What are the guideline sources, guidelines and references for Hypertension ?
Guideline sources The following summarized guidelines for the evaluation and management of hypertension (HTN) are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the American Association of Family Physicians (AAFP 2022), the Heart Failure Society of America (HFSA/AHA/ACC 2022), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2021), the U.S. Preventive Services Task Force (USPSTF 2021; 2020), the Hypertension Canada Guidelines (Hypertension Canada 2020), the European Society of Cardiology (ESC/ESH 2018), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the American College of Physicians (ACP/AAFP 2017), the American College of Endocrinology (ACE/AACE 2016), the Endocrine Society (ES 2015), and the Joint National Committee (JNC 2014). 1 2 3 3 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Definition According to the 2017 ACC/AHA, elevated BP (BP) is defined as systolic pressure between 120 and 129 mm Hg and diastolic pressure less than 80 mm Hg. Stage 1 HTN is defined as systolic BP https://web.pathway.md/diseases/reclWZaqSp36TX3eN 1/18 6/24/23, 12:46 PM Hypertension Pathway greater than 130 mm Hg or diastolic BP greater than 80 mm Hg. 3 Epidemiology Primary HTN etiology is multifactorial and most frequently associated with a combination of environmental (unhealthy diet, increased sodium intake, insufficient potassium intake, inadequate physical activity, overweight/obesity) and genetic factors (multiple risk alleles, gene-gene interactions, fetal programming, epigenetic mechanisms). Secondary HTN etiology includes primary aldosteronism, renal HTN, renal parenchymal disease, pheochromocytoma/paraganglioma, Cushing's syndrome, hypothyroidism, hyperthyroidism, hypercalcemia and primary hyperparathyroidism, congenital adrenal hyperplasia, acromegaly, coarctation of the aorta, and medication or recreational drug use (amphetamines, cocaine, phencyclidine). White-coat HTN and isolated systolic HTN are essential subtypes. 14 Pathophysiology HTN is highly prevalent worldwide. The prevalence of HTN in the United States is estimated at 31,900 per 100,000 adults based on the 140/90-mm Hg cutoff. Rates are highest in African Americans and increase with age. 3 Disease course HTN is mostly asymptomatic until an acute hypertensive crisis or end-organ complications occur. Manifestations of end-organ damage in HTN include motor or sensory deficit (brain); hypertensive retinopathy (retina); and AF, arrhythmias, pulmonary congestion and peripheral edema (heart). Secondary HTN presents with symptoms of the causal condition, for example, abdominal bruit in renal artery stenosis or abdominal masses in polycystic kidney disease. A fourth heart sound is often the earliest sign of hypertensive heart disease. HTN decreases health-related quality of life. 15 Prognosis and risk of recurrence Prognosis is highly dependant on the BP and end-organ damage. Higher BP and more severe retinopathy or organ damage are associated with a worse prognosis. Untreated or treatment- resistant HTN leads to lower survival rates. However, effective BP control raises 10-year survival rates to 70%. 16 CalculatorNYHA functional classification f Guidelines https://web.pathway.md/diseases/reclWZaqSp36TX3eN 2/18 6/24/23, 12:46 PM Hypertension Pathway 1. Screening and diagnosis Indications for screening, adults: As per USPSTF 2021 guidelines, obtain screening for HTN with office BP measurement in 18 years old adults. Obtain BP measurements outside of the clinical setting for diagnostic confirmation before starting treatment. A As per ESH/ESC 2018 guidelines, obtain screening for HTN with a measurement of office BP in all adult patients 18 years of age. Record the BP results in the patient's medical file and inform them about their BP. B As per PCNA/NMA/ASPC/ASH/APhA/AGS/ACPM/ABC/AAPA/AHA/ACC 2018 guidelines, screen for HTN in adults 18 years of age. A Indications for screening (pediatrics): insufficient evidence to assess the balance of benefits and harms of screening for high BP in children and adolescents. I Screening for white coat hypertension: consider obtaining daytime ambulatory BP monitoring or home BP monitoring to screen for white coat HTN in adult patients with untreated systolic BP > 130 mmHg but < 160 mmHg or diastolic BP > 80 mmHg but < 100 mmHg. C 2. Classification and risk stratification Staging: