, phones), and no one should speak with the patient during the rest period and readings Use a palpated estimate of radial pulse obliteration pressure (disappearance or resumption of pulse when cuff is inflated/deflated) to estimate SBP; inflate the cuff 20-30 mm Hg above this level to perform the auscultatory determination of the blood pressure level Use either the stethoscope diaphragm or bell for auscultatory readings After the five-minute rest period, inflate the cuff and use auscultation to determine SBP and DBP; determine SBP and DBP as the onset of the first of at least two consecutive Korotkoff sounds (beats) and the last audible Korotkoff sound, respectively Record the SBP and DBP reading Take the next reading(s) with at least a 30 second interval between readings and record SBP and DBP readings for each reading; record the average or median SBP and average or median DBP as the patient s blood pressure Appendix H: Guidance for Conducting Home Blood Pressure Measurement The following information has been adapted from the 2019 AHA Measurement of Blood Pressure in Patient training provided by healthcare staff or providers: Provide information about hypertension diagnosis and treatment Provide information on the proper selection of a device Provide instruction on how patients can measure their own blood pressure (if possible, demonstrate the procedure or instruct how to access training video) Provide instruction that the HBPM device and blood pressure readings (log or electronic recording) should be brought to healthcare visits Provide education that individual blood pressure readings may vary greatly (high and low) across the monitoring period Preferred devices and cuffs: Use an upper-arm cuff oscillometric device that has been validated Use a device that is able to automatically store all readings, if possible Use a device that can print results or can send blood pressure values electronically to the healthcare provider, if possible Use a cuff that is appropriately sized for the patient s arm circumference Table H-1. Proper Blood Pressure Cuff Sizes Cuff Size Arm Circumference (cm) Bladder Dimension (width x length, cm) Abbreviation: cm: centimeter Best practices for the patient: Preparation Have an empty bladder Rest quietly in seated position with back supported (e.g., leaning back in chair) for at least five minutes Do not talk or text Position Sit with back supported Keep both feet flat on the floor Legs should not be crossed Blood pressure cuff should be placed on bare arm (not over clothes) Blood pressure cuff should be placed directly above the antecubital fossa (bend of the arm) Center of the bladder of the cuff (commonly marked on the cuff by the manufacturer) should be placed over the arterial pulsation of the patient s bare upper arm Cuff should be pulled taut, with comparable tightness at the top and bottom edges of the cuff, around the bare upper arm The arm with the cuff should be supported on a flat surface such as a table Number of readings Take two readings at least one minute apart in the morning before taking any antihypertensive medications and two readings at least one min apart in the evening before going to bed; some recommend only recording the second measurement Duration of monitoring Preferred monitoring period is 7 days (i.e., 28 readings or more scheduled readings); a minimum period of three days (i.e., 12 readings) may be sufficient, ideally in the period immediately before the next appointment with provider Monitoring conducted over consecutive days is ideal; however, readings taken on nonconsecutive days may also provide valid data Analyzing readings For each monitoring period, the average of all readings should be obtained Some guidelines and scientific statements recommend excluding the first day of readings; if the first day of readings is excluded, the minimum and preferred periods of HBPM should be four and eight days, respectively For a video developed for patients by the VA and DoD with instructions on measuring blood pressure at home, please visit https://www.healthquality.va.gov/guidelines/CD/htn/ and click on the Home Blood Pressure Monitoring video. Appendix I: Participant List Angela A. Allerman, PharmD, BPCS Formulary Management Branch, Pharmacy Operations Division, Defense Health Agency San Antonio, TX Jennifer Ballard-Hernandez, DNP, NP, CCRN VA Central Office Washington, DC Dan Berlowitz, MD, MPH Edith Nourse Rogers Memorial Veterans Hospital Bedford, MA William C. Cushman, MD Co-Chair, VA Hypertension-Lipid Field Advisory Committee Chief, Preventive Medicine Section VA Medical Center Memphis, TN Elaine Furmaga, PharmD National Clinical Pharmacy Program Manager VA Pharmacy Benefits Management Services Hines, IL Peter Glassman, MBBs, MSc, FACP Chair, Medical Advisory Panel, Pharmacy Benefit Management Services, Department of Veterans Affairs Washington, DC Elvira O. Gosmanova, MD, FASN Albany Stratton VA Medical Center Albany, NY CDR Travis E. Harrell, MD, FACC, FACP Naval Medical Center San Diego, Department of Cardiology San Diego, CA Asha Jain, MA, RD, CDE Outpatient Nutrition Services Clinical Dietitian Walter Reed National Military Medical Center Bethesda, MD Lillian Pinault, MS, RD, CSG, CDE Baltimore VA Medical Center Baltimore, MD Pedro Roldan, MD, FAAFP VA Greater Los Angeles Healthcare System Los Angeles, CA Lt Col Joseph C Sky, MD, FACP, FACC Travis