little as 10 lbs), sodium restriction (<2000 mg daily),
and avoidance of excessive alcohol (greater than 1 drink per day for women, and 2 drinks a
day for men) should be recommended for all hypertensive individuals. For people not at high risk
and with mildly elevated blood pressure, lifestyle modifications alone are reasonable for
6-12 months. Benefits of physical activity on blood pressure can be seen when the individual does
30 minutes of sustained low- moderate intensity exercise on most days of the week. Activities
such as walking, stair climbing, bicycling, and rowing are examples of appropriate exercise.
Accumulating 30 minutes of low-moderate intensity exercise (i.e. even in 5-10 minute increments) by the
end of the day is another way to begin to reap the benefits of lowering blood pressure.
Medication Treatment:
1. First line drugs for treating hypertension are low dose diuretics e.g. (Maxzide or HCTZ 12.5-25 mg, HCTZ/triamterene25/37.5 mg), beta-blockers (atenolol 25-100 mg, metoprolol 50-200 mg), and Ace-inhibitors (Lisinopril 10-40mg). Angiotensin converting enzyme inhibitors along with beta-blockers are considered first line drugs in patients with coronary artery disease. Angiotensin II receptor antagonists can be used in selected heart failure patients, diabetic patients with proteinuria or LVH who are intolerant to angiotensin converting enzyme inhibitors because of cough. Diabetics with known CAD who are intolerant to angiotensin converting enzyme inhibitors because of cough can use a beta-blocker or angiotensin II receptor antagonists
2. The target office blood pressure varies depending on several factors. Ongoing persistent attempts to
achieve targets such as the addition of a drug or increasing the dosage should continue until most office or
home readings meet target or treatment is limited by intolerable side effects.
3. There is an individual variation in response to antihypertensive drugs that cannot be easily predicted. In
patients with mildly elevated blood pressure, monotherapy is often effective in achieving target blood
pressure. The initial drug chosen will be effective approximately 50% of the time. Changing to another
single agent will achieve blood pressure control 50% of the nonresponders. Patients with moderate to
severe hypertension will usually require two or more drugs for adequate control. Diuretics are the most
effective of all drugs in enhancing the antihypertensive activity of the other agents and thus should be one
of the medications in most antihypertensive regimens. The most studied combination is thiazide diuretics
and beta-blockers. For those patients who do not respond or have contraindications to a beta-blocker,
angiotensin converting enzyme inhibitors and thiazide diuretics are an effective alternative combination.
*KAISER PERMANENTE COLORADO REGION
ADULT HYPERTENSION TREATMENT ALGORITHM
1 ACE- inhibitors should be used as first line drugs in diabetics, those with renal insufficiency (Cr >1.5),
and those with impaired left ventricular systolic function (LVEF<40%). ACE- inhibitors along with beta-
blockers are considered first line drugs in patients with coronary artery disease. Angioedema with Ace-inhibitors
is a contraindication to angiotensin receptor blockers.
2 Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) are less costly and are the preferred class of Ca
Channel Blockers
3In elderly patients, verapamil can be intolerable due to constipation and should not be used in combination with beta-
blockers
Angiotensin II receptor antagonists can be used in selected heart failure patients, diabetic patients with proteinuria or LVH
who are intolerant to angiotensin converting enzyme inhibitors because of cough. Diabetics with known CAD who are intolerant to
angiotensin converting enzyme inhibitors because of cough can use a beta-blocker or angiotensin II receptor antagonists.
Alpha-blockers are most likely safe but may not be as cardio protective as other agents when used as monotherapy.
Clonidine should be used cautiously in combination with beta-blockers
Low dose reserpine (0.05mg qd) may be most beneficial in the treatment of ISH and can be used safely as
demonstrated in the SHEP study
In patients who may be volume overloaded, twice daily furosemide may be helpful.
9 When using minoxidil, most patients will also require both a diuretic and a beta-blocker.
*Refer to Appendix 1 for HTN Resources for Providers
APPENDIX 1:Hypertension Resources for Providers
Risk Factor / Kaiser Permanente Resource / Contact NumberWEIGHT MANAGEMENT / Weight Management Brochure. “It’s About You.”
Self paced workbook:
“ Weight
Management
Tool Kit”
KP Quarterly Health Education Class Schedule.
Weight Management Program
Weight Management Behavioral Health Seminars. / 303-788-1180
sent by mail (free)
303-788-1180
sent by mail $15
303-788-1180
303-788-1180
303-788-1180
PHYSICAL ACTIVITY / Personal Action Guide
Silver Sneakers: for senior members with silver plus, gold, or group membership. / 303-344-7255
303-338-3800
DIET COUNSELING & INFORMATION / 1:1 Dietician Consult (especially in members with co-morbidities)
Dash Diet Handout
Website:
/ 303-338-4545
Standard Stock # 00241730
STRESS MANAGEMENT / KP qua KP Quarterly Health Education Class Schedule
1.Stress Relief on the Run
(telecourse).
2.Stress Management Packet
(by mail).
3. Yoga and QiGong / 303-344-7255
TOBBACO USAGE / KP Quarterly Health Education Class Schedule.
1.Freedom from Cigarettes.
2.Stop Smoking Basics
3.Tobacco Free Living.
KP’s Stop Smoking Information Line
Smoking Cessation Packet
Colorado Tobacco Quit
Line.
To speak with health educator about quitting smoking on your own. / 303-344-7891
303-344-7891
303-344-7255
800-639-Quit (7848)
303-344-7305 between
9am-5pm. Monday-Friday.
HIGH BLOOD PRESSURE / “High Blood Pressure Here’s What You Can Do” pamphlet
“High Blood Pressure Your Steps Toward Control.”
Blood Pressure Monitoring Card
Blue Heart Labels (office tool)
“Ongoing Care My Goals for Change.” / SS#0022-7372
SS#0022-7373
SS#0003-2894
SS#0021-7135
SS#0023-3498
References
1. Appel, LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure
DASH Collaborative Research Group. N Engl. J Med. 1997; 336 (16): 1117-1124.
2. Davis B, Cutler J, Gordon D et al. Rationale and design for the antihypertensive and lipid lowering treatment to
prevent heart attack trial (ALLHAT). AJH 1995;9:342-360.
3. Effects of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes N Eng J Med
2001; 345:870-878.
4. Effects of Losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Eng
J Med 2001; 345:861-869.
5. Hansson L, Lindholm L, Niskanen L et al. Effect of angiotensin-converting-enzyme inhibition compared with
conventional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project
(CAPPP) randomised trial. Lancet 1999;353:611-616
6. Hansson L, Lindholm LH, Ekbom T et al. Randomised trial of old and new antihypertensive drugs in elderly
patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study
(STOP-2). Lancet 1999:354(9192):1751-6.
7. Joint National Committee. The sixth report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC VI). Arch of Internal Medicine. 1997; 157:2413-2446.