As per ESC 2018 guidelines, classify BP as optimal, normal, or high-normal, or grades 1-3 HTN, according to office BP. B As per ACC 2018 guidelines, classify BP as follows, in order to assist in appropriate prevention and treatment of high BP: normal (systolic BP < 120 mmHg and diastolic BP < 80 mmHg) elevated (systolic BP 120-129 mmHg and diastolic BP < 80 mmHg) stage 1 HTN (systolic BP 130-139 mmHg or diastolic BP 80-89 mmHg) stage 2 HTN (systolic BP 140 mmHg or diastolic BP 90 mmHg). B Cardiovascular risk stratification: As per CHEP 2020 guidelines, assess global cardiovascular risk in patients with HTN. Consider obtaining multifactorial risk assessment models to: predict more accurately a patient's global cardiovascular risk A help engage patients in conversations about health behavior change to lower BP B use antihypertensive therapy more efficiently. B Show 2 more As per ESC 2018 guidelines, obtain cardiovascular risk assessment with the SCORE system in patients with HTN not already at high or very high risk due to established CVD, renal disease, or diabetes. B https://web.pathway.md/diseases/reclWZaqSp36TX3eN 3/18 6/24/23, 12:46 PM Hypertension Pathway 3. Diagnostic investigations Office blood pressure measurement: As per KDIGO 2021 guidelines, obtain standardized office BP measurement in preference to routine office BP measurement for the management of high BP in adult patients. B Show 3 more As per ESC 2018 guidelines, repeat office BP measurements on more than one visit, except when HTN is severe (grade 3 and especially in high-risk patients). Record three BP measurements at each visit, 1-2 min apart, and perform additional measurements if the first two readings differ by > 10 mmHg. Recognize that the patient's BP is the average of the last two BP readings. B Out-of-office blood pressure measurement: As per KDIGO 2021 guidelines, consider obtaining out-of-office BP measurements with ambulatory BP monitoring or home BP monitoring to complement standardized office BP readings for the management of high BP. C As per CHEP 2020 guidelines, obtain ambulatory BP monitoring or home BP monitoring for follow-up of patients with demonstrated white coat effect. B Show 4 more As per ESC 2018 guidelines, obtain out-of-office BP measurement with ambulatory BP monitoring and/or home BP monitoring, provided that these measurements are logistically and economically feasible. B As per ACC 2018 guidelines, obtain out-of-office BP measurements to confirm the diagnosis of HTN and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions. A Show 2 more Initial investigations: As per CHEP 2020 guidelines, obtain the following routine tests for the evaluation of all patients with HTN: urinalysis blood chemistry (potassium, sodium, and creatinine) fasting blood glucose and/or Hgb A1C serum total cholesterol, LDL, high-density lipoprotein, non-HDL-C, and triglycerides. B Show 4 more As per ACC 2018 guidelines: Obtain the following tests in patients newly diagnosed with HTN: CBC serum creatinine with estimated GFR serum sodium, potassium, calcium lipid profile https://web.pathway.md/diseases/reclWZaqSp36TX3eN 4/18 6/24/23, 12:46 PM Hypertension Pathway fasting blood glucose TSH urinalysis ECG. Consider obtaining uric acid and urinary albumin to creatinine ratio on a case-by-case basis in patients with newly diagnosed HTN. Echocardiography: As per CHEP 2020 guidelines, do not obtain routine echocardiographic evaluation in patients with HTN. D Show 3 more As per ACC 2018 guidelines, consider obtaining echocardiography on a case-by-case basis in patients with newly diagnosed HTN. Evaluation for modifiable risk factors: As per CHEP 2020 guidelines, measure height, weight, and waist circumference and calculate BMI in all adults. B As per ACC 2018 guidelines, screen for and manage other modifiable CVD risk factors in adults with HTN. B Evaluation for drug or alcohol use: Assess for use of the following substances in patients with HTN: sodium-containing antacids; caffeine; nicotine (smoking); alcohol; nonsteroidal anti-inflammatory agents; oral contraceptives; cyclosporine or tacrolimus; sympathomimetics (decongestants, anorectics); cocaine, amphetamines and other illicit drugs; neuropsychiatric agents; ESAs; clonidine withdrawal; and herbal agents (Ma Huang, ephedra). B Obtain a toxicology screen to evaluate for drug or alcohol abuse in patients with HTN and symptoms