Air Force Base Travis, CA Addison Taylor, MD, PhD Michael E. DeBakey VA Medical Center Houston, TX LTC Tommy L. Thompson, DNP, FNP-C Assistant Clinical Professor Family Nurse Practitioner and Women s Health Nurse Practitioner Program Madigan Army Medical Center Tacoma, WA CDR Mark P. Tschanz, DO, MACM, FACP Naval Medical Center San Diego San Diego, CA Lt Col Jesse Wickham, DO, FACP Brooke Army Medical Center San Antonio, TX Appendix J: Literature Review Search Terms and Strategy A. EMBASE and Medline Embase.com Syntax Question Set # Concept Strategy Questions and Diagnosis and Management #1 Blood pressure blood pressure /exp OR blood pressure monitoring /exp OR diastolic blood pressure /exp OR systolic blood pressure /exp OR systole /de OR diastole /de #2 'blood pressure':ti,ab OR 'systolic pressure*':ti,ab OR 'diastolic pressure*':ti,ab OR 'arterial pressure*':ti,ab OR bp:ti,ab #3 (systol*:ti,ab OR diastol*:ti,ab OR arterial:ti,ab OR sbp:ti,ab OR dbp:ti,ab) AND (pressure*:ti,ab OR mmhg:ti,ab OR 'mm hg':ti,ab) #5 BP measurement, screening, or monitoring #4 AND (monitor* OR measure* OR record* OR screen* OR test* OR evaluat* OR track*):ti,ab OR monitoring /exp OR measurement /exp OR screening/exp) #6 ('blood pressure'/exp AND 'hypertension'/exp/dm_dm,dm_pc,dm_th) OR 'blood pressure monitoring'/exp OR blood pressure monitor /exp OR blood pressure measurement /exp) #8 Interventions/BP methods #4 AND ('ambulatory blood pressure'/exp OR 'ambulatory blood pressure measurement'/exp OR ambulatory monitoring /exp OR home monitoring /exp OR self care /exp OR self monitoring /exp OR general practice /de OR health center /de) #9 #4 AND (routine OR office* OR clinic OR clinics OR general practice OR kiosk OR primary care OR auscultatory OR center OR centers OR traditional OR standard OR attended OR unattended):ti #10 #4 AND ((office NEAR/3 blood pressure ) OR (office NEAR/3 BP )) #11 #4 AND (automated OR wake OR self-measure* OR self-record* OR self NEAR/2 monitor* OR self NEAR/2 manag* OR home OR out-of- office OR out of office OR day* OR night* OR evening OR bedtime OR bed time OR morning* OR 24-hour OR 24-hour OR home blood pressure monitoring OR HBPM OR home BP OR ambulatory OR ABPM OR (ambulatory NEAR/3 blood pressure ) OR (ambulatory NEAR/3 BP) OR tele-monitoring OR telemonitoring) #12 #4 AND (sphygmomanomet* OR oscillomet* OR manometer /exp OR sphymomanometer /exp) #15 Test characteristics predictive validity /de OR predictive value /de OR prognosis /de OR sensitivity and specificity /de OR diagnostic accuracy OR diagnostic test accuracy study /exp OR diagnostic value /exp OR hypertension /mj/dm_di #16 Predict*:ti,ab OR Prognos*:ti,ab OR Sensitivity:ti,ab OR Specificity:ti,ab OR accuracy:ti,ab OR accurate:ti,ab #17 (sensitiv* OR accura* OR specific* OR reliab* OR predict* OR prognostic):ti,ab Question Set # Concept Strategy Questions and Diagnosis and Management (cont.) #19 Adherence and impact (Adhere* OR compliance OR comply OR goal OR goals OR threshold* OR achiev* OR benef* OR impact* OR improv* OR useful* OR utility):ti #20 adherence /exp OR patient compliance /exp OR treatment outcome /exp prehypertension 'hypertension'/exp OR 'hypertensive patient'/exp OR 'resistant hypertension'/exp OR 'masked hypertension'/exp OR 'white coat hypertension'/exp OR 'prehypertension'/exp #23 hypertension:ti,ab OR hypertensive:ti,ab OR 'borderline hypertensive':ti,ab OR prehyperten*:ti,ab OR 'white coat hypertension' OR wch OR 'masked hypertension' OR ((masked:ti,ab OR 'white coat':ti,ab OR borderline:ti,ab) AND hypertension:ti,ab) #24 (normal OR low OR high OR elevated OR borderline) NEAR/3 'blood pressure' #26 Combine BP and measure, screen, monitor, methods, accuracy #27 To diagnose and manage HTN #28 Combine BP and measure, screen, monitor, methods, adherence, and HTN Apply hedges below Questions and Non Pharmacological Interventions #1 hypertension 'hypertension'/exp OR 'hypertensive patient'/exp OR 'resistant hypertension'/exp OR 'masked hypertension'/exp OR 'white coat hypertension'/exp OR 'prehypertension'/exp #2 hypertension:ti,ab OR hypertensive:ti,ab OR 'borderline hypertensive':ti,ab OR (pre NEXT/1 hypertens*):ti,ab OR prehypertensi*:ti,ab OR 'white coat hypertension' OR wch OR 'masked hypertension' OR ((masked:ti,ab OR 'white coat':ti,ab OR borderline:ti,ab) AND hypertens*:ti,ab) #3 (high OR elevated OR borderline OR lower OR lowering) NEAR/3 'blood pressure' #5 'blood pressure'/exp OR 'diastolic blood pressure'/exp OR 'systolic blood pressure'/exp OR 'systole'/de OR 'diastole'/de #6 'blood pressure':ti,ab OR 'systolic pressure*':ti,ab OR 'diastolic pressure*':ti,ab OR 'arterial pressure*':ti,ab OR bp:ti,ab OR sbp:ti,ab OR dpb:ti,ab OR ((systol*:ti,ab OR diastol*:ti,ab OR arterial:ti,ab) AND (pressure*:ti,ab OR mmhg:ti,ab OR 'mm hg':ti,ab)) #8 Obesity 'obesity'/exp/mj OR 'obese patient'/exp/mj OR 'body mass'/exp OR 'body weight'/exp OR obese:ti OR obesity:ti OR overweight:ti Question Set # Concept Strategy Questions and Non Pharmacological Interventions (cont.) #9 General treatment of overweight/obesity with the aim of preventing/ controlling hypertension 'obesity'/exp/dm_dm,dm_dt,dm_su,dm_th AND 'hypertension'/exp/dm_dm,dm_pc,dm_th #10 Obesity - pharma 'obesity'/exp/dm_dt OR 'tetrahydrolipstatin'/exp OR 'lorcaserin'/exp OR 'phentermine plus topiramate'/exp OR 'liraglutide'/exp OR ('obesity'/exp AND (antihypertensives