Harrison 21°

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Background

  • Hypertension is a sustained elevation of systemic arterial blood pressure. 
  • Hypertension is most commonly defi ned as systolic blood pressure (SBP) ≥ 140 mm Hgor diastolic blood pressure (DBP) ≥ 90 mm Hg, but defi nitions vary by professional orga-nization and by level of cardiovascular risk (see Defi nitions section for specific cutoffs).
  • Onset is generally at age 20-50 years, but prevalence increases with age.
  • Risk factors for hypertension include, but are not limited to, weight gain and obesity, al-cohol use (particularly for men), and exposure to insulin.
  • Most patients with hypertension have primary or essential hypertension, but in 10%-15%of patients it may be due to secondary causes.
  • Selected lifestyle interventions, including modifi cations in diet, regular exercise, and re-striction of alcohol intake, can lower blood pressure and prevent or reduce the likelihoodof developing hypertension.
  • Untreated or incompletely-treated hypertension is associated with an increased risk ofcardiovascular events and mortality

Evaluation

Initial Diagnosis

  • Measure blood pressure with the appropriate cuff size in a calm, seated position andwith the patient's arm supported at the level of the heart (Strong recommendation).
  • A hypertension diagnosis is based on ≥ 2 blood pressure measurements per visit, at ≥ 2 visits, with systolic blood pressure (SBP) ≥ 140 mm Hg and/or diastolic blood pressure(DBP) ≥ 90 mmHg when using manual measurement methods (Strong recommendation).

Confirmation

  • Blood pressure measurements obtained outside of a clinical setting (ambulatory bloodpressure monitoring [ABPM] and home BP monitoring) are recommended for the diag-nostic confi rmation of hypertension after the initial screening and before starting treat-ment ( Strong recommendation).
  • Consider using ABPM to screen for white coat hypertension and masked hypertension inselected patients and for confi rmation of diagnosis before intensifying antihypertensivedrug treatment in adults being treated for hypertension with elevated home blood pres-sure readings suggestive of masked uncontrolled hypertension (Weak recommendation).

Additional Testing

  • Uniformly recommended testing for all patients with hypertension includes (Strong recommendation):
    • blood tests (sodium, potassium, creatinine, fasting glucose, fasting lipid profi le)
    • urine tests (blood, protein) 
    • electrocardiogram (ECG) 
  • Other tests for consideration include
    • targeted testing for suspected causes of secondary hypertension (Strong recommen-dation). See the Secondary Causes of  Hypertension topic for additional information.
    • hemoglobin or hematocrit, serum uric acid, urine albumin (Weak recommendation)
    • echocardiogram if history, physical examination, or an ECG suggests left ventricularhypertrophy or other structural heart disease (Weak recommendation)

Assessment of 10-year Risk

  • Assess 10-year risk of cardiovascular events using a risk calculator, such as the ASCVDRisk Calculator
    • there is insuffi cient data to support superiority of 1 risk calculator over another
    • Pooled Cohort Equations (PCE) is based on 4 United States cohorts with ethnic di-versity but may overestimate risk (see Cardiovascular risk assessment topic fordetails)
    • Reynolds Risk Score may be more accurate than PCE based on a single study
    • SCORE is commonly used in Europe
  • Consider other factors that may not be included as part of the risk calculators, such as afamily history of premature coronary artery disease and elevated body mass index (seethe Cardiovascular Risk Assessment topic for additional information.)

Management

Nonpharmacologic Management

  • Encourage lifestyle modifi cations which reduce blood pressure and have other healthbenefi ts including:
    • weight reduction if overweight or obese (Strong recommendation)
    • dietary changes (decreased fat intake and increased intake of fruits, vegetables, andlow-fat dairy) (Strong recommendation)
    • physical activity (Strong recommendation)
    • smoking cessation (Strong recommendation) - see Treatment for Tobacco Use
  • Consider sodium restriction and limiting alcohol consumption, but the eff ects on reduc-ing cardiovascular events or mortality are ess certain (Weak recommendation).