suggestive of illicit drug use. B Evaluation for obstructive sleep apnea: Obtain a screening test for obstructive apnea (such as the Berlin Questionnaire, Epworth Sleepiness Score, or overnight oximetry) in patients with HTN meeting any of the following criteria: resistant HTN loss of normal nocturnal BP fall snoring, fitful sleep, breathing pauses during sleep daytime sleepiness obesity, Mallampati class III-IV. B Evaluation for renovascular disease: Obtain renal duplex Doppler ultrasound, MRA, or abdominal CT to evaluate for renovascular disease in patients meeting with HTN meeting any of the following criteria: resistant HTN, or increasingly difficult to control HTN of abrupt onset or worsening flash pulmonary edema https://web.pathway.md/diseases/reclWZaqSp36TX3eN 5/18 6/24/23, 12:46 PM Hypertension Pathway early-onset HTN, especially in women abdominal systolic-diastolic bruit bruits over other arteries. B Evaluation for renal parenchymal disease: Obtain renal ultrasound to evaluate for renal parenchymal disease in patients with HTN meeting any of the following criteria: history of UTIs or obstruction symptoms of hematuria, urinary frequency and nocturia history of analgesic abuse family history of polycystic kidney disease elevated serum creatinine, or abnormal urinalysis abdominal mass (polycystic kidney disease). B Evaluation for primary hyperaldosteronism: Screen for primary hyperaldosteronism in patients meeting any of the following criteria: resistant HTN spontaneous hypokalemia marked diuretic-induced hypokalemia incidentally discovered adrenal mass family history of early-onset HTN stroke at < 40 years of age. B Use plasma aldosterone to renin activity ratio as the first-line test for primary hyperaldosteronism in adults. B Evaluation for pheochromocytoma: Obtain 24-h urinary fractionated metanephrines (or plasma metanephrines under standard conditions) to screen for pheochromocytoma in patients with HTN meeting any of the following criteria: resistant HTN or paroxysmal HTN BP lability, headache, sweating, palpitations, pallor positive family history of pheochromocytoma/paraganglioma adrenal incidentaloma skin stigmata of neurofibromatosis (caf -au-lait spots; neurofibromas) orthostatic hypotension. B Evaluation for aortic coarctation: Obtain echocardiography to screen for aortic coarctation in patients with HTN meeting any of the following criteria: young patient with HTN (< 30 years of age) BP higher in upper extremities than in lower extremities absent femoral pulses continuous murmur over patient's back, chest, or abdominal bruit left thoracotomy scar (postoperative). B https://web.pathway.md/diseases/reclWZaqSp36TX3eN 6/18 6/24/23, 12:46 PM Hypertension Pathway Evaluation for thyroid disease: Obtain a TSH to screen for hypothyroidism in patients with HTN meeting any of the following criteria: dry skin; cold intolerance; constipation; hoarseness; weight gain delayed ankle reflex; periorbital puffiness; coarse skin; cold skin; slow movement; goiter. B Obtain a serum TSH to screen for hyperthyroidism in patients with HTN meeting any of the following criteria: warm, moist skin; heat intolerance; nervousness; tremulousness; insomnia; weight loss; diarrhea; proximal muscle weakness lid lag; fine tremor of the outstretched hands; warm, moist skin. B Evaluation for hyperparathyroidism: obtain a serum PTH to screen for primary hyperparathyroidism in patients with HTN and hypercalcemia. B Evaluation for congenital adrenal hyperplasia: Obtain screening for congenital adrenal hyperplasia in patients with HTN meeting any of the following criteria: HTN and hypokalemia; signs of virilization (11- -OH) incomplete masculinization (17-alpha-OH). B Evaluation for acromegaly: Obtain a serum GH level to screen for acromegaly in patients with HTN who meet any of the following criteria: enlarging shoe, glove, or hat size headache, visual disturbances concomitant diabetes mellitus acral features or frontal bossing. B Genetic testing: avoid routine genetic testing for hypertensive patients. D 4. Medical management Indications for treatment, general population: As per Hypertension Canada 2020 guidelines, initiate antihypertensive therapy for average diastolic BP measurements of 100 mmHg or average systolic BP measurements of 160 mmHg in patients without macrovascular target organ damage or other cardiovascular risk factors. A Show 2 more As per ESH/ESC 