OR 'anti hypertensives' OR (antihypertensive NEAR/1 drug*) OR ('anti hypertensive' NEAR/1 drug*))) OR 'antiobesity agent'/exp OR 'amfebutamone plus naltrexone'/de #11 phentemine OR topiramate OR qsymia OR lorcaserin OR belviq OR orlistat OR xenical OR alli OR (naltrexone NEXT/1 bupropion) OR contrave OR liraglutide OR saxenda OR victoza OR phentermine OR benzphetamine OR phendimetrazine OR diethylpropion OR (antiobesity NEXT/1 agent*) OR (antiobesity NEXT/1 drug*) OR (obesity NEXT/1 agent*) OR (obesity NEXT/1 drug*) #13 Obesity - surgery 'bariatric surgery'/exp OR 'roux-en-y gastric bypass'/exp OR 'obesity'/exp/dm_su #14 (obes*:ti,ab OR bariatric:ti,ab OR gastric*:ti,ab OR stomach:ti,ab OR 'weight loss':ti,ab) AND surg*:ti,ab #15 obes*:ti AND (sleeve*:ti,ab OR lapband*:ti,ab OR band*:ti,ab OR 'gastric bypass':ti OR gastrectomy:ti,ab OR 'roux n y':ti,ab OR 'roux- en-y':ti,ab OR 'roux en y':ti,ab OR rygb:ti,ab) #17 Obesity lifestyle modification 'body weight loss'/exp OR (('eating habit'/exp OR 'diet therapy'/exp OR 'healthy lifestyle'/exp OR 'obesity management'/exp OR 'sedentary lifestyle'/exp OR 'lifestyle modification'/exp) AND 'body weight'/exp) #18 (eat*:ti OR habit*:ti OR diet*:ti OR lifestyle*:ti OR sedentary:ti OR activity:ti OR active:ti OR activities:ti OR exercise:ti) AND (change*:ti OR modif*:ti OR improve*:ti OR manag*:ti) #19 (weight:ti OR 'body mass':ti) AND (lose:ti OR loss:ti OR lost:ti OR lowering:ti OR reduc*:ti OR manag*:ti) OR ((weight:ti OR 'body mass':ti) AND (diet*:ti OR nutrition*:ti OR food*:ti) AND (prescription:ti OR prescribed:ti)) OR (dash AND diet) OR (mediterranean AND diet) OR 'dietary approach* to stop hypertension' OR 'dash diet':ti,ab OR 'dash diet'/exp OR ((diet* OR nutrition*):ti,ab AND (sodium OR salt OR potassium):ti,ab)) #20 (weight:ti OR 'body mass':ti) AND (lose:ti OR loss:ti OR lost:ti OR lowering:ti OR reduc*:ti OR manag*:ti) #21 'obesity'/exp/mj AND 'lifestyle modification'/exp OR ((diet*:ti OR nutrition*:ti) AND ('bp':ti OR 'blood pressure':ti OR 'hypertension':ti OR 'cardiovascular disease':ti OR 'cvd':ti)) #23 Combine Obesity AND Obesity pharma #24 Combine Obesity AND surgery Question Set # Concept Strategy Questions and Non Pharmacological Interventions (cont.) #25 Combine Obesity AND lifestyle mod #26 Combine final sets of Obesity 9 OR 23 OR 24 OR 25 #27 Physical activity 'exercise'/exp OR 'physical activity'/exp OR 'meditation'/exp OR 'transcendental meditation'/exp OR 'qigong'/exp OR 'qigong exercise'/exp OR 'tai chi'/exp OR 'yoga'/exp OR 'aerobic exercise'/exp OR 'physical activity, capacity and performance'/exp OR 'exercise intensity'/exp OR 'resistance training'/exp #28 exercise:ti,ab OR 'physical activity':ti,ab OR training:ti,ab OR isometric*:ti,ab OR 'weight training':ti,ab OR 'weight lift*':ti,ab OR 'resistance training':ti,ab OR walk* OR run* OR jog* OR stress*:ti,ab OR swim*:ti,ab OR aerobics OR (aerobic NEAR/3 exercis*) OR (aerobic NEAR/3 fitness) OR (aerobic NEAR/3 training) #29 qigong:ti,ab OR taichi:ti,ab OR 'tai chi':ti,ab OR yoga:ti,ab OR relax*:ti,ab OR meditat*:ti,ab #30 (exercise:ti OR ((physical NEAR/2 activity):ti)) AND (change*:ti OR improve*:ti OR modif*:ti OR increase*:ti) #31 sedentary:ti,ab OR 'sedentary lifestyle'/exp OR 'physical inactivity'/exp OR 'laziness'/exp #32 Combine final sets of physical activity #33 Combine HTN OR BP 4 OR 7 #34 Combine HTN OR BP with final obesity set #35 Combine HTN OR BP with final phys act set Apply hedges below Question Set # Concept Strategy Questions and Blood pressure thresholds and goals for pharmacologic interventions prehypertension. WCH hypertension /exp OR hypertensive patient /exp OR resistant hypertension /exp OR masked hypertension /exp OR white coat hypertension /exp OR prehypertension /exp #2 Hypertension:ti,ab OR hypertensive:ti,ab OR borderline hypertensive :ti,ab OR prehyperten*:ti,ab OR white coat hypertension OR WCH OR masked hypertension OR ((masked OR white-coat OR white coat OR borderline):ti,ab AND hypertens*:ti,ab) #3 (high OR elevated OR borderline OR lower OR lowering) NEAR/3 blood pressure #5 Blood pressure 'blood pressure'/exp OR 'diastolic blood pressure'/exp OR 'systolic blood pressure'/exp OR 'systole'/de OR 'diastole'/de #6 'blood pressure':ti,ab OR 'systolic pressure*':ti,ab OR 'diastolic pressure*':ti,ab OR 'arterial pressure*':ti,ab OR bp:ti,ab OR sbp:ti,ab OR dpb:ti,ab OR ((systol*:ti,ab OR diastol*:ti,ab OR arterial:ti,ab) AND (pressure*:ti,ab OR mmhg:ti,ab OR 'mm hg':ti,ab)) mmhg':ti,ab OR '110 mmhg':ti,ab OR '120 mmhg':ti,ab OR '130 mmhg':ti,ab OR '140 mmhg':ti,ab OR '150 mmhg':ti,ab OR '160 mmhg':ti,ab OR '170 mmhg':ti,ab OR '180 mmhg':ti,ab #9 #8 AND ((best OR goal*:ti,ab OR standard*:ti,ab OR 'standard'/exp OR optimal:ti,ab OR ideal*:ti,ab OR target*:ti,ab) #10 'blood pressure goal*' OR 'blood-pressure goal*' OR 'blood pressure regulation'/exp #12 Antihypertensive drug therapy 'hypertension'/exp/dm_dt #13 'antihypertensive agent'/exp/mj OR 'antihypertensive therapy'/mj OR 'antihypertensive agent'/exp/dd_dt,dd_ad,dd_cm,dd_do #14 (antihypertens*:ti,ab OR 'anti hypertens*':ti,ab) AND (drug*:ti,ab OR pharma*:ti,ab OR medication*:ti,ab OR medicine*:ti,ab OR prescription*:ti,ab OR dose:ti,ab OR dosage:ti,ab) Apply hedges below Questions and Pharmacologic interventions prehypertension. WCH hypertension /exp OR hypertensive patient /exp OR resistant hypertension /exp