The Decision to Initiate Medications

  • The decision to start medications for blood pressure lowering should be individualizedwith shared decision making including considerations of
  • The patient’s estimated 10-year cardiovascular risk
  • The estimated risk reduction from medications (considering the patient’s baseline riskand systolic blood pressure)
  • The potential adverse eff ects and burdens of medications used
  • Any comorbidities or factors aff ecting risks for cardiovascular events or adverse effects
  • The patient’s values and preferences

Target Blood Pressure and Medications for Patients Without Comorbidities

  • For most patients without comorbidities
    • use a target blood pressure < 140/90 mm Hg for most patients (Strongrecommendation)
    • when starting antihypertensive medications:
      • use a thiazide-type diuretic, an angiotensin-converting enzyme (ACE) inhibitor, anangiotensin receptor blocker (ARB), or a calcium channel blocker for most patients(Strong recommendation).
        • Thiazide-type diuretics are a recommended option in most guidelines and areshown to reduce mortality.
        • ACE inhibitors or ARBs are a recommended option in most guidelines, especiallyfor non-Black patients.
        • Calcium channel blockers are a recommended option in most guidelines, buthave limited data on mortality reduction.
      • beta blockers are not recommended as an initial option in some guidelines, andmay be less eff ective for reducing cardiovascular events than other initial drug choices.
  • For selected patients ≥ 50 years old with increased 10-year cardiovascular risk who de-sire a more intensive approach, consider a target systolic blood pressure < 120 mm Hgusing an automated blood pressure measurement device.

Target Blood Pressure and Medications for Patients With Comorbidities

  • Consider comorbidities to guide the target blood pressure and initial drug selection. 
    • In patients with diabetes
      • guidelines vary but targets range from < 130/80 mm Hg to < 140/90 mm Hg 
      • use an ACE inhibitor or an ARB (Strong recommendation), particularly in those withmicroalbuminuria.
    • In patients with chronic kidney disease: 
      • consider a target of at least ≤ 140/90 mm Hg and consider targets of ≤ 130/80 mmHg or ≤ 120 mm Hg based on factors such as tolerability, presence of kidney trans-plantation, and other individual characteristics (Weak recommendation)
      • use an ACE inhibitor (Strong recommendation) or an ARB if there is ACE inhibitor in-tolerance in patients with accompanying proteinuria (Strong recommendation)
    • In patients with coronary artery disease: 
      • consider a target systolic blood pressure < 120 mm Hg using an automated bloodpressure measurement device
      • use an ACE inhibitor (Strong recommendation) or an ARB if there is ACE inhibitor intolerance (Strong recommendation)
      • use a beta blocker if recent myocardial infarction (Strong recommendation) 
    • In patients with heart failure, use an ACE inhibitor and a beta blocker (Strong recom-mendation) or consider an ARB if there is ACE inhibitor intolerance (Strongrecommendation).
  • In older patients who may be more prone to side eff ects, consider a target blood pres-sure < 150/90 mm Hg (Weak recommendation).
  • For patients with resistant hypertension, consider causes and approaches to treatmentof resistant hypertension (see also the Resistant Hypertension topic).
  • Hypertension in adults
    • 2017 ACC/AHA: persistent systolic blood pressure (SBP) ≥ 130 mm Hg and/or diastolic blood pressure (DBP) ≥ 80 mm Hg
    • 2020 International Society of Hypertension (ISH) and 2014 JNC 8: persistent SBP ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg
  • Hypertension in children
    • < 13 years of age: blood pressure ≥ 95th percentile or ≥ 130/80 mm Hg, whichever is lower
    • ≥ 13 years of age: persistent systolic blood pressure (SBP) ≥ 130 mm Hg and/or diastolic blood pressure (DBP) ≥ 80 mm Hg
  • Primary hypertension: hypertension with no identifiable cause
  • Secondary hypertension: hypertension caused by an identifiable underlying condition
  • Resistant hypertension: hypertension that remains uncontrolled (≥ 130/80 mm Hg) despite treatment with ≥ 3 antihypertensives OR requires ≥ 4 medications to be controlled