2018 guidelines: Initiate BP-lowering pharmacotherapy promptly in patients with grade 2-3 HTN at any level of cardiovascular risk, simultaneously with the initiation of lifestyle changes. A Avoid withdrawing BP-lowering pharmacotherapy on the basis of age, even when patients attain an age of 80 years, provided that treatment is well tolerated. D https://web.pathway.md/diseases/reclWZaqSp36TX3eN 7/18 6/24/23, 12:46 PM Hypertension Pathway As per PCNA/NMA/ASPC/ASH/APhA/AGS/ACPM/ABC/AAPA/AHA/ACC 2018 guidelines, initiate BP-lowering therapy for the primary prevention of CVD in adults with a systolic BP 140 mmHg or a diastolic BP 90 mmHg with an estimated 10-year ASCVD risk < 10%. B Indications for treatment (>= 60 years old patients): initiate treatment in adults 60 years of age with systolic BP persistently 150 mmHg to achieve a target systolic BP of < 150 mmHg to reduce the risk for mortality, stroke, and cardiac events. A Goals of treatment, general population: As per AAFP 2022 guidelines: Treat adult patients with HTN to a standard BP target (< 140/90 mmHg) to reduce the risk of all-cause and cardiovascular mortality. A Consider treating adult patients with HTN to a lower BP target (< 135/85 mmHg) to reduce the risk of myocardial infarction. C As per Hypertension Canada 2020 guidelines, treat adult patients with HTN to a systolic BP goal of < 140 mmHg B and a diastolic BP goal of < 90 mmHg. A As per JNC 2014 guidelines: Treat adult patients with HTN, both aged 18-29 B and 30-59 years, to lower BP to a goal of diastolic BP < 90 mmHg. A Treat adult patients with HTN aged < 60 years to lower BP to a goal of systolic BP < 140 mmHg. B Goals of treatment (>= 60 years old patients): Consider initiating or intensifying pharmacologic treatment to achieve a target systolic BP of < 140 mmHg with the goal of reducing the risk for stroke or cardiac event in selected 60 years old patients at high cardiovascular risk, based on individualized assessment. C Set treatment goals based on a periodic discussion of the benefits and harms of specific BP targets with the patient. Consider initiating or intensifying pharmacologic treatment to achieve a target systolic BP of < 140 mmHg with the goal of reducing the risk for stroke or cardiac events in 60 years old patients with a history of stroke or TIA. C Set treatment goals based on a periodic discussion of the benefits and harms of specific BP targets with the patient. Goals of treatment (patients at high CV risk): target a BP < 130/80 mmHg in adult patients with HTN and known CVD or 10-year ASCVD event risk 10%. B Show 4 more Updated evidence: SPRINT (secondary analysis) In patients 50 years of age with hypertension and increased cardiovascular risk, intensive BP control was not superior to standard BP control with respect to the rate of death from cardiovascular causes at a follow-up of 8.8 years. Byron C Jaeger et al. JAMA Cardiol. 2022 Nov 1. https://web.pathway.md/diseases/reclWZaqSp36TX3eN 8/18 6/24/23, 12:46 PM Hypertension Pathway Choice of antihypertensive (general principles): use once daily medication dosing, rather than multiple times daily, in order to improve adherence to antihypertensive therapy. B Show 2 more Choice of antihypertensive, initial therapy: As per Hypertension Canada 2020 guidelines, initiate treatment with either monotherapy or a single-pill combination, with choices including: monotherapy: a thiazide/thiazide-like diuretic, A preferably longer-acting B ; a -blocker, particularly in < 60 years old patients B ; an ACEI, particularly in nonblack patients B ; an ARB B ; a long-acting CCB B single-pill combinations: an ACEI with a CCB A ; an ARB with a CCB B ; an ACEI or ARB with a diuretic B Show 2 more As per ESH/ESC 2018 guidelines, initiate combination treatment as initial therapy in most patients with HTN. Prefer combinations of a RAAS blocker (either an ACEI or an ARB) with a CCB or diuretic. Consider using other combinations of the five major classes. Combine - blockers with any of the other major drug classes when there are specific clinical situations, such as angina, post-myocardial infarction, HF, or HR control. A Show 2 more As per PCNA/NMA/ASPC/ASH/APhA/AGS/ACPM/ABC/AAPA/AHA/ACC 2018 guidelines, initiate antihypertensive drug therapy with thiazide diuretics, CCBs, ACEIs, or ARBs as first-line agents. A Show 2 more Landmark trials: ALLHAT In patients aged 55 years with hypertension