OR masked hypertension /exp OR white coat hypertension /exp OR prehypertension /exp #2 Hypertension:ti,ab OR hypertensive:ti,ab OR borderline hypertensive :ti,ab OR prehyperten*:ti,ab OR white coat hypertension OR WCH OR masked hypertension OR ((masked OR white-coat OR white coat ):ti,ab AND hypertension:ti,ab) OR refractory hypertension :ti,ab OR resistant hypertension :ti,ab OR uncontrolled hypertension :ti,ab #3 (high OR elevated OR borderline OR low OR lowering) NEAR/3 blood pressure Question Set # Concept Strategy Questions and Pharmacologic interventions (cont.) Antihypertensive Pharma therapy hypertension /exp/dm_dt OR ( hypertension /exp/mj AND antihypertensive agent /exp) #6 antihypertensive agent /exp/mj OR antihypertensive therapy /mj OR 'antihypertensive agent'/exp/dd_dt,dd_ad,dd_cm,dd_do #7 ((antihypertens* OR 'anti hypertens*') NEAR/5 (drug* OR pharma* OR medication* OR medicine* OR prescription* OR dose OR dosage)):ti,ab #8 Drugs (list is from workgroup members) Thiazide* OR thiazide-like diuretic* OR Chlorthalidone OR Bendroflumethiazide OR Chlorothiazide OR Hctz OR hydrochlorothiazide OR (hydrochlorothiazide NEAR/2 triamterene) OR Methyclothiazide OR Indapamide OR metolazone #9 Angiotensin-converting enzyme inhibitor* OR Benazepril OR captopril OR Enalapril OR Fosinopril OR Lisinopril OR moexipril OR Perindopril OR Quinapril OR Ramipril OR Trandolapril OR Angiotensin II Receptor Blocker* OR Azilsartan OR Candesartan OR Eprosartan OR Irbesartan OR Losartan OR Olmesartan OR Telmisartan OR Valsartan #10 Long-Acting Dihydropyridine Calcium Channel Blocker* OR dihydropyridine* OR CCBs OR Amlodipine OR Felodipine OR Nifedipine sr OR nifedipine xl OR nifedipine cc OR Nicardipine SR OR Nisoldipine ER #11 Aldosterone NEAR/2 Antagonist* OR mineralocorticoid Receptor Antagonist* OR Eplerenone OR Spironolactone OR Direct Renin Inhibitor OR Aliskiren OR Potassium-sparing diuretic* OR Amiloride #12 Alpha-blocker* OR Doxazosin OR Prazosin OR Terazosin OR Beta- blocker* OR Propranolol OR Acebutolol OR Atenolol OR Betaxolol OR Bisoprolol OR Metoprolol tartrate OR Metoprolol succinate OR Nadolol OR Nebivolol OR Penbutalol OR Pindolol OR Timolol #13 Long-Acting non-DHP CCB* OR non-dihydropyridine* OR Verapamil sr OR Diltiazem sr OR (alpha NEXT/2 beta NEXT/2 (antagonist* OR blocker*)) OR Carvedilol OR Labetalol OR Reserpine OR Minoxidil OR Hydralazine OR Clonidine tablet OR Clonidine patch OR Methyldopa OR Guanabenz OR Guanfacine #15 Combine HTN with drugs #4 AND #14 Apply hedges below Question Set # Concept Strategy Questions and Telehealth, mobile applications, or other new technologies; alternative methods of delivering care #1 Hypertension, prehypertension. WCH hypertension /exp OR hypertensive patient /exp OR resistant hypertension /exp OR masked hypertension /exp OR white coat hypertension /exp OR prehypertension /exp #2 Hypertension:ti,ab OR hypertensive:ti,ab OR borderline hypertensive :ti,ab OR prehyperten*:ti,ab OR white coat hypertension OR WCH OR masked hypertension OR ((masked OR white-coat OR white coat ):ti,ab AND hypertension:ti,ab) OR refractory hypertension :ti,ab OR resistant hypertension :ti,ab OR uncontrolled hypertension :ti,ab #3 (high OR elevated OR borderline OR lower OR lowering) NEAR/3 blood pressure #5 Blood Pressure 'blood pressure'/exp OR 'diastolic blood pressure'/exp OR 'systolic blood pressure'/exp OR 'systole'/de OR 'diastole'/de #6 'blood pressure':ti,ab OR 'systolic pressure*':ti,ab OR 'diastolic pressure*':ti,ab OR 'arterial pressure*':ti,ab OR bp:ti,ab OR sbp:ti,ab OR dpb:ti,ab OR ((systol*:ti,ab OR diastol*:ti,ab OR arterial:ti,ab) AND (pressure*:ti,ab OR mmhg:ti,ab OR 'mm hg':ti,ab)) #8 Telehealth 'telehealth'/exp OR 'teleconsultation'/exp OR 'telenursing'/exp OR 'telemedicine'/exp OR telemonitoring /exp OR videoconferencing /exp #9 telemedicine:ti,ab OR teleconsult*:ti,ab OR telehealth*:ti,ab OR telenurs*:ti,ab OR telemonitor*:ti,ab OR telecare:ti,ab OR telehomecare:ti,ab OR telemanagement:ti,ab OR telemedical*:ti,ab OR telemetr*:ti,ab OR 'tele medicin*':ti,ab OR 'tele health*':ti,ab OR tele-monitor* OR 'tele nurs*':ti,ab OR ehealth:ti,ab OR 'e health':ti,ab OR bluetooth:ti,ab OR (remote NEXT/2 consult*):ti,ab OR (telephone NEXT/2 consult*):ti,ab OR telephone:ti,ab #10 Technology mobile health application /exp OR 'mobile application'/exp OR mobile phone /exp OR smartphone /exp OR artificial intelligence /exp OR (email OR e-mail OR mhealth OR m-health OR mobile OR phone OR phones OR iphone* OR remote* OR virtual OR digital OR apps OR app OR text OR texting OR texts OR technology supported management OR technology based intervention* OR web based OR internet based OR computer based OR web):ti,ab #11 (device* OR monitors OR technologies OR smartwatch* OR smartphone OR watch* OR wearable OR wireless):ti,ab #12 social media /de OR ( crowd-sensing OR facebook OR social media ):ti,ab #13 Combine telehealth and technology #14 Combine HTN with tech #4 AND #13 #15 Combine BP with tech #7 AND #13 Question Set # Concept Strategy Questions and Telehealth, mobile applications, or other new technologies; alternative methods of delivering care (cont.) #17 Other providers (nurse* OR nutritionist OR dietitian OR dietician OR pharmacist OR pharmacy OR clinic OR clinics OR specialist* OR nephrolog* OR cardiolog*):ti,ab) OR health care personnel /exp OR pharmacist /exp OR ( pharmacist run OR