https://web.pathway.md/diseases/reclWZaqSp36TX3eN 14/18 6/24/23, 12:46 PM Hypertension Pathway Show 2 more Patients with diabetes mellitus (lifestyle modifications): advise lifestyle interventions in patients with BP > 120/80 mmHg, consisting of weight loss when indicated, a Dietary Approaches to Stop HTN-style eating pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity. A Patients with diabetes mellitus, BP targets: As per ADA 2023 guidelines, individualize BP targets in patients with diabetes and HTN through a shared decision-making process addressing cardiovascular risk, potential adverse effects of antihypertensive medications, and patient preferences. B Show 2 more As per Hypertension Canada 2020 guidelines, treat HTN in patients with diabetes mellitus targeting systolic BP of < 130 mmHg B and diastolic BP of < 80 mmHg. A As per JNC 2014 guidelines, initiate pharmacologic treatment in adult patients with diabetes mellitus to lower BP at systolic BP 140 mmHg or diastolic BP 90 mmHg and treat to a goal of systolic BP < 140 mmHg and goal diastolic BP < 90 mmHg. B Patients with diabetes mellitus, pharmacotherapy: As per ADA 2023 guidelines, initiate and titrated pharmacologic therapy to achieve BP goal of < 130/80 mmHg in patients with confirmed office-based BP 130/80 mmHg. A Show 6 more As per PCNA/NMA/ASPC/ASH/APhA/AGS/ACPM/ABC/AAPA/AHA/ACC 2018 guidelines, initiate antihypertensive drug treatment at a BP 130/80 mmHg with a treatment goal of < 130/80 mmHg in adults with diabetes mellitus and HTN. B As per JNC 2014 guidelines: Initiate a thiazide-type diuretic, CCB, ACEI, or ARB as initial antihypertensive treatment in the general nonblack population, including patients with diabetes mellitus. B Initiate a thiazide-type diuretic or CCB as initial antihypertensive treatment in the general black population B , including patients with diabetes. B Patients with diabetes mellitus (pediatric patients): measure BP in young patients with T2DM at every visit. Consider obtaining ambulatory BP monitoring in young patients with high BP (BP 90th percentile for age, gender, and height or, in adolescents aged 13 years, 120/80 mmHg) on 3 separate measurements. B Show 3 more Patients with chronic kidney disease (lifestyle modifications): consider advising patients with HTN and CKD to target a sodium intake of < 2 g of sodium per day (or < 90 mmol of sodium per day or < 5 g of sodium chloride per day). C Show 5 more Patients with chronic kidney disease, antihypertensives: As per KDIGO 2021 guidelines, consider targeting systolic BP of < 120 mmHg, when tolerated, using standardized office BP measurement in adult patients with HTN and CKD. C Show 8 more https://web.pathway.md/diseases/reclWZaqSp36TX3eN 15/18 6/24/23, 12:46 PM Hypertension Pathway As per PCNA/NMA/ASPC/ASH/APhA/AGS/ACPM/ABC/AAPA/AHA/ACC 2018 guidelines, treat adults with HTN and CKD to a BP goal of < 130/80 mmHg. B Show 2 more As per JNC 2014 guidelines: Initiate pharmacologic treatment in adult patients with CKD to lower BP at systolic BP 140 mmHg or diastolic BP 90 mmHg and treat to the goal of systolic BP < 140 mmHg and diastolic BP < 90 mmHg. B Initiate an ACEI or ARB as the initial (or add-on) antihypertensive treatment to improve kidney outcomes in adult patients with CKD regardless of race or diabetes status. B Patients with coronary artery disease: Aim for a BP target of < 130/80 mmHg in adults with stable ischemic heart disease and HTN. B Treat adults with stable ischemic heart disease and HTN (BP 130/80 mmHg) with medications for compelling indications (e.g., -blockers, ACEIs, or ARBs for previous myocardial infarction or stable angina) as first-line therapy, with the addition of other drugs (e.g., dihydropyridine CCBs, thiazide diuretics, and/or mineralocorticoid receptor antagonists) as needed to further control HTN. B Patients with heart failure, reduced EF: As per HFSA/ACC/AHA 2022 guidelines, titrate guideline-directed medical therapy to the maximally tolerated target dose in patients with HF with reduced ejection fraction and HTN. B As per PCNA/NMA/ASPC/ASH/APhA/AGS/ACPM/ABC/AAPA/AHA/ACC 2018 guidelines, administer guideline-directed medical therapy titrated to attain a BP of < 130/80 mmHg in adults with HF with reduced ejection fraction and HTN. B Patients with heart failure, preserved EF: As per HFSA/ACC/AHA 2022 guidelines, titrate medication to attain BP targets in accordance with published clinical practice guidelines to prevent morbidity in patients with HFpEF and HTN. B As per PCNA/NMA/ASPC/ASH/APhA/AGS/ACPM/ABC/AAPA/AHA/ACC 2018 guidelines: Initiate diuretics to control HTN in adults with HFpEF who present with symptoms of volume overload. B Initiate ACEIs or ARBs and -blockers titrated to attain a systolic BP of < 130 mmHg in adults with HFpEF and persistent HTN after management of volume overload. B Patients with stroke or TIA: Resume antihypertensive treatment after a few days in patients with HTN who experience a stroke or transient ischemic, in