and at least 1 other coronary artery disease risk factor, treatment with one of three antihypertensive agent classes (amlodipine, lisinopril or chlorthalidone) did not result in any significant differences in major adverse cardiovascular events (fatal CHD or nonfatal myocardial infarction). The RRs for amlodipine (6-year rate, 11.3%) and lisinopril (6-year rate, 11.4%) were 0.98, 95% CI 0.90-1.07 and 0.99, 95% CI 0.91-1.08, respectively, when compared with chlorthalidone (6-year rate, 11.5%). The measurement of 5-year systolic BP was significantly higher with amlodipine (0.8 mmHg, p = 0.3) and lisinopril (2 mmHg, p < 0.001) therapy, as compared with chlorthalidone; the 5-year diastolic BP was significantly lower with amlodipine (0.8 mmHg, p < 0.001). The effect of treatment with amlodipine was similar to chlorthalidone in relation to all measured aspects of CHD and CVD adverse events, except for higher 6-year rate of HF with amlodipine (10.2% vs. 7.7%). On comparing the effects of treatment of lisinopril with chlorthalidone, lisinopril was associated with higher 6-year rates of combined CVD (33.3% vs. 30.9%), stroke (6.3% vs. 5.6%) and HF (8.7% vs. 7.7%). https://web.pathway.md/diseases/reclWZaqSp36TX3eN 9/18 6/24/23, 12:46 PM Hypertension Pathway ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. JAMA. 2002 Dec 18. Choice of antihypertensive, subsequent therapy: As per Hypertension Canada 2020 guidelines, add additional antihypertensive drugs if target BP levels are not achieved with standard-dose monotherapy. B Choose add-on drugs from first- line choices, such as thiazide/thiazide-like diuretics or CCBs with either ACEIs, ARBs, or - blockers. B Be cautious when combining a nondihydropyridine CCB and a -blocker. B Do not combine an ACEI and an ARB. A Show 2 more As per ESH/ESC 2018 guidelines, increase treatment to a three-drug combination, usually a RAAS blocker with a CCB and thiazide/thiazide-like diuretics, preferably as a single-pill combination, if BP is not controlled with a two-drug combination. A Show 2 more Landmark trials: PATHWAY-2 (spironolactone vs. placebo) In patients aged 18-79 years with seated clinic systolic BP 140 mmHg and home systolic BP 130 mmHg, despite treatment with maximally tolerated doses of 3 antihypertensive drugs for at least 3 months, spironolactone was superior to placebo with respect to reduction in home systolic BP through week 6 to week 12. Bryan Williams et al. Lancet. 2015 Nov 21. Management of hypertensive emergencies: admit adults with a hypertensive emergency to an ICU for continuous monitoring of BP and target organ damage and for parenteral administration of an appropriate agent. B Statin therapy: As per CHEP 2020 guidelines, initiate statin therapy in patients with HTN with 3 cardiovascular risk factors or with established atherosclerotic disease. A As per ESC 2018 guidelines, initiate statins in patients at high or very high cardiovascular risk. B Antiplatelet therapy: Avoid initiating aspirin for primary prevention in patients without CVD. D Initiate antiplatelet therapy, particularly low-dose aspirin, for secondary prevention in patients with HTN. A 5. Nonpharmacologic interventions Lifestyle modifications: As per ESC 2018 guidelines: https://web.pathway.md/diseases/reclWZaqSp36TX3eN 10/18 6/24/23, 12:46 PM Hypertension Pathway Recommend BP-lowering drug treatment and lifestyle interventions in fit older patients > 65 years but not > 80 years of age, when systolic BP is in the grade 1 range (such as 140-159 mmHg), provided that treatment is well tolerated. A Advise lifestyle changes in patients with high-normal BP (such as 130-139/85-89 mmHg). A As per ACC 2018 guidelines, offer effective behavioral and motivational strategies for adults with HTN to achieve a healthy lifestyle including tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet. B Dietary modifications: As per CHEP 2020 guidelines: Advise adopting a diet emphasizing fruits, vegetables, low-fat dairy products, whole grain foods rich in dietary fiber, protein from plant sources, and reduced in saturated fat and cholesterol in patients with HTN and nonhypertensive individuals at increased risk of developing HTN. B Advise increasing dietary potassium intake to reduce BP in patients not at risk of hyperkalemia. A As per ESC 2018 guidelines, encourage increased consumption of vegetables, fresh fruits, fish, nuts, and unsaturated fatty