pharmacist led OR nurse led OR nurse run OR clinics OR clinic OR center OR centers):ti,ab #18 Collaborative team 'collaborative care team'/exp OR 'collaborative care':ti,ab OR 'community care' OR 'interdisciplinary communication' OR 'multi disciplinary':ti OR multidisciplinary:ti OR collaborative:ti OR teambased:ti,ab OR 'team based':ti,ab OR integrate:ti OR integrated:ti #19 Combine HTN AND other providers #20 Combine HTN AND tech AND other providers #21 Combine HTN AND collaborative #22 Combine HTN AND collaborative AND tech Apply hedges below Question Screening prehypertension. WCH hypertension /exp OR hypertensive patient /exp OR resistant hypertension /exp OR masked hypertension /exp OR white coat hypertension /exp OR prehypertension /exp #2 Hypertension:ti,ab OR hypertensive:ti,ab OR borderline hypertensive :ti,ab OR prehyperten*:ti,ab OR white coat hypertension OR WCH OR masked hypertension OR ((masked OR white-coat OR white coat ):ti,ab AND hypertension:ti,ab) OR refractory hypertension :ti,ab OR resistant hypertension :ti,ab OR uncontrolled hypertension :ti,ab #3 (high OR elevated OR borderline) NEAR/3 blood pressure #5 Disease/Conditions to screen for chronic kidney failure /exp/dm_di,dm_ep,dm_et OR 'end stage renal disease'/exp/dm_di,dm_ep,dm_et OR 'estimated glomerular filtration rate'/exp OR proteinuria /exp OR albuminuria /exp #6 chronic kidney disease :ti,ab OR CKD :ti,ab OR esrd :ti,ab OR egfr :ti,ab OR glomerular filtration rate :ti,ab #7 Albuminuria:ti,ab OR proteinuria:ti,ab OR (urine NEXT/1 protein):ti,ab OR (urine NEXT/1 albumin):ti,ab #8 coronary artery disease /exp/dm_di,dm_ep,dm_et OR coronary artery disease :ti,ab #9 'peripheral vascular disease'/exp/dm_di,dm_ep,dm_et OR peripheral vascular disease :ti,ab Question Set # Concept Strategy Question Screening (cont.) #11 Screening Echo*:ti,ab OR ecg:ti,ab OR urine:ti,ab OR urine strip :ti,ab OR urinalysis:ti,ab OR ultrasound:ti,ab OR ankle-brachial index :ti,ab OR Doppler:ti,ab OR 'urinalysis'/exp OR 'urine test strip'/exp OR 'echography'/exp OR 'ultrasound'/exp OR 'Doppler flowmetry'/exp #12 'screening'/exp OR screen:ti,ab OR screening:ti,ab #13 'coronary calcium scoring'/exp OR 'coronary artery calcium score'/exp OR 'coronary calcium scor*' OR 'coronary calcium scan*' OR (cac AND artery) #15 Combine HTN and conditions and screening Apply hedges below General hedges applied to each section Date limit; Limit to English language publications; abstracts AND [1-12-2013]/sd NOT [11-3-2019]/sd AND [English]/lim AND [abstracts]/lim Remove undesired age ranges NOT (adolescen*:ti OR child*:ti OR infant*:ti OR neonat*:ti OR newborn*:ti OR paediatric*:ti OR pediatric*:ti OR youth:ti,ab) Remove undesired publication types (e.g., conferences, editorials) NOT ('conference paper'/exp OR 'case report'/de OR 'book'/de OR 'editorial'/de OR 'erratum'/de OR 'letter'/de OR 'note'/de OR 'short survey'/de OR book:it OR conference:it OR editorial:it OR erratum:it OR letter:it OR note:it OR 'short survey':it OR 'a case':ti,ab OR 'a patient':ti,ab OR 'year old':ti,ab OR book:pt OR 'conference proceeding':pt OR 'case report':ti OR comment:ti) Remove animal studies NOT (mouse OR mice OR rabbit* OR rat OR rats OR rodent* OR sheep OR swine OR canine* OR dog* OR porcine OR fish OR equine) Study type hedges applied as needed Limit to meta-analyses and systematic reviews AND ('meta analysis'/de OR 'systematic review'/de OR meta analysis /exp OR ('meta analysis' OR 'meta analytic' OR metaanaly* OR 'research synthesis' OR 'systematic review'/exp OR systematic review OR pooled OR pooling OR search*):ti,ab OR ('critical review' OR 'evidence based' OR systematic*):ti OR cochrane:jt OR [Cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim OR ((systematic* NEAR/2 review*):ab,ti) OR metaanaly*:ab,ti OR meta analysis :ab,ti OR meta analyses :ab,ti) Limit to randomized controlled trials AND ('random sample'/de OR 'randomized controlled trial'/exp OR randomization/de OR random*:ti,ab OR randomized controlled trial /exp) Limit to comparative studies (used only when appropriate) AND ( case control study /exp OR 'cohort analysis'/de OR comparative study /exp OR controlled study /exp OR cross- sectional study /de OR diagnostic test accuracy study /de OR epidemiology/exp/mj OR follow up /de OR 'longitudinal study'/de OR observational study /de OR 'prospective study'/de OR retrospective study /de OR ( case control OR case series OR cohort OR compar* OR controlled study OR controlled trial OR cross sectional OR follow-up OR followup OR longitudinal OR matched controls OR placebo OR prospective OR retrospective):ti,ab OR (epidemiolog* OR versus OR vs):ti) B. PsycINFO with Ovid Syntax Question Set # Concept Strategy Questions and Treatments for obesity, lifestyle modifications, physical activity #1 Population (adults with hypertension) Exp hypertension/ OR Hypertension.mp. OR hypertensive.mp. OR 'borderline hypertensive'.ti,ab. OR prehypertensi*.ti,ab. OR 'white coat hypertension' OR 'masked hypertension' #2 (high OR elevated OR borderline OR lower OR lowering) adj3 'blood pressure' #4 Obesity Exp Obesity/ OR obese.ti. OR obesity.ti. OR overweight.ti. #5 Obesity surgery Exp bariatric surgery/ OR exp weight control/ "roux en y".mp. OR "gastric bypass".mp. OR "obesity treatment".id. #6 (obes*.ti. OR bariatric.ti. OR gastric*.ti. OR stomach.ti. OR weight loss .ti. OR weight-loss.ti.) AND