order to reduce the risk of recurrent stroke and other vascular events. A Lower BP slowly to < 185/110 mmHg before initiating thrombolytic therapy in adults with acute ischemic stroke and elevated BP who are eligible for treatment with intravenous tPA. B Patients with acute intracerebral hemorrhage: https://web.pathway.md/diseases/reclWZaqSp36TX3eN 16/18 6/24/23, 12:46 PM Hypertension Pathway Consider initiating a continuous intravenous antihypertensive drug infusion with close BP monitoring to lower systolic BP in adults with intracerebral hemorrhage who present with systolic BP > 220 mmHg. C Avoid immediate lowering of systolic BP to < 140 mmHg in adults with spontaneous intracerebral hemorrhage who present within 6 hours of the acute event and have a systolic BP 150 mmHg-220 mmHg, given the lack of demonstrated benefit and evidence of potential harm. D Patients with valvular heart disease: Initiate pharmacological treatment for HTN in adults with asymptomatic aortic stenosis, starting at low doses, and gradually titrating upward as needed. B Consider using agents that do not slow the HR (avoid -blockers) in patients with HTN and chronic aortic insufficiency. C Patients with thoracic aortic disease: use -blockers as the preferred antihypertensive agents in patients with HTN and thoracic aortic disease. B Patients with peripheral artery disease: treat adults with HTN and PAD similarly to patients with HTN who do not have PAD. B Patients with atrial fibrillation: consider ARBs in patients with AF to prevent recurrence. C Patients with obstructive sleep apnea: insufficient evidence to establish the efficacy of CPAP to reduce BP in adults with HTN and obstructive sleep apnea. I Renal transplant recipients: consider treating patients with HTN to a BP goal of < 130/80 mmHg after kidney transplantation. B 9. Follow-up and surveillance Indications for specialist referral: As per ACC 2018 guidelines: Refer adults with HTN and a positive screening test for primary aldosteronism to a HTN specialist or endocrinologist for further evaluation and treatment. B Consider referring patients with secondary HTN to a HTN specialist with relevant expertise. C As per JNC 2014 guidelines, consider referring patients to a HTN specialist if BP goal cannot be attained using the recommended strategy or for the management of complicated patients requiring additional clinical consultation. C Assessment of treatment response: As per ESC 2018 guidelines, reduce BP to < 140/90 mmHg as the first objective of treatment in all patients, and provided that the treatment is well tolerated, target treated BP values to 130/80 mmHg in most patients. A Show 2 more As per ACC 2018 guidelines, perform a follow-up evaluation of adherence and response to treatment at monthly intervals until control is achieved for adults initiating a new or adjusted drug https://web.pathway.md/diseases/reclWZaqSp36TX3eN 17/18 6/24/23, 12:46 PM Hypertension Pathway regimen for HTN. B As per JNC 2014 guidelines, increase the dose of the initial drug or add a second drug from one of the classes (thiazide-type diuretic, CCB, ACEI, or ARB) if goal BP is not reached within a month of treatment. Continue to assess BP and adjust the treatment regimen until goal BP is reached. B Show 2 more References 1. Doreen M Rabi, Kerry A McBrien, Ruth Sapir-Pichhadze et al. Hypertension Canada's 2020 Comprehensive Guidelines for the Prevention, Diagnosis, Risk Assessment, and Treatment of Hypertension in Adults and Children. Can J Cardiol. 2020 May;36 5 596 624. Open 2. Williams B, Mancia G, Spiering W et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018 Sep 1;39 33 3021 3104. Open 3. Paul K Whelton, Robert M Carey, Wilbert S Aronow et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71 6):e13-e115. Open 4. James PA, Oparil S, Carter BL et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee JNC 8 . JAMA. 2014 Feb 5;311 5 507 20. Open 5. Qaseem A, Wilt TJ, Rich R et al. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017 Mar 21;166 6 430 437. Open 6. Steven E. Kahn, Cheryl A.M. Anderson, John B. Buse et al. Standards of Care in Diabetes 2023. Diabetes Care. 2023 Jan;46 Supplement_1 S1 S291. Open 7. Apovian CM, Aronne LJ, Bessesen DH et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015 Feb;100 2 342 62. Open 8. Kidney Disease: Improving Global Outcomes KDIGO Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021 Mar;99 3S S1 S87. Open 9. Sarah Coles, Lynn Fisher, Kenneth W Lin et al. Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From the AAFP. Am Fam Physician. 2022 Dec;106 6 Online. Open 10. W Timothy Garvey, Jeffrey I Mechanick, Elise M Brett et al. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY. Endocr Pract. 2016 Jul;22 Suppl 3 1 203. Open 11. US Preventive Services Task Force, Alex H Krist, Karina W Davidson et al. Screening for High Blood Pressure in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. https://web.pathway.md/diseases/reclWZaqSp36TX3eN 18/18