acids; low consumption of red meat; and consumption of low-fat dairy products. A As per ACC 2018 guidelines: Advise adopting a heart-healthy diet, such as the Dietary Approaches to Stop HTN diet, in order to achieve a desirable weight in adult patients with elevated BP or HTN. A Advise increasing intake of potassium, preferably via dietary modification, in adult patients with elevated BP or HTN unless contraindicated by the presence of CKD or the use of drugs reducing potassium excretion. A Salt restriction: As per CHEP 2020 guidelines, consider reducing sodium intake to 2 g (5 g of salt or 87 mmol of sodium) per day to prevent HTN in nonhypertensive individuals and reduce BP in adult patients with HTN. B As per ESC 2018 guidelines, advise restricting salt intake to < 5 g per day. A As per ACC 2018 guidelines, advise reducing sodium intake in adult patients with elevated BP or HTN. A Alcohol restriction: As per CHEP 2020 guidelines: Advise abstaining from alcohol or reducing alcohol intake to 2 drinks per day prevent HTN in healthy adults. B Advise reducing alcohol intake to decrease BP in adult patients with HTN drinking 2 drinks per day. Advise reducing alcohol intake to 2 drinks per day to decrease BP in adult patients with HTN drinking 6 drinks per day. A https://web.pathway.md/diseases/reclWZaqSp36TX3eN 11/18 6/24/23, 12:46 PM Hypertension Pathway As per ESC 2018 guidelines: Restrict alcohol consumption to < 14 units per week for males and < 8 units per week for females. A Advise against binge drinking. B As per ACC 2018 guidelines, advise limiting alcohol consumption ( 2 standard drinks per day foe males and 1 standard drink per day for females) in patients with elevated BP or HTN. A Weight loss: As per CHEP 2020 guidelines: Advise maintaining a healthy body weight (BMI 18.5-24.9) and waist circumference (< 102 cm for males and < 88 cm for females) for nonhypertensive individuals to prevent HTN (Grade C) and for hypertensive patients to reduce BP. B Offer weight loss in all patients with HTN and overweight. Offer a multidisciplinary approach for weight loss, including dietary education, increased physical activity, and behavioral intervention. B As per ESC 2018 guidelines, advise controlling body weight to avoid obesity (such as BMI > 30 kg/m or waist circumference > 102 cm in males and > 88 cm in females) and aim for a healthy BMI (about 20-25 kg/m ) and waist circumference values (< 94 cm in males and < 80 cm in females) to reduce BP and cardiovascular risks. A As per ACC 2018 guidelines, advise losing weight to reduce BP in adult patients with elevated BP or HTN with obesity or overweight. A Exercising: As per CHEP 2020 guidelines: Advise practicing moderate-intensity dynamic exercise, such as walking, jogging, cycling, or swimming, for 4-7 days per week (30-60 minutes in total) in addition to the routine activities of daily living to reduce BP in patients with HTN and to reduce the possibility of becoming hypertensive in nonhypertensive individuals. B Do not discourage practicing resistance or weight training exercise (such as free-weight lifting, fixed-weight lifting, or handgrip exercise) in patients with systolic BP/diastolic BP of 140- 159/90-99 mmHg as it does not adversely influence BP. D As per ESC 2018 guidelines, advise practicing regular aerobic exercises ( 30 minutes of moderate dynamic exercise on 5-7 days per week) in adult patients with HTN. A As per ACC 2018 guidelines, advise increasing the level of physical activity with a structured exercise program in adult patients with elevated BP or HTN. A Smoking cessation: As per CHEP 2020 guidelines: Update tobacco use status on a regular basis in all patients with HTN and advise to quit smoking. B Offer pharmacologic therapy (such as varenicline, bupropion, nicotine replacement therapy) in all smokers with a goal of smoking cessation. B https://web.pathway.md/diseases/reclWZaqSp36TX3eN 12/18 6/24/23, 12:46 PM Hypertension Pathway As per ESC 2018 guidelines, advise smoking cessation, provide supportive care, and refer to smoking cessation programs. B Stress management: Consider offering stress management in patients with HTN if stress appears to be contributing to high BP. C Offer individualized cognitive-behavioral interventions when relaxation techniques are used. B Supplements: do not offer supplementation of calcium or magnesium for the prevention or treatment of HTN. D