surg*.ti. #7 obes*.ti. and (sleeve or lapband or band* or "gastric bypass" or gastrectomy or "roux n y" or rygb).ti,ab. #8 Combine obesity surgery AND HTN #9 Obesity pharma Exp obesity AND exp drug therapy #10 (((tetrahydrolipstatin or lorcaserin or phentermine) adj2 topiramate) or liraglutide or phentemine or topiramate or phentemine or topiramate or qsymia or lorcaserin or belviq or orlistat or xenical or alli or (naltrexone adj1 bupropion) or contrave or liraglutide or saxenda or victoza or phentermine or benzphetamine or phendimetrazine or diethylpropion or (antiobesity adj1 agent*) or (antiobesity adj1 drug*) or (obesity adj1 agent*) or (obesity adj1 drug*)).mp. #11 ((antihypertensive* or "anti hypertensive*" or antihypertensive) adj1 drug*) or 'anti hypertensive') adj1 drug*).mp. or exp antiobesity agent/ #13 Combine obesity with pharma #14 Obesity lifestyle mod to control weight Exp weight control/ OR exp weight loss/ OR weight loss.mp. OR ((weight OR body mass) AND (lose OR loss OR lost OR lowering OR reduc* OR manag*)).ti. #15 Exp diets/ or diet therapy.mp. #16 (eat* OR diet* OR food OR sedentary OR lazy OR laziness OR activity OR active OR activities OR exercise).ti. AND (habit* OR choice* OR modif* OR change* OR improve* OR manag*).ti. #17 (Dash adj3 diet).mp. OR (Mediterranean adj3 diet).mp. OR ((diet* OR nutrition*).ti AND (sodium OR salt OR potassium).ti.) #18 exp Behavior Modification/ OR exp Lifestyle Changes/ OR lifestyle modification.mp. #19 Combine weight control AND HTN #20 Combine diets AND HTN Question Set # Concept Strategy Questions and Treatments for obesity, lifestyle modifications, physical activity (cont.) #22 Exp meditation/ OR meditation.mp. OR exp mindfulness/ OR mindfulness.mp. OR qigong.mp. OR exp martial arts/ OR tai chi.mp. OR exp yoga/ OR yoga.mp. #23 Exp weightlifting/ OR resistance training.mp. #24 Exp running/ OR run*.ti. OR jog.ti. OR exp walking/ OR walk*.ti. OR swim*.ti. OR aerobics.ti. OR (aerobic adj2 exercise*).ti. OR (aerobic adj2 fitness).ti. OR (aerobic adj2 training).ti. #25 ((exericse or (physical adj2 activity)) and (change* or improve* or modif* or increase*)).ti. #26 Combine physical activity #27 Combine obesity AND phys activity #28 Combine obesity AND phys activity AND HTN #29 Exp sedentary behavior/ OR (sedentary OR inactive OR inactivity OR lazy OR laziness).ti,ab. #32 Apply limits See search hedges below Questions and Telehealth, mobile applications, or other new technologies; alternative methods of delivering care #1 Hypertension Exp hypertension/ #2 Hypertension.mp. OR hypertensive.mp. OR 'borderline hypertensive'.ti,ab. OR prehypertensi*.ti,ab. OR 'white coat hypertension' OR 'masked hypertension' #3 (high OR elevated OR borderline) adj3 'blood pressure' #5 Blood Pressure Exp blood pressure/ OR systolic pressure/ OR diastolic pressure/ #6 Blood pressure.ti,ab. OR systolic*.ti,ab OR diastolic.ti,ab. OR arterial pressure.ti,ab. OR bp.ti,ab. OR sbp.ti,ab. OR dbp.ti,ab. OR ((systole* OR diastol* OR arterial).ti. AND (pressure* OR mm hg OR mmgh).ti.) #8 Technology exp telemedicine/ or exp telenursing/ or exp remote consultation/ Question Set # Concept Strategy Questions and Telehealth, mobile applications, or other new technologies; alternative methods of delivering care (cont.) #9 exp cellular phones/ or exp mobile devices/ or exp technology/ or exp electronic communication/ or exp internet/ or exp computer applications/ or exp online therapy/ or exp social media/ or exp websites/ or exp digital computers/ #10 ((cellular OR mobile) adj2 phone).ti. OR (telemedicine OR telehealth OR telenursing OR ehealth OR e health OR remote consult* OR telephone).ti. #11 ("personal digital assistant" OR smart phone OR cell* phone OR mobile phone OR smart watch OR androic* OR hand held OR iphone OR ipad OR webbased OR web based OR laptop OR "mobile health application" OR email OR e mail OR mhealth OR remote OR virtual OR digital OR apps OR app OR text OR texting OR texts OR "technology supported management" OR "technology based intervention" OR internet based or computer based).ti,ab. #12 (device* OR monitors OR technologies OR smartwatch* OR smartphone OR watch* OR wearable OR wireless OR "social media" OR facebook).ti,ab. #13 (telemedicine OR teleconsult* OR telehealth OR telenurs* OR telemonitor* OR telecare OR telehomecare OR telemanagement OR telemedical OR telemetr* OR ehealth OR bluetooth).ti,ab. OR (remote adj2 consult*).ti. OR (telephone adj2 consult*).ti. #15 Combine HTN AND Technology #16 Combine BP with Technology #17 Combine final technology sets #18 Allied health/delivery of care (nurse* OR nutritionist OR dietitian OR dietician OR pharmacist* OR pharmacy OR health care personnel).ti. OR (pharmacist adj1 run).ti,ab. OR (pharmacist adj1 led).ti,ab. OR (nurse adj1 led).ti,ab. OR (nurse adj1 run).ti,ab. OR (clinics OR clinic OR center OR centers).ti,ab. #19 exp health personnel/ OR exp pharmacists/ OR exp nurses/ #21 Combine delivery of care with HTN OR BP Apply limits and hedges See hedges below Question Set # Concept Strategy Search hedges applied to each strategy Limit to English language and publication year AND (english language AND yr="2013 - 2019") Population ("300 adulthood <age 18 yrs and older>" or 320 young adulthood <age 18 to 29 yrs> or 340 thirties <age 30 to 39 yrs> or 360 middle age <age 40 to 64 yrs> or "380 aged <age 65 yrs and older>" or "390 very