Telehealth interventions: consider using telehealth strategies as adjuncts to other interventions shown to reduce BP for adults with HTN. B Adjuncts to control of hypertension: consider using performance measures in combination with other quality improvement strategies at patient-, provider-, and system-based levels to facilitate optimal HTN control. C 6. Therapeutic procedures Renal artery revascularization: consider referring patients with renal artery stenosis for consideration of renal artery revascularization when medical management has failed (refractory HTN, worsening renal function, and/or intractable HF) and when renal artery stenosis is due to nonatherosclerotic disease, including FMD. C Device-based therapies: avoid using device-based therapies for the routine treatment of HTN, unless in the context of clinical studies and RCTs, until further evidence regarding their safety and efficacy becomes available. D 7. Perioperative care Perioperative management of antihypertensives: continue -blockers in patients with HTN undergoing major surgery who have been on -blockers chronically. B Show 4 more 8. Specific circumstances Elderly patients: As per ESC 2018 guidelines, recommend BP-lowering drug treatment and lifestyle interventions in fit older patients with HTN even if > 80 years of age when systolic BP 160 mmHg. A As per AHA 2018 guidelines, treat HTN with a systolic BP treatment goal of < 130 mmHg for noninstitutionalized ambulatory community-dwelling adults 65 years of age with an average systolic BP 130 mmHg. A As per JNC 2014 guidelines: https://web.pathway.md/diseases/reclWZaqSp36TX3eN 13/18 6/24/23, 12:46 PM Hypertension Pathway Initiate pharmacologic treatment in the general population aged 60 years to lower BP at systolic BP 150 mmHg or diastolic BP 90 mmHg and treat to a goal of systolic BP < 150 mmHg and diastolic BP < 90 mmHg. A Do not adjust treatment in the general population aged 60 years if pharmacotherapy for high BP results in lower achieved systolic BP (< 140 mmHg) and treatment is well tolerated and without adverse effects on health or quality of life. D Pregnant patients: Transition women with HTN who become pregnant or are planning to conceive to treatment with methyldopa, nifedipine, and/or labetalol. B Avoid prescribing ACEIs, ARBs, or direct renin inhibitors in women with HTN who become pregnant. D Patients of black background: use a thiazide-type diuretic or CCB for initial antihypertensive treatment in black adults with HTN but without HF or CKD, including those with diabetes mellitus. B Patients with stage 1 hypertension: As per ESC 2018 guidelines, in patients with grade 1 HTN: advise lifestyle interventions to determine if this will normalize BP. (Class : I, LOE : B) administer BP-lowering drug treatment in patients with grade 1 HTN at low-moderate-risk and without evidence of HTN-mediated organ damage, if the patient remains hypertensive after a period of lifestyle intervention initiate drug treatment promptly with simultaneous lifestyle interventions, in patients with grade 1 HTN at high risk or with evidence of HTN-mediated organ damage. (Class : I, LOE : A). A As per ACC 2018 guidelines, manage adults with an elevated BP or stage 1 HTN who have an estimated 10-year ASCVD risk < 10% with nonpharmacological therapy and repeat BP evaluation within 3 to 6 months. B Patients with obesity: As per AACE 2016 guidelines, prefer orlistat, lorcaserin, phentermine/topiramate ER, and liraglutide 3 mg in patients with existing HTN. (Grade B; BEL 1) Obtain careful monitoring of HR in patients receiving liraglutide 3 mg and phentermine/topiramate ER. A Show 2 more As per ES 2015 guidelines: Do not use sympathomimetic agents phentermine and diethylpropion in patients with uncontrolled HTN or a history of heart disease. D Consider offering non-sympathomimetic agents (such as lorcaserin and/or orlistat) as weight loss pharmacotherapy in patients with CVD. C Patients with diabetes mellitus (screening): measure BP at every routine clinical visit. Confirm BP using multiple readings, when possible, in patients found to have elevated BP (systolic BP 120-129 mmHg and diastolic < 80 mmHg), including measurements on a separate day, to diagnose HTN. Diagnose HTN in case of a systolic BP 130mmHg or a diastolic BP 80 mmHg based on an average of 2 measurements obtained on 2 occasions. A 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