old <age 85 yrs and older>") Exclude conference publications, books, letters, editorials, case studies, etc NOT ((("column/opinion" OR "comment/reply" OR dissertation OR editorial OR letter OR book).dt. OR book.pt.) OR (letter/ or editorial/ OR news/ OR comment/ OR case report OR case reports/ OR note/ OR conference paper/) OR (letter OR editorial OR news OR comment OR case reports OR conference abstract$).pt. Limit to meta-analyses and systematic reviews AND (meta analysis/ OR (systematic review OR meta analysis).mp. OR (meta-analysis OR systematic review).ti.) Limit to randomized controlled trials AND (Randomized controlled trials OR random allocation OR double-blind method OR single-blind method OR placebos OR cross-over studies).de. OR placebo$.mp. OR random$.ti. OR randomized controlled trial.pt. OR crossover$.mp. OR cross over.mp. OR ((singl* OR doubl* OR tripl* OR trebl*) ADJ3 (blind* OR mask* OR sham*)).mp. OR latin square.mp. OR ISRTCN OR ACTRN* OR (NCT* not NCT) OR (clinical trials/ AND random*.ti.) Limit to other study types, as needed AND (exp Cohort Analysis/ OR exp longitudinal studies/ OR exp prospective studies/ OR exp retrospective studies/ OR exp clinical trials/ OR (cohort* OR longitudinal OR prospective OR retrospective OR "case control" OR compar* OR "control group" OR "controlled study" OR "controlled trial" OR "cross over" OR crossover OR "double blind" OR "double blinded" OR "matched controls" OR placebo* OR random* OR sham OR validat*).ti,ab. OR ((versus OR vs).ti.) Limit to database study types AND ("0300 clinical trial" or "0430 followup study" or "0450 longitudinal study" or "0451 prospective study" or "0453 retrospective study" or "0830 systematic review" or 1200 meta analysis or 1300 metasynthesis or 2100 treatment outcome) Appendix K: Alternative Text Descriptions of Algorithms A. Module A: Screening and Diagnosis 1. Module A begins with Box 1, in the shape of a rounded rectangle: Adult in healthcare system 2. Box 1 connects to Box 2, in the shape of a hexagon, asks the question: Is the patient currently being treated for HTN? a. If the answer is Yes to Box 2, then Box 3, in the shape of an oval: Go to Module B, b. If the answer is No to Box 2, then Box 4, in the shape of a rectangle: Obtain office blood pressure (see Sidebar 1) 3. Box 4 connects to Box 5, in the shape of a hexagon, asks the question: When measured properly (see Appendix G), is SBP 120 mm Hg or DBP 80 mm Hg? a. If the answer is Yes to Box 5, then Box 6, in the shape of a hexagon, asks the question: Does patient have an acute injury or illness? i. If the answer is Yes to Box 6, then Box 7, in the shape of a rectangle: Return after acute episode resolved (typically within 4 weeks) 1. Box 7 connects to Box 4, in the shape of a rectangle: Obtain office blood pressure (see Sidebar 1) ii. If the answer No to Box 6, then Box 8, in the shape of a rectangle: Assess the need for and implement lifestyle modification, then follow up for adherence (e.g., diet, exercise, weight loss, alcohol moderation) b. If the answer is No to Box 5, then Box 15, in the shape of a rectangle: Screen blood pressure periodically; address other CV risk factors (including healthy diet and physical activity); in patients with known or suspected target organ damage (see Sidebar 3), consider possibility of masked HTN (consider HBPM or ABPM) 4. Box 8 connects to Box 9, in the shape of a hexagon, asks the question: Is SBP 130 mm Hg or DBP 90 mm Hg a. If the answer is Yes to Box 9, then Box 10, in the shape of a hexagon, asks the question: Confirm diagnosis of HTN by measuring blood pressure after 1-4 weeks (see Sidebar 2); is diagnosis confirmed? i. If the answer is Yes to Box 10, then Box 11, in the shape of a rectangle: Obtain history and physical and assess for target organ damage and comorbid conditions (see Sidebar 3); consider baseline testing (e.g., basic metabolic panel, urinalysis, EKG, A1c, other tests), as appropriate ii. If the answer is No to Box 10, then Box 15, in the shape of a rectangle: Screen blood pressure periodically; address other CV risk factors (including healthy diet and physical activity); in patients with known or suspected target organ damage (see Sidebar 3), consider possibility of masked HTN (consider HBPM or ABPM) b. If the answer is No to Box 9, then Box 15, in the shape of a rectangle: Screen blood pressure periodically; address other CV risk factors (including healthy diet and physical activity); in patients with known or suspected target organ damage (see Sidebar 3), consider possibility of masked HTN (consider HBPM or ABPM) 5. Box 11 connects to Box 12, in the shape of a hexagon, asks the question: Is secondary cause suspected? a. If the answer is Yes to Box 12, then Box 13, in the shape of a rectangle: Evaluate, as indicated; consider referral i. Box 13 connects to Box 14, in the shape of an oval: Initiate treatment (go to Module B) b. If the answer is No to Box 12, then Box 14, in the shape of an oval: Initiate treatment (go to Module B) B. Module B: Treatment 1. Module B begins with Box 16, in the shape of a rounded rectangle: Patient appropriate for HTN treatment 2. Box 16 connects to Box 17, in the shape of a rectangle: Determine blood pressure goal (see Sidebar 4) 3. Box 17 connects to Box 18, in the shape of a rectangle, asks the question: Implement SDM to assess patient values and preferences; assess the need for and implement lifestyle modification. Is the patient willing to engage in pharmacotherapy? a. If the answer is Yes to Box 18, then Box 19, in the shape of an rectangle: Initiate treatment if drug na ve or optimize existing therapy (see Sidebar 5) b. If the answer is No to Box 18, then Box 20, in the shape of a rounded rectangle: Patient refuses pharmacotherapy; consider nurse-led and dietitian-led interventions to improve blood pressure control 4. Box 20 connects to Box 21, in the shape of a rounded rectangle: Follow up periodically; reassess preferences 5. Box 21 connects to Box 17, in the shape of a rectangle: Determine blood pressure goal (see Sidebar 4) 6. Box 19 connects to Box 22, in the shape of a rectangle: Consider offering and/or adjusting HBPM with co-interventions (tailored medication titration, education, and/or lifestyle counseling 7. Box 22 connects to Box 23, in the shape of a rectangle: Follow up regularly (e.g., monthly) until: blood pressure is at goal, treatment regimen is optimized (see Sidebar 6), comorbid conditions and/or other patient preferences direct otherwise 8. Box 23 connects to Box 24, in the shape of a hexagon, asks the question: Is the patient s blood pressure at or below goal? a. If the answer is Yes to Box 24, then Box 25, in the shape of a rectangle: Follow up annually or more frequently as dictated by comorbid conditions (to include lab monitoring, if indicated) b. If the answer is No to Box 24, then Box 22, in the shape of a rectangle: Consider offering and/or adjusting HBPM with co-interventions (tailored medication titration, education, and/or lifestyle counseling) Appendix L: Abbreviations Abbreviation Definition AASK African American Study of Kidney Disease and Hypertension AA aldosterone antagonist ABI ankle-brachial index ABPM ambulatory blood pressure monitoring ACC American College of Cardiology ACCOMPLISH Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension ACCORD Action to Control Cardiovascular Risk in Diabetes ACEI angiotensin-converting enzyme inhibitor ADVANCE Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation AE adverse effect AHA American Heart Association AHRQ Agency for Healthcare Research and Quality ALLHAT Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack ( AOBP automated office blood pressure ARB angiotensin II receptor blocker AUC area under curve AV atrioventricular bid twice daily BMI body mass index BPH benign prostatic hyperplasia BPROAD Blood Pressure Control Target in Diabetes CAC coronary artery calcification CAD coronary artery disease CCB calcium channel blocker CHF chronic heart failure CKD chronic kidney disease cm centimeter CMS Centers for Medicare and Medicaid Services COB central operating base COI conflict of interest COR contracting officer's representative CPG clinical practice guideline CS clinical study CV cardiovascular CVD cardiovascular disease DASH Dietary Approaches to Stop Hypertension DBP diastolic blood pressure DHP dihydropyridines Abbreviation Definition DoD Department of Defense DRI direct renin inhibitors EBPWG Evidence-Based Practice Work Group ECG electrocardiogram ECHO echocardiogram eGFR estimated glomerular filtration rate EKG electrocardiogram FDA U.S. Food and Drug Administration FOB forward operating base GI gastrointestinal GRADE Grading of Recommendations Assessment, Development and Evaluation HBPM home blood pressure monitoring HC high-unrefined carbohydrate, low-fat diet HCTZ hydrochlorothiazide HEC Health Executive Committee HFrEF reduced ejection fraction HIPAA Health Insurance Portability and Accountability Act HTN hypertension HYVET Hypertension in the Very Elderly Trial IPAD Intervention for High-normal or Borderline-elevated Blood Pressure in Adults with Type 2 Diabetes IR immediate release Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure K+ Potassium KQ key question LA DHP long-acting dihydropyridine LC low-carbohydrate, high-unsaturated/low-saturated fat diet LDL low-density lipoprotein LIFE Losartan Intervention For Endpoint reduction LV left ventricular LVH left ventricular hypertrophy MACE major adverse cardiovascular events MD mean difference MHS Military Health System MI myocardial infarction mL milliliter MRA mineralocorticoid receptor antagonist MRC Medical Research Council MRE Meals Ready to Eat MTF military treatment facilities Abbreviation Definition NHANES National Health and Nutrition Examination Survey NICE National Institute for Health and Care Excellence NPV negative predictive value OSA obstructive sleep apnea PCC patient-centered care PICOTS population, intervention, comparison, outcome, timing and setting PPV positive predictive value PREDIMED PREvenci n con DIeta MEDiterr nea PVD perpherial vascular disease RCT randomized control trial RHT resistant hypertension SBP systolic blood pressure SDM shared decision making SLE systemic lupus erythematosus SME subject matter expert SMS short message service SPRINT Systolic Blood Pressure Intervention Trial SR systematic review Tbsp tablespoon TOHP II Trials of Hypertension Prevention Phase II TONE Trial of Non-pharmacologic Interventions in the Elderly TOPCAT Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial U.S. United States US ultrasound USPSTF U.S. Preventive Services Task Force VA Veterans Affairs VHA Veterans Health Administration References 1. 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